**Meet the editor**

Dr. Theodoros K. Aslanidis received his Doctor of Medicine degree from the Plovdiv Medical University, Bulgaria and his PhD degree from the Aristotle University of Thessaloniki, Greece. After serving in the Hellenic Army Force as a medical doctor, he worked as a rural physician at the Outhealth Centre, Iraklia and Serres General Hospital, Greece. He completed his residency in

Anaesthesiology from the "Hippokratio" General Hospital of Thessaloniki, followed by fellowship training in Critical Care at the AHEPA University Hospital, and a postgraduate program in Prehospital Emergency Medicine. He served as an EMS Physician and Emergency Communication Centre Medic at Hellenic National Centre for Emergency Care before moving to his current post as a consultant-researcher at the Intensive Care Unit of St. Paul General Hospital of Thessaloniki, Greece. His research interests are medical writing, data analysis, critical emergency medicine, neurosonology, and electrodermal activity.

Contents

**Preface VII**

**Physician 3** Theodoros Aslanidis

**Resuscitation 41**

**Resuscitation 57**

Purificación Saiz and Jesus M. Ruiz

Chapter 1 **Introductory Chapter: The Role of Emergency Medical Service**

Chapter 2 **Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment of High-Risk Patients 9** Alain Kalmar, Nicky Van Der Vekens, Henk Vanoverschelde, Diederik Van Sassenbroeck, Jan Heerman and Tom Verbeke

Chapter 3 **Resuscitation of Term Infants in the Delivery Room 25** Francesca Viaroli and Georg M. Schmölzer

Chapter 4 **Ultrasound-Guided Vascular Access during Cardiopulmonary**

Chapter 5 **Applications of the Transthoracic Impedance Signal during**

Anton Kasatkin, Aleksandr Urakov and Anna Nigmatullina

Digna M. González-Otero, Sofía Ruiz de Gauna, José Julio Gutiérrez,

**Section 1 Introduction 1**

**Section 2 Special Topics 7**

## Contents

#### **Preface XI**

Preface

more personalized approach is growing.

Over 50 years have passed since the proposed "close chest cardiac massage" by Kouwen‐ hoven and the "race against the D(eath)-time," and the challenge for better outcomes re‐ mains. On one hand, we have moved to a more holistic approach—from cardiac massage to cardiopulmonary resuscitation (CPR) to advance life support (ALS), while research on a

Today, assisted-device CPR, alternative CPR position, e.g. prone-CPR, patient-centric blood pressure targeted CPR, flow-enhanced CPR, neuroprotection during resuscitation, new training methods in resource-limited health systems, implementation of phone-assister CPR, and implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO), the

Within this frame, this book, published by IntechOpen, comes as a natural sequel after the previous publications on the subject. Divided into two sections, it focuses on specific resus‐ citation topics from the role of the physician in prehospital care to possible future applica‐

The authors offer the reader not only a "vigorous" review of the current literature but also a research path for further advancement. A path proves that resuscitation is anything but an

> **Theodoros K. Aslanidis MD, PhD** Anesthesiology-Intensive Care Pre hospital Emergency Medicine

> > Intensive Care Unit St. Paul General Hospital Thessaloniki, Greece

so-called E-CPR, are only some of the issues currently being researched.

tions, such as the use of transthoracic impedance in the field.

exhausted subject for both the clinician and the researcher.

## Preface

Over 50 years have passed since the proposed "close chest cardiac massage" by Kouwen‐ hoven and the "race against the D(eath)-time," and the challenge for better outcomes re‐ mains. On one hand, we have moved to a more holistic approach—from cardiac massage to cardiopulmonary resuscitation (CPR) to advance life support (ALS), while research on a more personalized approach is growing.

Today, assisted-device CPR, alternative CPR position, e.g. prone-CPR, patient-centric blood pressure targeted CPR, flow-enhanced CPR, neuroprotection during resuscitation, new training methods in resource-limited health systems, implementation of phone-assister CPR, and implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO), the so-called E-CPR, are only some of the issues currently being researched.

Within this frame, this book, published by IntechOpen, comes as a natural sequel after the previous publications on the subject. Divided into two sections, it focuses on specific resus‐ citation topics from the role of the physician in prehospital care to possible future applica‐ tions, such as the use of transthoracic impedance in the field.

The authors offer the reader not only a "vigorous" review of the current literature but also a research path for further advancement. A path proves that resuscitation is anything but an exhausted subject for both the clinician and the researcher.

> **Theodoros K. Aslanidis MD, PhD** Anesthesiology-Intensive Care Pre hospital Emergency Medicine Intensive Care Unit St. Paul General Hospital Thessaloniki, Greece

**Section 1**

**Introduction**

**Section 1**

## **Introduction**

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: The Role of Emergency Medical**

**1. Introduction: emergency medical services as medical subspecialty**

Almost 45 years since the inception of first modern emergency medical services (EMS) in the United States with the Highway Safety Act of 1966 and the EMS Services Development Act of 1973 [1, 2], the American Board of Medical Specialties (ABMS) voted in 2011 to create a new physician subspecialty called "emergency medical services" [3]. The American Board of Emergency Medicine was named the parent board for this subspecialty and held its first

The first suggestions about an EMS subspecialty head back to late 1990s by the creation of an ABEM task force and later, in 2001, by National Association of Emergency Medical Society Physicians (NAEMSP's EMS Physician) Certification Task Force. Yet, it took another ten years and the continuous tremendous advance in prehospital care in the last decades that finally led

**Introductory Chapter: The Role of Emergency Medical**

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.80916

**Service Physician**

**Service Physician**

Theodoros Aslanidis

Theodoros Aslanidis

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.80916

board certification exam in 2013.

to the new emergency medicine subspecialty [4].

• anesthesiology critical care medicine,

• internal medicine-critical care medicine,

• emergency medical services, • hospice and palliative medicine,

• pediatric emergency medicine,

• medical toxicology,

• pain medicine,

Today, the list of the existing subspecialties of emergency medicine [5] is:

#### **Introductory Chapter: The Role of Emergency Medical Service Physician Introductory Chapter: The Role of Emergency Medical Service Physician**

DOI: 10.5772/intechopen.80916

Theodoros Aslanidis

Additional information is available at the end of the chapter Theodoros AslanidisAdditional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.80916

#### **1. Introduction: emergency medical services as medical subspecialty**

Almost 45 years since the inception of first modern emergency medical services (EMS) in the United States with the Highway Safety Act of 1966 and the EMS Services Development Act of 1973 [1, 2], the American Board of Medical Specialties (ABMS) voted in 2011 to create a new physician subspecialty called "emergency medical services" [3]. The American Board of Emergency Medicine was named the parent board for this subspecialty and held its first board certification exam in 2013.

The first suggestions about an EMS subspecialty head back to late 1990s by the creation of an ABEM task force and later, in 2001, by National Association of Emergency Medical Society Physicians (NAEMSP's EMS Physician) Certification Task Force. Yet, it took another ten years and the continuous tremendous advance in prehospital care in the last decades that finally led to the new emergency medicine subspecialty [4].

Today, the list of the existing subspecialties of emergency medicine [5] is:

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

thus covering almost all kinds of emergency medical care.

However, outside US, emergency medical systems are considered a relative new addition to the Healthcare systems [2]. Even now (2018), the state of EMS still varies drastically from developed to developing countries [6].

Even in the US, EMS agencies have significant practice variability with regard to quality improvement resources, medical direction, and specific clinical quality measures [16]. At the same time, there is a lack of share in understanding of which quality indicators to be used by physician-staffed EMS [17]. The heterogeneity of EMS systems in terms of organization (Anglo-American concept or European), equipment availability, staffing (EMTs, paramedics, EMS physicians, anesthesiologists, etc.), and level of training, on the one hand, and the national or regional determinants of prehospital healthcare system (geographical, socioeco-

Introductory Chapter: The Role of Emergency Medical Service Physician

http://dx.doi.org/10.5772/intechopen.80916

5

The formation of a self-regulatory quality improvement system (SQIS) with flexible model of best human recourse utilization, adapted to the data feedback from the local or regional characteristics of EMS utilization, may be the most prudent way for resolving the problem.

nomic factors, etc.), on the other hand, make it even harder to find the answer.

Intensive Care Unit, St. Paul General Hospital of Thessaloniki, Thessaloniki, Greece

[1] Emergency Medical Services Systems Development Act of 1973. Hearings. 93rd Congress, 1st Session, on §504.and §654. Washington, DC: United States Congress, Senate, Com-

[2] Shah MN. The formation of the emergency medical services system. American Journal of

[3] American Board of Medical Specialties. Emergency Medical Services: Eligibility Vriteria for Certification. 2011. Available from: http://www.naemsp.org/Documents/

[4] Escott M. EMS Subspecialty creates an opportunity to change the role of the paramedic. JEMS: A Journal of Emergency Medical Services. 2015;**40**(1). https://www.jems.com/articles/print/volume-40/issue-1/departments-columns/field-physicians/ems-subspecialty-

mittee on Labor and Public Welfare, Subcommittee on Health; 1973. pp. 691-694

Public Health. 2006;**96**(3):414-423. DOI: 10.2105/AJPH.2004.048793

EMSEligCriteriaFINALApril2011.pdf [Accessed: 9-7-2018]

creates-opportunity-cha.html [Accessed: 10-7-2018]

**Conflict of interests**

**Author details**

Theodoros Aslanidis

**References**

The author has no conflict of interest.

Address all correspondence to<EMAIL_ADDRESS>
Within the aforementioned frame, the present article aims at describing the possible roles of the EMS physician.

#### **2. The role of EMS physician**

#### **2.1. On scene**

EMS personnel are recognized as the extension of the physician in the field, a "delegated practitioner." Even though the current level of training in other EMS personnel (EMTs, Paramedics) is continuously raising, active involvement of the physicians in prehospital emergency care of patients is still needed.

There are several studies about out-of-hospital cardiac arrest (OHCA), synthesized in a recent meta-analysis [7], that suggests that EMS-physician-guided CPR in OHCA is associated with improved survival outcomes. Yet, due to the fact that the meta-analysis is based solely on observational studies, some authors doubt its results [8]. The same dispute is ongoing when it comes to single country studies about the same subject [9]. On the contrary, in cases of traumatic OHCA and in cases of severe injured patients, the presence of an EMS physician on the field is related with increased survival [10–12].

#### **2.2. Beyond direct patient care**

The high level of EMS personnel allows the system to work, most of the time, independently on the scene. Yet, the role of EMS physician extent beyond direct patient care; as he can serve as a coordinator or team leader, as an EMS educator, as the legal component of the system, as the patient advocate, or as the link between EMS and the hospital health care [13].

