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Three Part Question

Does the use of [cognitive aids] (e.g. smart phone applications, posters, aid memories, checklists) during advanced life support improve [adherence to guidelines] by [rescuers].

Clinical Scenario

An emergency medicine trainee is called to a 66-year-old man in the Emergency Department (ED), who has just had a cardiac arrest. Advanced life support (ALS) has started. The trainee knows the guidelines have recently been updated, but is not familiar with the changes. The resuscitation attempt is unsuccessful and the patient dies. Later she wonders whether using a checklist (e.g. from her smart phone or on a poster) would have been useful during the arrest to ensure that current guidelines were followed and whether this would have improved the patients chances of survival.

Search Strategy

Studies on guidance for lay persons by emergency medical service telephone dispatchers, and studies of prompt/feedback devices to improve quality of chest compressions were excluded.

Medline via Ovid (between 1st January 1950 and 28th June 2011)
• Topic search:
o [Advanced cardiac life support/Advanced life support/arrest/cardiac arrest/emergency/emergency treatment/heart arrest/life support care/resuscitation/treatment]
• Intervention search:
o [aid memoire/aid/aids/audiovisual aids/cellular phone/checklist/cognitive/cognitive aids/computers, handheld/internet/memoire/mnemonic/posters as topic/poster/recall/reminder/reminder systems/self-help devices/smartphone/support]
The topic search and the intervention search were combined with the Ovid Medline “and” function and limited to produce 546 results.
• 4 relevant results were found.
o Reference lists were searched and one further paper was found.

Google Scholar search terms:
Search Terms: Cognitive aids in CPR, Smartphone CPR, Audiovisual aids CPR
o One relevant new paper (Literature review, quoted in discussion).
o One paper sourced from reference list.

Cochrane library:
Search terms: (Cognitive aids/Memory aids/Checklists/Posters) and (CPR/Resuscitation/ALS)
o 23 articles, none relevant.
CINAL from 1980→current:
Search terms: (cognitive aids/aid memoire) and (Advanced life support/ALS/CPR) within title
• 308 results
• One relevant result (already found in previous Ovid search).

Search Outcome

879 articles found, 6 included in final review and one additional paper included in the discussion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Schneider et al 1995 USA	39 Anaesthesia residents presented with two simulated emergency scenarios (ventricular tachycardia and second degree heart block) with (N1=20) or without (N2=19) the use of a computer based prompter in the form of an algorithm available on a touch screen. Participants were videoed and treatment compared to guidelines.	Randomised controlled trial	Correct lidocaine dosage	n1=19 n2=11 P= 0.015	Computer technology was still in its infancy and many developments in technology and our understanding technology have occurred since. The paper only included “selected responses” to the algorithm i.e. not all actions taken by participants were reported, suggesting the statistical differences between the groups may not have been as apparent as suggested.
			Correct ordering of magnesium sulphate	n1=12 n2=2 P=0.003
			Atropine followed by dopamine infusion	n1=12 n2=2 P=0.0004
			Procainamide was administered.	n1=6 n2=3 P>0.04
			Verapamil infusion was incorrectly given.	n1=1 n2=1 P>0.04
			Adrenaline (epinephrine) infusion administered.	N1=18 n2=6 P=0.0004
			Adrenaline (epinephrine) infused at correct rate.	N1=17 N2=3 P=-0.00003
Harrison TK et al. 2006 USA	47 Anaesthetic 1st and 2nd year clinical trainees controlling a multidisciplinary team during a simulated malignant hyperthermia scenario (MH) with two different clinical presentations (24 simple MH 23 MH with a confounder of graves disease) each with access to a algorithm poster and their own resources (including mobile phones and textbooks).	Observational study in a simulated environment	% of teams that opted to use a cognitive aid	Simple MH 79%, Confounded MH 78%	Retrospective study, scenarios designed for teaching rather than investigation. No measures of how skilled the participants were in MH management before the simulation. Also this study did not look at cardiac arrest.
			Correlation between frequency of aid referral and score on validated checklist.	Simple MH Spearman r=0.59, P<0.01, Confounded MH r=0.68 P<0.001
Berkenstadt H et al. 2006 Israel	29 Anaesthesia residents allocated to either use the “On-Line Electronic Help” information system made available through a Philips IntelliVue monitor (N1=15), or to a control group (N2=14) to manage a simulated episode of MH.	Randomised Controlled Trial	Score on the Harrison et al.2 performance evaluation for treatment of malignant hypertension.	21.5 (±4.9) versus 15.5 (±7.6) P=0.018	Participants may have anticipated the acute event during the session and scored higher as a result. The study design did not allow for conclusions on variables such as how quickly the diagnosis of MH was reached, i.e. did using aids slow down response?
Nelson et al. 2008 USA	60 Paediatric residents in a simulated cardiopulmonary arrest scenario given the opportunity to use any cognitive aid available to them for their assistance if they wished.	Case-control study.	% of Doctors who chose to use a Cognitive Aid.	Ventricular tachycardia: 84.3% Pulseless electrical activity: 60.5%	No measure of quality of CPR provided by those who chose correct algorithm, nor indication of impact having free-choice over which cognitive aid to use slowed administration of CPR.
			% Of Cognitive aid users who selected the incorrect treatment algorithm.	25.5%
			Hand placement correct in those who chose to use a cognitive aid compared to those who did not.	97% Vs 75%
Bould MD et al. 2009 Canada	32 Anaesthetic residents performing CPR on an infant manikin with or without a poster detailing St. Michael’s Hospital’s self designed life support protocol.	Single blinded randomised controlled trial.	Participants score on a previously validated checklist by an external observer.	Median scores: 20.3 (18.3-21.3) versus 18.2 (15.0-20.5) P=0.08 No participants correctly performed all life-saving interventions needed to pass the checklist.	Small sample size. Baby manikin was used which is designed to represent a 6-month-old baby rather than a newborn. Time from neonatal life support training not adjusted for.
Low et al. 2011 UK	31 ALS trained junior doctors within 5 years of qualification randomised to undertake a simulated ALS scenario with or without the help of a smart phone application providing ALS current guidelines (16 iResus© app, 15 no app).	Randomised controlled trial.	Scored on previously validated Resuscitation Council UK cardiac arrest simulation tests, observed with a checklist.	Median Score (inter quartile range) Smart phone: 84 (75.5-92.5) No smart phone: 72 (62-78) P=0.02	No pre-testing of candidates so ALS standards may have varied. Assessment not blinded.