Thus, EMS physician can serve as the ideal Medical Director that can provide management, supervision, and guidance in an effort to assure quality of care [14]. The recent American College of Emergency Physicians (ACEP) policy statement gives the main principles of the role [15].

#### **2.3. The challenge for the best EMS physicians' utilization**

Though recognition of EMS subspecialty seems to create a new dynamic in prehospital emergency medicine, the optimum way of utilization of EMS physicians remains a question. Even in the US, EMS agencies have significant practice variability with regard to quality improvement resources, medical direction, and specific clinical quality measures [16]. At the same time, there is a lack of share in understanding of which quality indicators to be used by physician-staffed EMS [17]. The heterogeneity of EMS systems in terms of organization (Anglo-American concept or European), equipment availability, staffing (EMTs, paramedics, EMS physicians, anesthesiologists, etc.), and level of training, on the one hand, and the national or regional determinants of prehospital healthcare system (geographical, socioeconomic factors, etc.), on the other hand, make it even harder to find the answer.

The formation of a self-regulatory quality improvement system (SQIS) with flexible model of best human recourse utilization, adapted to the data feedback from the local or regional characteristics of EMS utilization, may be the most prudent way for resolving the problem.

#### **Conflict of interests**

The author has no conflict of interest.

#### **Author details**

• sports medicine, and

4 Special Topics in Resuscitation

the EMS physician.

**2.1. On scene**

of patients is still needed.

**2.2. Beyond direct patient care**

• undersea and hyperbaric medicine;

developed to developing countries [6].

**2. The role of EMS physician**

the field is related with increased survival [10–12].

**2.3. The challenge for the best EMS physicians' utilization**

thus covering almost all kinds of emergency medical care.

However, outside US, emergency medical systems are considered a relative new addition to the Healthcare systems [2]. Even now (2018), the state of EMS still varies drastically from

Within the aforementioned frame, the present article aims at describing the possible roles of

EMS personnel are recognized as the extension of the physician in the field, a "delegated practitioner." Even though the current level of training in other EMS personnel (EMTs, Paramedics) is continuously raising, active involvement of the physicians in prehospital emergency care

There are several studies about out-of-hospital cardiac arrest (OHCA), synthesized in a recent meta-analysis [7], that suggests that EMS-physician-guided CPR in OHCA is associated with improved survival outcomes. Yet, due to the fact that the meta-analysis is based solely on observational studies, some authors doubt its results [8]. The same dispute is ongoing when it comes to single country studies about the same subject [9]. On the contrary, in cases of traumatic OHCA and in cases of severe injured patients, the presence of an EMS physician on

The high level of EMS personnel allows the system to work, most of the time, independently on the scene. Yet, the role of EMS physician extent beyond direct patient care; as he can serve as a coordinator or team leader, as an EMS educator, as the legal component of the system, as

Thus, EMS physician can serve as the ideal Medical Director that can provide management, supervision, and guidance in an effort to assure quality of care [14]. The recent American College of Emergency Physicians (ACEP) policy statement gives the main principles of the role [15].

Though recognition of EMS subspecialty seems to create a new dynamic in prehospital emergency medicine, the optimum way of utilization of EMS physicians remains a question.

the patient advocate, or as the link between EMS and the hospital health care [13].

Theodoros Aslanidis

Address all correspondence to<EMAIL_ADDRESS>
Intensive Care Unit, St. Paul General Hospital of Thessaloniki, Thessaloniki, Greece

#### **References**

[5] American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2011. Available from: https://www.abms.org/member-boards/specialty-subspecialty-certificates [Accessed: 10-7-2018]

**Section 2**

**Special Topics**

**Section 2**

## **Special Topics**

[5] American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2011. Available from: https://www.abms.org/member-boards/specialty-subspecialty-certifi

[6] Aslanidis T. EMS Health Staff Problems: Facts and Solution: Asian Hospital Healthcare & Management. 2018. Available from: https://www.asianhhm.com/articles/ems-staff-

[7] Bottiger BW, Berhhard M, Knapp J, Nagele P. Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: Systematic review and

[8] Von Vopelious-Feld J, Benger J. Response to: Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation. Critical Care. 2016;**20**:324.

[9] Fouche P, Jennings PA. Physician presence at out-of-hospital cardiac arrest is not neces

[10] Fjaeldstad A, Kirk MH, Knudsen L, Bjerring J, Christensen EF. Physician-staffed emer

[11] Den Hartog D, Romeo J, Ringburg AN, Verhofstad MH, Van Lieshout EM. Survival ben

[12] Fukuda T, Ohashi-Fukuda N, Kondo Y, Hayashida K, Kukita I. Association of prehospi

[13] American College of Emergency Physicians (ACEP); National Association Of EMS Physicians (NAEMSP); National Association Of State EMS Officials (NASEMSO). Role of the state EMS medical director. Prehospital Emergency Care 2010;**14**(3):402. DOI:

[14] Munjal KG. The Role of the medical director: A more collaborative, multidisciplinary

[15] American College of Emergency Physicians. The Role of the Physician Medical Director in Emergency Medical Services Leadership: Policy Statement. 2017. Available from: https://www.acep.org/globalassets/new-pdfs/policy-statements/the.role.of.the.physi

[16] Redenier M, Olivieri P, Loo GT, Muniai K, Hilton MT, Potkin KT, et al. National assess

[17] Haugland H, Uleberg O, Klepstad P, Kruger A, Rehn M. Quality measurement in phy

ment of quality programs in emergency medical services. Prehospital Emergency Care.

sician-staffed emergency medical services: A systematic literature review. International

;**30**(4). DOI: 10.1093/intqhc/mzy106

sarily the cause of improved survival. Scandinavian Journal of Trauma, Resuscitation

gency helicopter reduces transportation time from alarm call to highly specialized cen

efit of physician-staffed helicopter emergency medical services (HEMS) assistance for severely injured patients. Injury. 2015;**46**(7):1281-1286. DOI: 10.1016/j.injury.2015.04.013

tal advanced life support by physician with survival after out-of-hospital cardiac arrest with blunt trauma following traffic collisions: Japanese registry-based study. JAMA

meta-analysis. Critical Care. 2016;**20**:4. DOI: 10.1186/s13054-015-1156-6

and Emergency Medicine. 2016;**24**(1):88. DOI: 10.1186/s13049-016-282-8

Surgery. 2018;**153**(6):e180674. DOI: 10.1001/jamasurg.2018.0674

oversight is called for in the future. EMS World. 2016;Suppl:10-11

cian.medical.director.in.ems.leadership.pdf [Accessed: 06-08-2018]

2018;**22**(3):370-378. DOI: 10.1080/10903127.2017.1800094

Journal for Quality in Health Care. 2018

cates [Accessed: 10-7-2018]

6 Special Topics in Resuscitation

health-problems [Accessed: 08-07-2018]

DOI: 10.1186/s13054-016-1495-y

10.3109/10903121003770688

tre. Danish Medical Journal. 2013;**60**(7):A4666

**Chapter 2**

**Provisional chapter**

**Managing the Prevention of In-Hospital Resuscitation**

**Managing the Prevention of In-Hospital Resuscitation**

Alain Kalmar, Nicky Van Der Vekens,

Alain Kalmar, Nicky Van Der Vekens,

Jan Heerman and Tom Verbeke

Jan Heerman and Tom Verbeke

http://dx.doi.org/10.5772/intechopen.79651

**Abstract**

proactive rounding

**1. Introduction**

Henk Vanoverschelde, Diederik Van Sassenbroeck,

Henk Vanoverschelde, Diederik Van Sassenbroeck,

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

**by Early Detection and Treatment of High-Risk Patients**

In hospitalized patients, cardiorespiratory collapse mostly occurs after a distinct period of deterioration. This deterioration can be discovered by a systematic quantification of a set of clinical parameters. The combination of such a detection system—to identify patients at risk in an early stage —and a rapid response team—which can intervene immediately—can be implemented to prevent life-threatening situations and reduce the incidence of in-hospital cardiac arrests outside the intensive care setting. The effectiveness of both of these systems is influenced by the used trigger criteria, the number of rapid response team (RRT) activations, the in- or exclusion of patients with a DNR code >3, proactive rounding, the team composition, and its response time. Each of those elements should be optimized for maximal efficacy, and both systems need to work in tandem with little delay between patient deterioration, accurate detection, and swift intervention. Dependable diagnostics and scoring protocols must be implemented, as well as the organization of a 24/7 vigilant and functional experienced RRT. This implies a significant financial investment to provide an only sporadically required fast intervention and sustained alertness of the people involved.

**Keywords:** early warning score, rapid response team, in-hospital cardiac arrest,

While the organization and optimization of resuscitation of in-hospital cardiorespiratory collapse already receives due attention, there is a growing consciousness that a more

**by Early Detection and Treatment of High-Risk Patients**

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.79651

**Chapter 2 Provisional chapter**

#### **Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment of High-Risk Patients Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment of High-Risk Patients**

DOI: 10.5772/intechopen.79651

Alain Kalmar, Nicky Van Der Vekens, Henk Vanoverschelde, Diederik Van Sassenbroeck, Jan Heerman and Tom Verbeke Alain Kalmar, Nicky Van Der Vekens, Henk Vanoverschelde, Diederik Van Sassenbroeck, Jan Heerman and Tom Verbeke

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79651

#### **Abstract**

In hospitalized patients, cardiorespiratory collapse mostly occurs after a distinct period of deterioration. This deterioration can be discovered by a systematic quantification of a set of clinical parameters. The combination of such a detection system—to identify patients at risk in an early stage —and a rapid response team—which can intervene immediately—can be implemented to prevent life-threatening situations and reduce the incidence of in-hospital cardiac arrests outside the intensive care setting. The effectiveness of both of these systems is influenced by the used trigger criteria, the number of rapid response team (RRT) activations, the in- or exclusion of patients with a DNR code >3, proactive rounding, the team composition, and its response time. Each of those elements should be optimized for maximal efficacy, and both systems need to work in tandem with little delay between patient deterioration, accurate detection, and swift intervention. Dependable diagnostics and scoring protocols must be implemented, as well as the organization of a 24/7 vigilant and functional experienced RRT. This implies a significant financial investment to provide an only sporadically required fast intervention and sustained alertness of the people involved.

**Keywords:** early warning score, rapid response team, in-hospital cardiac arrest, proactive rounding

#### **1. Introduction**

While the organization and optimization of resuscitation of in-hospital cardiorespiratory collapse already receives due attention, there is a growing consciousness that a more

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

proactive strategy by improved detection of deteriorating patients and adequate intervention may prevent many inpatient deaths. This awareness is reflected in the 5 Million Lives campaign [1].

The managerial task for enabling such an effective program is, therefore, the implementation of reliable early identification of patient deterioration, followed by a fast and appropriate response without significantly increasing nurse workload and without turning ward areas into ICUs [15]. It consists of two separate systems working in tandem: an early warning sys-

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment…

http://dx.doi.org/10.5772/intechopen.79651

11

Repetitive nursing staff education must provide fast and reliable patient scoring with high sensitivity and acceptable specificity. Secondly, to permit swift intervention when necessary, a dedicated hospital informatics system is required enabling the RRT to view all the patients in the hospital. Thirdly, detection of a deteriorating patient must prompt swift

The British National Institute for Health and Clinical Excellence documented in the National Institute of Health and Clinical Excellence (NICE) 2007 guidelines [16] that physiological track and trigger systems should be used to monitor all adult patients and facilitate the recognition of patient deterioration. According to the scoring (low, medium, or high score group), a graded response strategy should be followed (**Figure 1**). A score is given to different

tem and a rapid response team.

**2. The EWS scoring system**

**Figure 1.** Example of a formalized decision process with graded response.

intervention.

In the UK, the incidence of in-hospital cardiac arrest is 1.6/1000 hospital admissions [2]. Still, between 25 and 67% of the successfully in-hospital resuscitated patients die during the first 24 h after the return of spontaneous circulation (ROSC) [3]. In comparison, the survival to discharge after in-hospital cardiopulmonary resuscitation for cardiac arrest in nonelderly (18–64 years) in the US (2007–2012) was reported as only 30.4% and for patients >18 years as 27.4% [4, 5].

Particularly, in-hospital cardiorespiratory collapse is more frequently caused by preventable or correctable factors like respiratory problems or sepsis, compared to prehospital cardiorespiratory collapse, which is more frequently preceded by sudden, unexpected causes like cardiac rhythm disturbances or trauma [6].

In general, patients admitted to the intensive care unit (ICU) from hospital wards have a higher mortality risk compared to patients from theaters, postoperative recovery, or the emergency department. As such, there should be a focus on hospital wards to recognize patients who are critically ill prior to cardiopulmonary collapse [7].

Several studies have identified physiological abnormalities as a marker for clinical deterioration. Kause et al. [8] identified threatened airway, respiratory rate < 5, respiratory rate > 36, pulse rate < 40, pulse rate > 140, systolic blood pressure < 90 mmHg, fall of GCS by two points or more, and prolonged seizure activity. Goldhill et al. [9] defined the level of consciousness, heart rate, age, systolic pressure, and respiratory rate as predictive markers.

Based on a combination of those parameters, multiple scoring systems to identify patients at risk have been conceived, but they often lack validation [10].

Experience teaches that an exclusive implementation of a cardiac arrest team is both ineffective and expensive [7]. Keeping such a team continuously operational requires a significant financial investment [11], and the outcome remains poor [12]. Likewise, even advanced detection strategies, based on scoring systems to identify deteriorating patients, produced disappointing results [13]. This might be owing to a lack of validation of the scoring system [14]. In the MERIT study, a medical emergency team was implemented in 12 hospitals, and the outcome was compared with 11 other hospitals without such a team. The implementation of the team "greatly increased emergency team calling, but did not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death". In this study, a rapid response team was implemented but still with disappointing results, which may be due to the lack of a reliable early warning system [12].

Above all, both afferent and efferent components are needed to be effective: a track-andtrigger system must be organized to firstly detect deteriorating patients early with suitable sensitivity and specificity, followed by a fast intervention by a professional team to optimize the treatment or bring the patient to an intensive care unit.

The managerial task for enabling such an effective program is, therefore, the implementation of reliable early identification of patient deterioration, followed by a fast and appropriate response without significantly increasing nurse workload and without turning ward areas into ICUs [15]. It consists of two separate systems working in tandem: an early warning system and a rapid response team.

Repetitive nursing staff education must provide fast and reliable patient scoring with high sensitivity and acceptable specificity. Secondly, to permit swift intervention when necessary, a dedicated hospital informatics system is required enabling the RRT to view all the patients in the hospital. Thirdly, detection of a deteriorating patient must prompt swift intervention.

#### **2. The EWS scoring system**

proactive strategy by improved detection of deteriorating patients and adequate intervention may prevent many inpatient deaths. This awareness is reflected in the 5 Million Lives

In the UK, the incidence of in-hospital cardiac arrest is 1.6/1000 hospital admissions [2]. Still, between 25 and 67% of the successfully in-hospital resuscitated patients die during the first 24 h after the return of spontaneous circulation (ROSC) [3]. In comparison, the survival to discharge after in-hospital cardiopulmonary resuscitation for cardiac arrest in nonelderly (18–64 years) in the US (2007–2012) was reported as only 30.4% and for patients >18 years as

Particularly, in-hospital cardiorespiratory collapse is more frequently caused by preventable or correctable factors like respiratory problems or sepsis, compared to prehospital cardiorespiratory collapse, which is more frequently preceded by sudden, unexpected causes like

In general, patients admitted to the intensive care unit (ICU) from hospital wards have a higher mortality risk compared to patients from theaters, postoperative recovery, or the emergency department. As such, there should be a focus on hospital wards to recognize patients

Several studies have identified physiological abnormalities as a marker for clinical deterioration. Kause et al. [8] identified threatened airway, respiratory rate < 5, respiratory rate > 36, pulse rate < 40, pulse rate > 140, systolic blood pressure < 90 mmHg, fall of GCS by two points or more, and prolonged seizure activity. Goldhill et al. [9] defined the level of consciousness,

Based on a combination of those parameters, multiple scoring systems to identify patients at

Experience teaches that an exclusive implementation of a cardiac arrest team is both ineffective and expensive [7]. Keeping such a team continuously operational requires a significant financial investment [11], and the outcome remains poor [12]. Likewise, even advanced detection strategies, based on scoring systems to identify deteriorating patients, produced disappointing results [13]. This might be owing to a lack of validation of the scoring system [14]. In the MERIT study, a medical emergency team was implemented in 12 hospitals, and the outcome was compared with 11 other hospitals without such a team. The implementation of the team "greatly increased emergency team calling, but did not substantially affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death". In this study, a rapid response team was implemented but still with disappointing results, which may be due

Above all, both afferent and efferent components are needed to be effective: a track-andtrigger system must be organized to firstly detect deteriorating patients early with suitable sensitivity and specificity, followed by a fast intervention by a professional team to optimize

heart rate, age, systolic pressure, and respiratory rate as predictive markers.

campaign [1].

10 Special Topics in Resuscitation

27.4% [4, 5].

cardiac rhythm disturbances or trauma [6].

who are critically ill prior to cardiopulmonary collapse [7].

risk have been conceived, but they often lack validation [10].

to the lack of a reliable early warning system [12].

the treatment or bring the patient to an intensive care unit.

The British National Institute for Health and Clinical Excellence documented in the National Institute of Health and Clinical Excellence (NICE) 2007 guidelines [16] that physiological track and trigger systems should be used to monitor all adult patients and facilitate the recognition of patient deterioration. According to the scoring (low, medium, or high score group), a graded response strategy should be followed (**Figure 1**). A score is given to different

**Figure 1.** Example of a formalized decision process with graded response.

physiological measurements, which are often already routinely measured and recorded in hospitals. The magnitude of the score reflects how extreme the parameter deviates from the norm. The different scores are aggregated and uplifted for people requiring oxygen [17]. Depending on each calculated score, the algorithm provides a recommendation. At moderate scores, the frequency of subsequent clinical monitoring is increased to enable accelerated detection of deterioration. At higher scores, an increasingly urgent clinical assessment up to emergency intervention is triggered [17].

receive opioids [15]. The respiratory rate is elevated significantly above normal in a majority

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13

Hypertension can be a manifestation of cardiovascular disease or be a consequence of pain. Hypotension can be due to rhythm disturbance, CNS depression or naturally low blood pressure, or can reflect circulatory compromise such as sepsis, volume depletion, or cardiac failure. Hypotension is more indicative of acute illness than hypertension. Importantly, a change of systolic blood pressure was identified as an independent predictor of cardiac arrest [19],

This is quantified by alert-reaction to voice-reaction to pain-unresponsive (AVPU). This score is assessed in sequence and records only one outcome. Agitation also counts as an independent scoring point. Confusion is not part of the AVPU assessment, but recently developed confusion or worsening of confusion is a major concern and must trigger urgent clinical evaluation. Consciousness just failed statistical significance to predict cardiac arrest but was considered clinically significant, and therefore it was incorporated into the activation criteria [19]. Moreover, prior research had shown that 42% of the patients with cardiac arrest had

This is not always incorporated in the scores owing to the necessity for additional hardware. Pulse oximetry, however, is noninvasive and permits a rapid indication of oxygen levels but may be misleading due to false positive alarms. Pattern recognition of the waveform may improve the accuracy of these measurements [15]. Pulse oximetry cannot replace measurement of the respiratory rate [19], for which capnography is sometimes put forward as an

• The requirement of supplemental oxygen for patients, which includes routine oxygen delivery by mask or nasal cannula. If present, a weighting score of two should be added,

In a model reported in 2005, aiming to predict the need for intervention, all physiological components except temperature contributed significantly. Additionally, in the model predicting hospital outcome, all components except temperature and heart rate contributed [24]. Moreover, a higher number of events experienced by a patient were correlated with a higher

In addition to the components included in the National Early Warning Score of the UK (NEWS), several variables are known risk factors for patient deterioration. The mortality increases significantly with age, although including age in the model offers little practical benefit in this context [18, 23, 25]. The urine output is essential for some patients, but it is not

of patients with cardiac arrest [22] and is predictive of cardiac arrest [23].

although earlier reports had concluded the opposite [23].

• Temperature, as a measure of pyrexia or hypothermia

because patients are at greater clinical risk.

• Systolic blood pressure

• Level of consciousness

alterations in mental function [22].

• Oxygen saturation

risk of mortality [20].

alternative.

In the past, several scoring systems were proposed, where the weight allocated to each parameter defines the sensitivity of the final score to trigger a response. An expert working group reviewed the weightings used in a number of early warning score (EWS) systems such as the VitalPAC early warning score (ViEWS) [18] and made small adjustments based on the clinical opinion from the working group [17]. Different approaches can be proposed with divergent consideration and often conflicting priorities. In clinical practice, a scoring system needs to be integrated into daily practice and should, therefore, be user friendly and not too complex. Failure to meet this requirement will result in noncompliance and unreliable scoring. As such, the features of a system aiming for 100% sensitivity and specificity will differ from a convenient screening tool. The group also recommended a color-coded clinical chart to aid identification of abnormal clinical parameters.