Comment(s)

The international Liaison Committee on Resuscitation (ILCOR) states that during basic life support, ALS and anaesthetic emergencies: “It is reasonable to use cognitive aids (e.g. checklists) during resuscitation, provided that they do not delay the start of resuscitative efforts. Aids should be validated using simulation or patient trials, both before and after implementation, to guide rapid cycle improvement.”7 Studies that specifically address the use of cognitive aids during hospital ALS is significantly smaller than those that explore cognitive aids in the context of CPR alone. Of those included here, all but one looked at an individual’s use of cognitive aids rather than in a team setting, not reflecting a typical ALS situation. Although cognitive aids improved adherence to guidelines during simulated scenarios, pitfalls include using the wrong cognitive aid (e.g. wrong algorithm or checklist) and delays in starting treatments. There are no studies looking at the effect of cognitive aids during ALS for cardiac arrest in real patients or on actual patient outcomes.

Editor Comment

Currently being checked by Dr Soar 08/05/2012 KW

Clinical Bottom Line

The use of a cognitive aid by ALS providers can improve adherence to CPR guidelines in simulated scenarios. There are no studies to look at their effects on adherence to guidelines and survival during cardiac arrest in real patients.

References

1. Schneider AJL, Murray WB, et al. "Helper": A critical events prompter for unexpected emergencies. Journal of Clinical Monitoring 1995;11(6),358-64
2. Harrison TK, Manser T, et al. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg. 2006; 103:551-6.
3. Berkenstadt H, Yusim Y, et al. An assessment of a point of care information system for anesthesia provider in simulated malignant hyperthermia crisis. Anesthesia and Analgesia 2006;102:530-2.
4. Nelson K, Shilkofski N, et al. The use of cognitive aids during simulated paediatric cardiopulmonary arrest. Simulation in Healthcare. 2008;3(3),138-45.
5. Bould MD, Hayter MA, et al. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. British Journal of Anaesthesia. 2009;103(4):570-5.
6. Low D, Clarke N, et al. A Randomised controlled trial to determine if use of the iResus application on a smart phone improves the performance of an advance life support provider in a simulated medical emergency. Anaesthesia. 2011; 66(4):255-62.
7. Soar J Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, Ma MH, Perkins DG, Rodgers DL Hazinski MF. Education, Implementation and Teams Chapter Collaborators. Part 12: Education, implementation and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 2010;81:e288-330