#### **2.1. Different parameters**

Known statistically significant risk factors for cardiac arrest are as follows: abnormal respiratory rate, abnormal breathing, abnormal pulse, reduced systolic blood pressure, abnormal temperature, reduced pulse oximetry, chest pain, and nurse or doctor concern [19].

In addition, several clinical observations are significant predictors of mortality: decrease in Glasgow Coma score by two points, onset of coma, hypotension <90 mmHg, respiratory rate < 6/min, oxygen saturation < 90%, and bradycardia >30/min [20].

The National Institute for Health and Clinical Excellence (NICE) [16] and the National Early Warning Score (NEWS) Development and Implementation Group [17] recommended:

• Pulse rate

Tachycardia can reflect pyrexia, pain, general distress, cardiac arrhythmia, or circulatory compromise such as in sepsis, volume depletion, or cardiac failure. Bradycardia can be induced by medication, hypothermia, central nervous system (CNS) depression, heart block, and hypothyroidism.

• Respiratory rate

The respiratory rate is frequently the first parameter to change in the advent of clinical deterioration. Tachypnea can be induced by pain, distress, sepsis, CNS disturbance, and metabolic disturbance. Bradypnea can be due to CNS depression or narcosis [21]. Respiratory deterioration is one of the most common reasons for ICU admission. Early identification and treatment of these patients may, therefore, reduce ICU admission. Increased risk factors are chronic respiratory disease, sedation outside the operating room, and administration of patients who receive opioids [15]. The respiratory rate is elevated significantly above normal in a majority of patients with cardiac arrest [22] and is predictive of cardiac arrest [23].

• Systolic blood pressure

physiological measurements, which are often already routinely measured and recorded in hospitals. The magnitude of the score reflects how extreme the parameter deviates from the norm. The different scores are aggregated and uplifted for people requiring oxygen [17]. Depending on each calculated score, the algorithm provides a recommendation. At moderate scores, the frequency of subsequent clinical monitoring is increased to enable accelerated detection of deterioration. At higher scores, an increasingly urgent clinical assessment up to

In the past, several scoring systems were proposed, where the weight allocated to each parameter defines the sensitivity of the final score to trigger a response. An expert working group reviewed the weightings used in a number of early warning score (EWS) systems such as the VitalPAC early warning score (ViEWS) [18] and made small adjustments based on the clinical opinion from the working group [17]. Different approaches can be proposed with divergent consideration and often conflicting priorities. In clinical practice, a scoring system needs to be integrated into daily practice and should, therefore, be user friendly and not too complex. Failure to meet this requirement will result in noncompliance and unreliable scoring. As such, the features of a system aiming for 100% sensitivity and specificity will differ from a convenient screening tool. The group also recommended a color-coded clinical chart

Known statistically significant risk factors for cardiac arrest are as follows: abnormal respiratory rate, abnormal breathing, abnormal pulse, reduced systolic blood pressure, abnormal

In addition, several clinical observations are significant predictors of mortality: decrease in Glasgow Coma score by two points, onset of coma, hypotension <90 mmHg, respiratory

The National Institute for Health and Clinical Excellence (NICE) [16] and the National Early

Tachycardia can reflect pyrexia, pain, general distress, cardiac arrhythmia, or circulatory compromise such as in sepsis, volume depletion, or cardiac failure. Bradycardia can be induced by medication, hypothermia, central nervous system (CNS) depression, heart block, and

The respiratory rate is frequently the first parameter to change in the advent of clinical deterioration. Tachypnea can be induced by pain, distress, sepsis, CNS disturbance, and metabolic disturbance. Bradypnea can be due to CNS depression or narcosis [21]. Respiratory deterioration is one of the most common reasons for ICU admission. Early identification and treatment of these patients may, therefore, reduce ICU admission. Increased risk factors are chronic respiratory disease, sedation outside the operating room, and administration of patients who

Warning Score (NEWS) Development and Implementation Group [17] recommended:

temperature, reduced pulse oximetry, chest pain, and nurse or doctor concern [19].

rate < 6/min, oxygen saturation < 90%, and bradycardia >30/min [20].

emergency intervention is triggered [17].

12 Special Topics in Resuscitation

to aid identification of abnormal clinical parameters.

**2.1. Different parameters**

• Pulse rate

hypothyroidism. • Respiratory rate Hypertension can be a manifestation of cardiovascular disease or be a consequence of pain. Hypotension can be due to rhythm disturbance, CNS depression or naturally low blood pressure, or can reflect circulatory compromise such as sepsis, volume depletion, or cardiac failure. Hypotension is more indicative of acute illness than hypertension. Importantly, a change of systolic blood pressure was identified as an independent predictor of cardiac arrest [19], although earlier reports had concluded the opposite [23].

• Level of consciousness

This is quantified by alert-reaction to voice-reaction to pain-unresponsive (AVPU). This score is assessed in sequence and records only one outcome. Agitation also counts as an independent scoring point. Confusion is not part of the AVPU assessment, but recently developed confusion or worsening of confusion is a major concern and must trigger urgent clinical evaluation. Consciousness just failed statistical significance to predict cardiac arrest but was considered clinically significant, and therefore it was incorporated into the activation criteria [19]. Moreover, prior research had shown that 42% of the patients with cardiac arrest had alterations in mental function [22].

• Oxygen saturation

This is not always incorporated in the scores owing to the necessity for additional hardware. Pulse oximetry, however, is noninvasive and permits a rapid indication of oxygen levels but may be misleading due to false positive alarms. Pattern recognition of the waveform may improve the accuracy of these measurements [15]. Pulse oximetry cannot replace measurement of the respiratory rate [19], for which capnography is sometimes put forward as an alternative.

In a model reported in 2005, aiming to predict the need for intervention, all physiological components except temperature contributed significantly. Additionally, in the model predicting hospital outcome, all components except temperature and heart rate contributed [24]. Moreover, a higher number of events experienced by a patient were correlated with a higher risk of mortality [20].

In addition to the components included in the National Early Warning Score of the UK (NEWS), several variables are known risk factors for patient deterioration. The mortality increases significantly with age, although including age in the model offers little practical benefit in this context [18, 23, 25]. The urine output is essential for some patients, but it is not available at first assessment and is not routinely performed. It is recommended that it should only be assessed when clinically appropriate [16, 17]. Pain scores are included in the chart in NEWS but are not part of the aggregated scoring system.

While more time-consuming, an aggregate weighted scoring system is more sensitive than

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment…

http://dx.doi.org/10.5772/intechopen.79651

15

Clusters of hospitals often use the same scoring system. For instance, the patient-at-risk score (PARS) [24] is used in all hospitals of the Worcestershire Mental Help Partnership Trust. It facilitates patient and staff transfer between hospitals within the Trust. A particular purpose of nation-wide standardized systems, such as NEWS in the UK, is to avoid a lack of familiarity

Importantly, NEWS cannot be used in children, pregnant women, or patients with chronically disturbed physiology, for example, chronic obstructive pulmonary disease (COPD), for which alternative systems are needed [17]. Such specific scoring systems are proposed for patients with chronic respiratory disease (e.g., CREWS – S-NEWS [31], sequential sepsis-related organ failure assessment [qSOFA]), and systemic inflammatory response syndrome [SIRS]) or in patients with suspected sepsis [32]. Implementation of a proposed pediatric scoring system (Bedside PEWS) however did not result in reduced mortality [33]. A specific neonatal trigger

To optimize the effectiveness of the RRT, particularly in case of automated recordings, the informatics system of the hospital should provide an electronic dashboard showing all hospital patients in a single view, ranked by EWS score and updated in real time. This permits immediate notification of deviant scores and swift intervention. Such a display also allows the RRT to take a proactive approach to see patients, monitor patients and review patients at risk, rather than relying exclusively on bedside nurses to activate the RRT. Until further research, the clinical benefit of an electronic dashboard remains unproven [35]. Nevertheless, it has a very promising advantage that it permits an active search for the patients who are the most at risk in the hospital. This allows the RRT to visit and eventually treat the patients in the ward proactively. In addition, the electronic dashboard can also be considered an approach to

Of particular importance for optimal performance is the managerial endorsement that the EWS assessments and consequential RRT interventions are a hospital-wide standard-of-care protocol. As such, all measurements are standardized nursing measures for which no permission or instruction of the physician is required. Only individualized opting-out is possible, but this must be prescribed for each individual patient as a written medical order if deemed

In patients with a do not resuscitate (DNR) code higher than 3, the RRT will not be mobilized. Still, also when the RRT is mobilized, they will consider the DNR code in further patient

single parameter systems and therefore promoted in most guidelines [29].

score (Neonati), however, showed better than PEWS [34].

**2.3. Specific EWS systems**

with local systems.

**2.4. Hospital informatics**

reduce alert fatigue in the RRT.

suitable.

**2.6. DNR registration**

**2.5. EWS scoring as standard-of-care**

Gender, ethnicity, and obesity alter several values, but this is not considered in most scoring systems. Likewise, during pregnancy, most parameters are modified. Conventional EWS triggers are therefore inapplicable in patients who are pregnant [17]. Several variables and comorbidities are for now not included in the EWS but may improve the model upon improved modeling. Abdominal pain, for instance, is not considered statistically significant in general but may be relevant in specific subpopulations [19]. Likewise, immunosuppression or other conditions may require disease-specific scoring systems. In addition, the inclusion of routine laboratory tests does not add sufficient consistency to be included in current EWS models [22], but advances in hospital informatics may change this in the future.

#### **2.2. Scoring algorithms**

The modified early warning score [26] prescribes a minimum frequency of monitoring of 12 h unless a decision has been made at a senior level to increase or decrease this frequency for an adult patient [17, 27]. If abnormal values are detected, the frequency of monitoring should increase [16]. The threshold should regularly be reviewed to optimize sensitivity and specificity [16]. Several strategies were explored to trigger the response [16]:

• Single-parameter system:

This consists of periodic observations of selected vital signs that are compared with a simple set of criteria with predefined thresholds, with a response algorithm being activated when any of the criteria are met [20, 28]. Advantages of such a system are its ease of use and reproducibility. A significant disadvantage is that it permits only limited grade response strategy, and has low sensitivity, resulting in a lot of false negatives.

• Multiparameter system

This response algorithm requires more than one criterion to be met, or the response differs according to the number of criteria met [9, 24]. This strategy allows monitoring and graded response strategy and has a higher sensitivity [29] but is expensive—owing to increased clinical contact time and additional equipment—and has low specificity when only one abnormal observation is present.

• Aggregate scoring system

Weighted scores are assigned to physiological values and compared with predefined trigger thresholds [19, 26, 30]. Since this permits simple monitoring and a graded response strategy, it is widely used. It is however also expensive and is prone to human errors. The specificity and sensitivity depend on the used cut-off value.

• Combination system:

This strategy is defined as multiple parameter systems used in combination with aggregate weighted scoring systems.

While more time-consuming, an aggregate weighted scoring system is more sensitive than single parameter systems and therefore promoted in most guidelines [29].

#### **2.3. Specific EWS systems**

available at first assessment and is not routinely performed. It is recommended that it should only be assessed when clinically appropriate [16, 17]. Pain scores are included in the chart in

Gender, ethnicity, and obesity alter several values, but this is not considered in most scoring systems. Likewise, during pregnancy, most parameters are modified. Conventional EWS triggers are therefore inapplicable in patients who are pregnant [17]. Several variables and comorbidities are for now not included in the EWS but may improve the model upon improved modeling. Abdominal pain, for instance, is not considered statistically significant in general but may be relevant in specific subpopulations [19]. Likewise, immunosuppression or other conditions may require disease-specific scoring systems. In addition, the inclusion of routine laboratory tests does not add sufficient consistency to be included in current EWS

The modified early warning score [26] prescribes a minimum frequency of monitoring of 12 h unless a decision has been made at a senior level to increase or decrease this frequency for an adult patient [17, 27]. If abnormal values are detected, the frequency of monitoring should increase [16]. The threshold should regularly be reviewed to optimize sensitivity and specific-

This consists of periodic observations of selected vital signs that are compared with a simple set of criteria with predefined thresholds, with a response algorithm being activated when any of the criteria are met [20, 28]. Advantages of such a system are its ease of use and reproducibility. A significant disadvantage is that it permits only limited grade response

This response algorithm requires more than one criterion to be met, or the response differs according to the number of criteria met [9, 24]. This strategy allows monitoring and graded response strategy and has a higher sensitivity [29] but is expensive—owing to increased clinical contact time and additional equipment—and has low specificity when only one

Weighted scores are assigned to physiological values and compared with predefined trigger thresholds [19, 26, 30]. Since this permits simple monitoring and a graded response strategy, it is widely used. It is however also expensive and is prone to human errors. The

This strategy is defined as multiple parameter systems used in combination with aggregate

models [22], but advances in hospital informatics may change this in the future.

ity [16]. Several strategies were explored to trigger the response [16]:

strategy, and has low sensitivity, resulting in a lot of false negatives.

specificity and sensitivity depend on the used cut-off value.

NEWS but are not part of the aggregated scoring system.

**2.2. Scoring algorithms**

14 Special Topics in Resuscitation

• Single-parameter system:

• Multiparameter system

• Aggregate scoring system

• Combination system:

weighted scoring systems.

abnormal observation is present.

Clusters of hospitals often use the same scoring system. For instance, the patient-at-risk score (PARS) [24] is used in all hospitals of the Worcestershire Mental Help Partnership Trust. It facilitates patient and staff transfer between hospitals within the Trust. A particular purpose of nation-wide standardized systems, such as NEWS in the UK, is to avoid a lack of familiarity with local systems.

Importantly, NEWS cannot be used in children, pregnant women, or patients with chronically disturbed physiology, for example, chronic obstructive pulmonary disease (COPD), for which alternative systems are needed [17]. Such specific scoring systems are proposed for patients with chronic respiratory disease (e.g., CREWS – S-NEWS [31], sequential sepsis-related organ failure assessment [qSOFA]), and systemic inflammatory response syndrome [SIRS]) or in patients with suspected sepsis [32]. Implementation of a proposed pediatric scoring system (Bedside PEWS) however did not result in reduced mortality [33]. A specific neonatal trigger score (Neonati), however, showed better than PEWS [34].

#### **2.4. Hospital informatics**

To optimize the effectiveness of the RRT, particularly in case of automated recordings, the informatics system of the hospital should provide an electronic dashboard showing all hospital patients in a single view, ranked by EWS score and updated in real time. This permits immediate notification of deviant scores and swift intervention. Such a display also allows the RRT to take a proactive approach to see patients, monitor patients and review patients at risk, rather than relying exclusively on bedside nurses to activate the RRT. Until further research, the clinical benefit of an electronic dashboard remains unproven [35]. Nevertheless, it has a very promising advantage that it permits an active search for the patients who are the most at risk in the hospital. This allows the RRT to visit and eventually treat the patients in the ward proactively. In addition, the electronic dashboard can also be considered an approach to reduce alert fatigue in the RRT.

#### **2.5. EWS scoring as standard-of-care**

Of particular importance for optimal performance is the managerial endorsement that the EWS assessments and consequential RRT interventions are a hospital-wide standard-of-care protocol. As such, all measurements are standardized nursing measures for which no permission or instruction of the physician is required. Only individualized opting-out is possible, but this must be prescribed for each individual patient as a written medical order if deemed suitable.

#### **2.6. DNR registration**

In patients with a do not resuscitate (DNR) code higher than 3, the RRT will not be mobilized. Still, also when the RRT is mobilized, they will consider the DNR code in further patient management. The awareness of the importance of the DNR code on the RRT interventions will often also result in its more correct and timely registration. The subsequently improved decision-making regarding patient suitability for DNR orders can be one of the explanations of reduced incidence of resuscitations in several reports [29].

present which evaluate the effect of the resuscitationist on the outcome of the patient population [44]. Since these physicians are specialized in resuscitation, trauma, and critically ill and

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment…

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17

Similar to other physicians, both the acute care physician and hospitalist can bring valuable knowledge to the RRT but are often not able to prioritize RRT calls due to additional tasks and a usually high workload. In practice, a specialized nurse-driven team is therefore often necessary to guarantee an immediate RRT response, while close communication and cooperation

Because of the significant financial cost of a 24/7 operational RRT, while the team is not performing interventions most of the time, they are often attributed other responsibilities within the hospital. It is however imperative that absolute priority is given to the necessary monitoring and interventions to preserve its full effect. When the RRT is not operational 100% of the time, there exists a significant risk that during the absence of the trained RRT, its responsibilities are passed back on the most inexperienced members of the clinical team [29]. Following the NEWS guidelines, the RRT should be free of other clinical responsibilities and available 24/7 [17].

In addition to the implementation of the EWS and RRT, a strong and sustained educational component is of vital importance toward both reducing cardiac arrests and improving decision-making [29]. Recent studies have shown that for an RRT to be successful, it must be implemented with a continuing medical education program [45]. A nurse-driven approach often lowers the threshold for effective communication, improving the educational effect on the nursing staff, ultimately leading to more accurate detection of patient deterioration.

The impact of EWS-RRT implementation has been extensively described and resumed in a comprehensive review [29]. Beneficial effects have been shown for specific outcomes, but a comparison is difficult owing to heterogeneities, including but not limited to study design, team composition, duration, RRT area, and nomenclature [38]. As such, standardized reporting is needed to enable comparative analysis [46]. Decreases have been reported in the incidence of cardiac arrest [47–50] and in cardiac arrest mortality [49, 51]. A reported decrease in in-hospital mortality of 1580 lives in the study population would extrapolate to over 100,000

The economic implications of an implementation are difficult to measure [11], as the cost of the monitoring outreach team and additional costs at ward level, the use of equipment, and clinical contact time must be compared to the reduction in ICU admissions/readmissions [16].

emergency patients [44] they might have essential skills to participate in the RRT.

with specialized physicians are expected to improve the decision-making process.

**3.3. Organization of 24/7 availability**

**3.4. Educational component**

**4. Impact of EWS-RRT implementation**

lives saved in Western Europe [50, 52].

#### **3. The rapid response team**

#### **3.1. Organization of the response**

After reliable identification of patients at risk, the efferent component of the system must be initiated as fast as possible. The first report about the institution of RRTs is dated from 1995 [36]. Initially, in-hospital interventions were also assigned to the regular medical emergency team, but soon specific teams were "tailored to the specific population it serves" [29].

Likewise, the decision to mobilize the RRT was initially left to the personal assessment of the nurse, but in subsequent improvements, the decision-making process was increasingly formalized. An example of such a formalized decision process is shown in **Figure 1**.

#### **3.2. Composition of the team**

The composition of the current teams varies between different countries and care systems [8, 29]. Of utmost importance, effective inter-professional communication between and among nurses and doctors is essential for an adequate response [37]. There is still discussion about whether a physician should be part of the RRT, and a meta-analysis did not identify the presence of a physician to be significantly associated with mortality reduction [38]. In addition, the effect of the presence of a physician might be different in university hospitals versus community hospitals, and the response to deterioration might be most effective when a clinician leads it [29]. A recent comprehensive review concluded that there is evidence that RRTs are effective in reducing readmission to ICU (2+) and in reducing hospital mortality (2+) [29].

Hospitalist physicians have been integrated on the general wards in US hospitals since 1996 [39] and might be useful members of the rapid response team. These hospitalists are mostly specialized in general internal medicine and have a coordinating function with a focus on the general medical care of hospitalized patients [40]. Not only are they an important information pool for patients, family members, nurses, and consultants, they also can assign additional diagnostic and therapeutic activities in case of urgent situations [40]. A positive effect of the introduction of hospitalists on the patients' average length of hospital stay and total hospital costs has already been demonstrated [39] but seems to be dependent on the hospitalist workload [41]. Including a hospital physician in the rapid response team can immediately increase the knowledge of a specific patient and decrease the code call rate. However, it does not seem to affect the general hospital mortality rate [42].

Recently, it is believed that there is a need for an acute care physician or so-called resuscitationist who cooperates with specialized trauma surgeons [43]. Currently, there is no data present which evaluate the effect of the resuscitationist on the outcome of the patient population [44]. Since these physicians are specialized in resuscitation, trauma, and critically ill and emergency patients [44] they might have essential skills to participate in the RRT.

Similar to other physicians, both the acute care physician and hospitalist can bring valuable knowledge to the RRT but are often not able to prioritize RRT calls due to additional tasks and a usually high workload. In practice, a specialized nurse-driven team is therefore often necessary to guarantee an immediate RRT response, while close communication and cooperation with specialized physicians are expected to improve the decision-making process.

#### **3.3. Organization of 24/7 availability**

management. The awareness of the importance of the DNR code on the RRT interventions will often also result in its more correct and timely registration. The subsequently improved decision-making regarding patient suitability for DNR orders can be one of the explanations

After reliable identification of patients at risk, the efferent component of the system must be initiated as fast as possible. The first report about the institution of RRTs is dated from 1995 [36]. Initially, in-hospital interventions were also assigned to the regular medical emergency

Likewise, the decision to mobilize the RRT was initially left to the personal assessment of the nurse, but in subsequent improvements, the decision-making process was increasingly

The composition of the current teams varies between different countries and care systems [8, 29]. Of utmost importance, effective inter-professional communication between and among nurses and doctors is essential for an adequate response [37]. There is still discussion about whether a physician should be part of the RRT, and a meta-analysis did not identify the presence of a physician to be significantly associated with mortality reduction [38]. In addition, the effect of the presence of a physician might be different in university hospitals versus community hospitals, and the response to deterioration might be most effective when a clinician leads it [29]. A recent comprehensive review concluded that there is evidence that RRTs are effective

Hospitalist physicians have been integrated on the general wards in US hospitals since 1996 [39] and might be useful members of the rapid response team. These hospitalists are mostly specialized in general internal medicine and have a coordinating function with a focus on the general medical care of hospitalized patients [40]. Not only are they an important information pool for patients, family members, nurses, and consultants, they also can assign additional diagnostic and therapeutic activities in case of urgent situations [40]. A positive effect of the introduction of hospitalists on the patients' average length of hospital stay and total hospital costs has already been demonstrated [39] but seems to be dependent on the hospitalist workload [41]. Including a hospital physician in the rapid response team can immediately increase the knowledge of a specific patient and decrease the code call rate. However, it does not seem

Recently, it is believed that there is a need for an acute care physician or so-called resuscitationist who cooperates with specialized trauma surgeons [43]. Currently, there is no data

team, but soon specific teams were "tailored to the specific population it serves" [29].

formalized. An example of such a formalized decision process is shown in **Figure 1**.

in reducing readmission to ICU (2+) and in reducing hospital mortality (2+) [29].

of reduced incidence of resuscitations in several reports [29].

**3. The rapid response team**

16 Special Topics in Resuscitation

**3.1. Organization of the response**

**3.2. Composition of the team**

to affect the general hospital mortality rate [42].

Because of the significant financial cost of a 24/7 operational RRT, while the team is not performing interventions most of the time, they are often attributed other responsibilities within the hospital. It is however imperative that absolute priority is given to the necessary monitoring and interventions to preserve its full effect. When the RRT is not operational 100% of the time, there exists a significant risk that during the absence of the trained RRT, its responsibilities are passed back on the most inexperienced members of the clinical team [29]. Following the NEWS guidelines, the RRT should be free of other clinical responsibilities and available 24/7 [17].

#### **3.4. Educational component**

In addition to the implementation of the EWS and RRT, a strong and sustained educational component is of vital importance toward both reducing cardiac arrests and improving decision-making [29]. Recent studies have shown that for an RRT to be successful, it must be implemented with a continuing medical education program [45]. A nurse-driven approach often lowers the threshold for effective communication, improving the educational effect on the nursing staff, ultimately leading to more accurate detection of patient deterioration.

#### **4. Impact of EWS-RRT implementation**

The impact of EWS-RRT implementation has been extensively described and resumed in a comprehensive review [29]. Beneficial effects have been shown for specific outcomes, but a comparison is difficult owing to heterogeneities, including but not limited to study design, team composition, duration, RRT area, and nomenclature [38]. As such, standardized reporting is needed to enable comparative analysis [46]. Decreases have been reported in the incidence of cardiac arrest [47–50] and in cardiac arrest mortality [49, 51]. A reported decrease in in-hospital mortality of 1580 lives in the study population would extrapolate to over 100,000 lives saved in Western Europe [50, 52].

The economic implications of an implementation are difficult to measure [11], as the cost of the monitoring outreach team and additional costs at ward level, the use of equipment, and clinical contact time must be compared to the reduction in ICU admissions/readmissions [16].

An unexpected additional advantage may be a more accurate registration of the DNR code [50]. As the RRT improves the quality of care via early identification/reversal of physiological decompensation, this may lead to a more timely activation of palliative therapies and as such enhanced end-of-life care [53].

**References**

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10.1093/qjmed/94.10.507

DOI: 10.1093/bja/aeh113

DOI: 10.1016/j.resuscitation.2007.12.004

237-245. DOI: 10.1007/s00134-006-0326-z

2017;**10**(2):e003194. DOI: 10.1161/circoutcomes.116.003194

America. 2012;**30**(1):25-34. DOI: 10.1016/j.emc.2011.09.005

2004;**62**(3):275-282. DOI: 10.1016/j.resuscitation.2004.05.016

[1] Lewis C. 5 Million lives campaign. Journal of Vascular Nursing. 2007;**25**(3):57. DOI: 10.

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment…

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19

[2] Nolan JP, Soar J, Smith GB, Gwinnutt C, Parrot F, Power S, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.

[3] Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: Incidence, prognosis and possible measures to improve survival. Intensive Care Medicine. 2007;**33**(2):

[4] Mallikethi-Reddy S, Briasoulis A, Akintoye E, Jagadeesh K, Brook RD, Rubenfire M, et al. Incidence and survival after in-hospital cardiopulmonary resuscitation in noneldery adults: US experience, 2007 to 2012. Circulation: Cardiovascular Quality and Outcomes.

[5] Kolte D, Khera S, Aronow WS, Palaniswamy C, Mujib M, Ahn C, et al. Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States.

[6] Monteleone PP, Lin CM. In-hospital cardiac arrest. Emergency Medicine Clinics of North

[7] Goldhill DR. The critically ill: following your MEWS. QJM. 2001;**94**(10):507-510. DOI:

[8] Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom – The ACADEMIA study. Resuscitation.

[9] Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult inpatients. British Journal of Anaesthesia. 2004;**92**(6):882-884.

[10] Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Review and performance evaluation of aggregate weighted 'track and trigger' systems. Resuscitation. 2008;**77**(2):170-179.

[11] Murphy A, Cronin J, Whelan R, Drummond FJ, Savage E, Hegarty J. Economics of early warning scores for identifying clinical deterioration – A systematic review. Irish Journal

[12] Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. MERIT study investigators. Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet. 2005;**365**(9477):2091-2097. DOI: 10.1016/s0140-6736(05)66733-5

of Medical Science. 2018;**187**(1):193-205. DOI: 10.1007/s11845-017-1631-y

Circulation. 2015;**131**(16):1415-1425. DOI: 10.1161/circulationaha.114.014542

Resuscitation. 2014;**85**(8):987-992. DOI: 10.1016/j.resuscitation.2014.04.002

#### **5. Pitfalls during the implementation**

The response of the RRT may suffer from excessive false alerts, making the team desensitized, leading to alarm fatigue [15, 38, 54]. This underlines the necessity of a scoring system with sufficient specificity, such as an aggregate score like EWS.

Manual registration of some variables, such as the respiratory rate, might incite the recording of inaccurate values to limit subsequent burden. Moreover, it is generally recommended that the respiratory rate be counted over a whole minute or two 30 s intervals, and this procedure can represent a significant investment in nursing time in the ward setting, such that accurate rates may only be recorded as little as 37% of the time [15]. The respiratory rate is therefore often particularly poorly recorded, although it may be the most important early manifestation of critical illness [7, 21]. The long-term effectiveness of the program may also decrease in the absence of periodic training and therefore requires continued educational investment [51].

#### **6. Conclusions**

The prevention of in-hospital resuscitations requires a "whole system" approach, consisting of a reliable EWS, combined with an effective RRT, sustained feedback, and focused education. In addition to the implementation of the dedicated systems and teams, its effectiveness necessitates a changing culture of the whole organization.

#### **Conflict of interest**

No conflicts of interest.

#### **Author details**

Alain Kalmar\*, Nicky Van Der Vekens, Henk Vanoverschelde, Diederik Van Sassenbroeck, Jan Heerman and Tom Verbeke

\*Address all correspondence to<EMAIL_ADDRESS>
Department of Anesthesia and Critical Care Medicine, Maria Middelares Hospital, Ghent, Belgium

#### **References**

An unexpected additional advantage may be a more accurate registration of the DNR code [50]. As the RRT improves the quality of care via early identification/reversal of physiological decompensation, this may lead to a more timely activation of palliative therapies and as such

The response of the RRT may suffer from excessive false alerts, making the team desensitized, leading to alarm fatigue [15, 38, 54]. This underlines the necessity of a scoring system with

Manual registration of some variables, such as the respiratory rate, might incite the recording of inaccurate values to limit subsequent burden. Moreover, it is generally recommended that the respiratory rate be counted over a whole minute or two 30 s intervals, and this procedure can represent a significant investment in nursing time in the ward setting, such that accurate rates may only be recorded as little as 37% of the time [15]. The respiratory rate is therefore often particularly poorly recorded, although it may be the most important early manifestation of critical illness [7, 21]. The long-term effectiveness of the program may also decrease in the absence of periodic training and therefore requires continued educational investment [51].

The prevention of in-hospital resuscitations requires a "whole system" approach, consisting of a reliable EWS, combined with an effective RRT, sustained feedback, and focused education. In addition to the implementation of the dedicated systems and teams, its effectiveness

Alain Kalmar\*, Nicky Van Der Vekens, Henk Vanoverschelde, Diederik Van Sassenbroeck,

Department of Anesthesia and Critical Care Medicine, Maria Middelares Hospital, Ghent,

enhanced end-of-life care [53].

18 Special Topics in Resuscitation

**6. Conclusions**

**Conflict of interest**

No conflicts of interest.

Jan Heerman and Tom Verbeke

**Author details**

Belgium

**5. Pitfalls during the implementation**

sufficient specificity, such as an aggregate score like EWS.

necessitates a changing culture of the whole organization.

\*Address all correspondence to<EMAIL_ADDRESS>

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22 Special Topics in Resuscitation

2009.09.026

**Chapter 3**

Provisional chapter

**Resuscitation of Term Infants in the Delivery Room**

DOI: 10.5772/intechopen.79394

The majority of newborn infants make the transition from fetal-to-neonatal live without help. However, around 20% of newborn infants fail to initiate breathing at birth. In these cases, the clinical team has to provide respiratory support, which remains the cornerstone of neonatal resuscitation. This chapter will discuss respiratory support during neonatal resuscitation in both term and preterm infants. The chapter will discuss the respiratory fetal-to-neonatal transition, use of oxygen, mask ventilation and their pitfalls, the application of sustained inflation, positive end expiratory pressure, continuous positive airway pressures, and whether extremely low birth weight infants should be intubated immedi-

Before birth, the fetus uses the placenta for gas exchange; however, immediately after birth, the infants has to clear lung liquid fluid and replace it with air, start spontaneous breathing, establish a functional residual capacity (FRC) in order to achieve gas exchange [1–3]. Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after PPV, 2% will be intubated to support respiratory function, and 0.1% will require CC and/or epinephrine to achieve this transition [4–6]. When newborns fail to initiate spontaneous breathing, the International Liaison Committee on Resuscitation (ILCOR) recommend several steps to support the transition of newborn infants [4–6]. The initial steps of stabilization algorithm include providing warmth to maintain a normal body temperature by drying the infant, clearing any secretion if needed by using suction, and stimulating the infant to initiate breathing [4–6]. If these steps are unsuccessful, the clinical

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Resuscitation of Term Infants in the Delivery Room

Francesca Viaroli and Georg M. Schmölzer

Francesca Viaroli and Georg M. Schmölzer

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

ately after birth or supported noninvasively.

Keywords: delivery room, resuscitation, newborn, infants

http://dx.doi.org/10.5772/intechopen.79394

Abstract

1. Introduction

#### **Resuscitation of Term Infants in the Delivery Room** Resuscitation of Term Infants in the Delivery Room

DOI: 10.5772/intechopen.79394

Francesca Viaroli and Georg M. Schmölzer Francesca Viaroli and Georg M. Schmölzer

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79394

#### Abstract

The majority of newborn infants make the transition from fetal-to-neonatal live without help. However, around 20% of newborn infants fail to initiate breathing at birth. In these cases, the clinical team has to provide respiratory support, which remains the cornerstone of neonatal resuscitation. This chapter will discuss respiratory support during neonatal resuscitation in both term and preterm infants. The chapter will discuss the respiratory fetal-to-neonatal transition, use of oxygen, mask ventilation and their pitfalls, the application of sustained inflation, positive end expiratory pressure, continuous positive airway pressures, and whether extremely low birth weight infants should be intubated immediately after birth or supported noninvasively.

Keywords: delivery room, resuscitation, newborn, infants

#### 1. Introduction

Before birth, the fetus uses the placenta for gas exchange; however, immediately after birth, the infants has to clear lung liquid fluid and replace it with air, start spontaneous breathing, establish a functional residual capacity (FRC) in order to achieve gas exchange [1–3]. Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after PPV, 2% will be intubated to support respiratory function, and 0.1% will require CC and/or epinephrine to achieve this transition [4–6]. When newborns fail to initiate spontaneous breathing, the International Liaison Committee on Resuscitation (ILCOR) recommend several steps to support the transition of newborn infants [4–6]. The initial steps of stabilization algorithm include providing warmth to maintain a normal body temperature by drying the infant, clearing any secretion if needed by using suction, and stimulating the infant to initiate breathing [4–6]. If these steps are unsuccessful, the clinical

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

team must initiate mask positive pressure ventilation (PPV) using a face mask and a ventilation device [4–6]. Adequate ventilation is the cornerstone of successful neonatal resuscitation; therefore, it is mandatory that anybody involved in neonatal resuscitation is trained in mask ventilation techniques [4–6]. In the rare cases (0.1% in term infants) where mask PPV is unsuccessful, more extensive resuscitation measures (chest compression (CC) and epinephrine) are needed (Figure 1) [4–6]. This chapter will discuss these various steps during stabilization/

Resuscitation of Term Infants in the Delivery Room http://dx.doi.org/10.5772/intechopen.79394 27

The initial steps of newborn stabilization/resuscitation are to maintain normal temperature of the infant, position the infant in a "sniffing" position to open the airway, clear secretions if needed with a bulb syringe or suction catheter, dry the infant, and stimulate the infant [4–6]. Most newborn infants are breathing or crying and have good tone immediately after birth [7, 8]. However, they must be dried and kept warm to avoid hypothermia, which can happen while the baby is lying on the mother's chest to avoid separation of mother and baby [4–6]. Maintaining normal temperature after birth is crucial due to a dose-dependent increase in mortality for temperatures <36.5C [9]. Simple interventions (e.g., skin-to-skin contact or kangaroo mother care, plastic wrap, radiant warmer, thermal mattress, or warmed humidified resuscitation gases) to prevent hypothermia during transition (birth until 1 to 2 hours of life) can reduce mortality [4– 6, 10, 11]. Maternal hyperthermia in labor is associated with adverse neonatal effects including increased mortality, neonatal seizures, and adverse neurologic states like encephalopathy [4–6]. Similarly, neonatal hyperthermia >38.0C should be avoided due to the potential associated risks

Suctioning immediately after birth, whether with a bulb syringe or suction catheter, should only be done if the airway appears obstructed or if PPV is required [4–6]. Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia due to suctioning of the nasopharynx [4–6]. The presence of meconium-stained amniotic fluid may indicate fetal distress and increases the risk that the infant will require resuscitation after birth; therefore, a team that includes an individual skilled in tracheal intubation should be present at the time of birth [4–6]. Any infant who is vigorous with good respiratory effort and muscle tone may stay with their mother to receive the initial steps of newborn care [4–6]. Any infant presenting with poor muscle tone and inadequate breathing efforts after being born through meconium-stained amniotic fluid should receive the initial steps of resuscitation under a radiant warmer [4–6]. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed [4–6]. Routine intubation for tracheal suction in this setting is not suggested, because

Tactile stimulation including warming, drying, and rubbing the back or the soles of the feet is recommended in the current ILCOR guidelines [4–6]. Tactile stimulation is the first step to stimulate spontaneous breathing in newborn infants [4–6]. Retrospective studies reported a large variability in the use of tactile stimulation during the stabilization of infants at birth [12].

there is insufficient evidence to continue recommending this practice [4–6].

2. Initial steps of stabilization (drying, suction, and stimulation)

resuscitation of term infants in the delivery room (DR).

[4–6].

Figure 1. NRP algorithm.

team must initiate mask positive pressure ventilation (PPV) using a face mask and a ventilation device [4–6]. Adequate ventilation is the cornerstone of successful neonatal resuscitation; therefore, it is mandatory that anybody involved in neonatal resuscitation is trained in mask ventilation techniques [4–6]. In the rare cases (0.1% in term infants) where mask PPV is unsuccessful, more extensive resuscitation measures (chest compression (CC) and epinephrine) are needed (Figure 1) [4–6]. This chapter will discuss these various steps during stabilization/ resuscitation of term infants in the delivery room (DR).

#### 2. Initial steps of stabilization (drying, suction, and stimulation)

The initial steps of newborn stabilization/resuscitation are to maintain normal temperature of the infant, position the infant in a "sniffing" position to open the airway, clear secretions if needed with a bulb syringe or suction catheter, dry the infant, and stimulate the infant [4–6]. Most newborn infants are breathing or crying and have good tone immediately after birth [7, 8]. However, they must be dried and kept warm to avoid hypothermia, which can happen while the baby is lying on the mother's chest to avoid separation of mother and baby [4–6]. Maintaining normal temperature after birth is crucial due to a dose-dependent increase in mortality for temperatures <36.5C [9]. Simple interventions (e.g., skin-to-skin contact or kangaroo mother care, plastic wrap, radiant warmer, thermal mattress, or warmed humidified resuscitation gases) to prevent hypothermia during transition (birth until 1 to 2 hours of life) can reduce mortality [4– 6, 10, 11]. Maternal hyperthermia in labor is associated with adverse neonatal effects including increased mortality, neonatal seizures, and adverse neurologic states like encephalopathy [4–6]. Similarly, neonatal hyperthermia >38.0C should be avoided due to the potential associated risks [4–6].

Suctioning immediately after birth, whether with a bulb syringe or suction catheter, should only be done if the airway appears obstructed or if PPV is required [4–6]. Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia due to suctioning of the nasopharynx [4–6]. The presence of meconium-stained amniotic fluid may indicate fetal distress and increases the risk that the infant will require resuscitation after birth; therefore, a team that includes an individual skilled in tracheal intubation should be present at the time of birth [4–6]. Any infant who is vigorous with good respiratory effort and muscle tone may stay with their mother to receive the initial steps of newborn care [4–6]. Any infant presenting with poor muscle tone and inadequate breathing efforts after being born through meconium-stained amniotic fluid should receive the initial steps of resuscitation under a radiant warmer [4–6]. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed [4–6]. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice [4–6].

Tactile stimulation including warming, drying, and rubbing the back or the soles of the feet is recommended in the current ILCOR guidelines [4–6]. Tactile stimulation is the first step to stimulate spontaneous breathing in newborn infants [4–6]. Retrospective studies reported a large variability in the use of tactile stimulation during the stabilization of infants at birth [12].

Figure 1. NRP algorithm.

26 Special Topics in Resuscitation

Furthermore, a recent randomized trial reported an increase in respiratory effort during repetitive stimulation compared to standard tactile stimulation with less oxygen requirements during transport to the NICU [13]. However, it did not reach significance, and further studies are needed.

PEEP and cannot deliver CPAP [32–37]. A flow-inflating bag provides variable and operator dependent PEEP [16, 38]. With a T-piece device more consistent, predetermined levels of PEEP and PIP can be delivered [34, 35]. In addition, a T-piece device has been shown to be the most

Resuscitation of Term Infants in the Delivery Room http://dx.doi.org/10.5772/intechopen.79394 29

Effective and consistent PPV is important to facilitate lung aeration, establishment of a functional residual capacity, and gas exchange, which should occur in a predictable manner so that the clinician can avoid under- or over-inflating the lungs [2, 42–44]. However, PPV is often complicated by mask leak or airway obstruction [23–29]. Currently, clinicians can either use a face mask or a nasal prong during mask PPV [4–6]; however, face mask ventilation remains the primary mode of resuscitation. There are a variety of face masks available to provide PPV [25, 45, 46]. The Fisher & Paykel (F&P) (Fisher & Paykel Healthcare, Auckland, New Zealand) and the Laerdal round masks are the most commonly used commercially available products [47–52]. Although, face masks for preterm infants <33 weeks' do not adequately fit their face [53], the only study comparing F&P vs. Laerdal masks reported no difference in mask leak during PPV in the DR in preterm infants <33 weeks' [25]. Similarly, two studies compared face masks to nasal prongs in the DR and reported no difference in intubation in the delivery room [45, 46]. These data suggest that either face mask or nasal prong could be used for PPV in the DR and the focus should rather

Archie Brain, a British anesthetist, described the laryngeal mask airway (LMA) as an alternative to endotracheal intubation in 1981 [54]. A LMA consists of an airway tube connected distally to a soft elliptical mask with an inflatable rim to fit over the laryngeal inlet, whereas the proximal end connects to the ventilation device [54]. LMAs are routinely used in emergency and operating rooms for adult and pediatric anesthesia and ambulance services [55, 56]. In newborn infants, there is increasing evidence from randomized trials [57, 58], suggesting that a LMA can provide an effective rescue airway during resuscitation if both mask ventilation and endotracheal intubation have been unsuccessful. Current neonatal resuscitation guidelines recommend the use of LMA in infants >34 weeks' gestation or > 2000 g birth weight. Furthermore, LMA have been described during neonatal transport [59–61], provision of prolonged mechanical ventilation in particular for infants with upper airway abnormalities [62–64], and surfactant and epinephrine administration [65–69]. Although LMAs are recommended by various neonatal resuscitation guidelines, they are not routinely used during

accurate device for delivering a sustained inflation [35, 39–41].

be on delivery of an adequate tidal volume to achieve lung aeration.

5. Interfaces

5.2. Laryngeal mask

neonatal resuscitation [4–6].

5.1. Face mask and nasal prongs

#### 2.1. Oxygen delivery during stabilization/resuscitation

The fetal oxygen saturation before birth is between 40 and 60% [14], which increases in uncompromised term infants within the first 10 minutes following birth to levels between 90 and 100% [15], thus resulting in the appearance of cyanosis during that time [16]. In addition, clinical assessment of skin color or the lack of cyanosis is a very poor indicator of oxygen saturation during that period [16–19]. The optimal management of oxygen during neonatal resuscitation becomes particularly important because of the evidence that either insufficient or excessive oxygenation can be harmful to the term infant with hypoxia and ischemia are known to result in injury to multiple organs and hyperoxia causing increased mortality [16, 20, 21]. Therefore, infants >35 weeks' gestation should be resuscitated in 21% oxygen and oxygen should be increased only if heart rate does not increase despite adequate ventilation.

#### 3. Mask ventilation

Approximately, 10% of newborns require respiratory support at birth [22]. ILCOR and various national guidelines recommend techniques and equipment for neonatal resuscitation [4–6]. They all agree that mask ventilation is the cornerstone of respiratory support immediately after birth [4–6]. The purpose of PPV is to establish FRC, deliver an adequate VT to facilitate gas exchange, and stimulate breathing while minimizing lung injury [2]. Several factors can reduce the effectiveness of mask ventilation, including poor face mask technique resulting in leak or airway obstruction, spontaneous movements of the baby, movements by or distraction of the resuscitator, and procedures such as changing the wraps or fitting a hat [23, 24]. Delivery room studies have shown that mask PPV is difficult, and mask leak and airway obstruction are common [23– 29]. Both leak and obstruction are usually unrecognized unless expired CO2 detectors or respiratory function monitors (RFM) are used [23–29]. In addition, airway maneuvers (e.g., jaw thrust or chin lift) to maintain airway patency is a crucial step during mask PPV [30].

#### 4. Ventilation devices during respiratory support in the delivery room

There is currently limited evidence to guide clinicians' choice of the device to be used to provide PPV in the DR [31]. Self-inflating bags, flow-inflating bags, or T-piece devices may all be used for mask PPV [4–6]. A self-inflating bag, however, does not provide PEEP or continuous positive airway pressure (CPAP) [32, 33]. An attached PEEP-valve provides inconsistent PEEP and cannot deliver CPAP [32–37]. A flow-inflating bag provides variable and operator dependent PEEP [16, 38]. With a T-piece device more consistent, predetermined levels of PEEP and PIP can be delivered [34, 35].

#### 5. Interfaces

Furthermore, a recent randomized trial reported an increase in respiratory effort during repetitive stimulation compared to standard tactile stimulation with less oxygen requirements during transport to the NICU [13]. However, it did not reach significance, and further studies

The fetal oxygen saturation before birth is between 40 and 60% [14], which increases in uncompromised term infants within the first 10 minutes following birth to levels between 90 and 100% [15], thus resulting in the appearance of cyanosis during that time [16]. In addition, clinical assessment of skin color or the lack of cyanosis is a very poor indicator of oxygen saturation during that period [16–19]. The optimal management of oxygen during neonatal resuscitation becomes particularly important because of the evidence that either insufficient or excessive oxygenation can be harmful to the term infant with hypoxia and ischemia are known to result in injury to multiple organs and hyperoxia causing increased mortality [16, 20, 21]. Therefore, infants >35 weeks' gestation should be resuscitated in 21% oxygen and oxygen

should be increased only if heart rate does not increase despite adequate ventilation.

or chin lift) to maintain airway patency is a crucial step during mask PPV [30].

4. Ventilation devices during respiratory support in the delivery room

There is currently limited evidence to guide clinicians' choice of the device to be used to provide PPV in the DR [31]. Self-inflating bags, flow-inflating bags, or T-piece devices may all be used for mask PPV [4–6]. A self-inflating bag, however, does not provide PEEP or continuous positive airway pressure (CPAP) [32, 33]. An attached PEEP-valve provides inconsistent

Approximately, 10% of newborns require respiratory support at birth [22]. ILCOR and various national guidelines recommend techniques and equipment for neonatal resuscitation [4–6]. They all agree that mask ventilation is the cornerstone of respiratory support immediately after birth [4–6]. The purpose of PPV is to establish FRC, deliver an adequate VT to facilitate gas exchange, and stimulate breathing while minimizing lung injury [2]. Several factors can reduce the effectiveness of mask ventilation, including poor face mask technique resulting in leak or airway obstruction, spontaneous movements of the baby, movements by or distraction of the resuscitator, and procedures such as changing the wraps or fitting a hat [23, 24]. Delivery room studies have shown that mask PPV is difficult, and mask leak and airway obstruction are common [23– 29]. Both leak and obstruction are usually unrecognized unless expired CO2 detectors or respiratory function monitors (RFM) are used [23–29]. In addition, airway maneuvers (e.g., jaw thrust

2.1. Oxygen delivery during stabilization/resuscitation

are needed.

28 Special Topics in Resuscitation

3. Mask ventilation

#### 5.1. Face mask and nasal prongs

Effective and consistent PPV is important to facilitate lung aeration, establishment of a functional residual capacity, and gas exchange, which should occur in a predictable manner so that the clinician can avoid under- or over-inflating the lungs [2, 42–44]. However, PPV is often complicated by mask leak or airway obstruction [23–29]. Currently, clinicians can either use a face mask or a nasal prong during mask PPV [4–6]; however, face mask ventilation remains the primary mode of resuscitation. There are a variety of face masks available to provide PPV [25, 45, 46]. The Fisher & Paykel (F&P) (Fisher & Paykel Healthcare, Auckland, New Zealand) and the Laerdal round masks are the most commonly used commercially available products [47–52]. Although, face masks for preterm infants <33 weeks' do not adequately fit their face [53], the only study comparing F&P vs. Laerdal masks reported no difference in mask leak during PPV in the DR in preterm infants <33 weeks' [25]. Similarly, two studies compared face masks to nasal prongs in the DR and reported no difference in intubation in the delivery room [45, 46]. These data suggest that either face mask or nasal prong could be used for PPV in the DR and the focus should rather be on delivery of an adequate tidal volume to achieve lung aeration.

#### 5.2. Laryngeal mask

Archie Brain, a British anesthetist, described the laryngeal mask airway (LMA) as an alternative to endotracheal intubation in 1981 [54]. A LMA consists of an airway tube connected distally to a soft elliptical mask with an inflatable rim to fit over the laryngeal inlet, whereas the proximal end connects to the ventilation device [54]. LMAs are routinely used in emergency and operating rooms for adult and pediatric anesthesia and ambulance services [55, 56]. In newborn infants, there is increasing evidence from randomized trials [57, 58], suggesting that a LMA can provide an effective rescue airway during resuscitation if both mask ventilation and endotracheal intubation have been unsuccessful. Current neonatal resuscitation guidelines recommend the use of LMA in infants >34 weeks' gestation or > 2000 g birth weight. Furthermore, LMA have been described during neonatal transport [59–61], provision of prolonged mechanical ventilation in particular for infants with upper airway abnormalities [62–64], and surfactant and epinephrine administration [65–69]. Although LMAs are recommended by various neonatal resuscitation guidelines, they are not routinely used during neonatal resuscitation [4–6].

#### 5.3. Oropharyngeal airway

In 1907, Sir Fredrick Hewitt presented the first known artificial oral "air-way" to alleviate upper airway obstruction, a common problem during general anesthesia [31]. In 1933, Arthur Guedel presented "the Guedel oropharyngeal airway" [37], designed to hold the tongue away from the back of the pharynx, thus providing a clear channel for respired gases [70]. An oropharyngeal airways may be used to open the airway in floppy newborn infants, or if mask ventilation is ineffective [71–74]. In addition, various surveys evaluating neonatal resuscitation practice reported that Guedel airways are part of the neonatal resuscitation equipment [50, 75]. Guedel airways for newborn infants come in traditional sizes of 000, 00, and 0. However, oropharyngeal airways during neonatal resuscitation have not been systematically studied, and only one trial is currently ongoing comparing an oropharyngeal airway for prevention of airway obstruction during PPV in preterm infants <34 weeks' gestation in the DR [49]. Until further evidence is available, oropharyngeal airway should be used with caution.

the newborn, meconium aspiration syndrome, respiratory distress syndrome, pulmonary

Resuscitation of Term Infants in the Delivery Room http://dx.doi.org/10.5772/intechopen.79394 31

About 0.1% of term infants and up to 15% of preterm infants [76, 77] receive chest compression (CC) or epinephrine in the DR, which results in 1 million newborn deaths annually worldwide. Infants who received epinephrine in the DR had a high incidence of mortality (41%) and short-term neurologic morbidity (57% hypoxic-ischemic encephalopathy and seizures) [78]. Furthermore, newborns receiving prolonged CC and epinephrine with no signs of life at 10 minutes following birth have up to 83% mortality, with 93% of survivors suffering moderate-to-severe disability [79]. Asphyxia could result from either failure of placental gas exchange before delivery (e.g., abruption and chorioamnionitis) or deficient pulmonary gas exchange immediately after birth (e.g., pulmonary hypertension) [80]. This condition of impaired gas exchange with simultaneous hypoxia and hypercapnia is leading to a mixed metabolic and respiratory acidosis [80]. Newborn infants are typically born with severe bradycardic or asystole. Current resuscitation guidelines recommend CC if the heart rate remains <60/min despite adequate PPV with 100% oxygen for 30 seconds; CC should be then performed at a rate of 90/min with 30 ventilations 3:1 C:V (compression:ventilation) ratio [4–6]. Rationales for using a 3:1 C:V ratio include (i) higher physiological heart rate (120–160/min) and breathing rates (40–60/min) in newborns compared to adults; (ii) profound bradycardia or cardiac arrest caused by hypoxia rather than primary cardiac compromise; therefore, providing ventilation is more likely to be beneficial in neonatal CPR compared to adult CPR [4–6].

However, the optimal C:V ratio that should be used during neonatal resuscitation to optimize coronary and cerebral perfusion while providing adequate ventilation of an asphyxiated newborn remains unknown [81]. Studies using newborn piglets with asphyxia-induced cardiac arrest demonstrated that combining CC with ventilations improves the return of spontaneous circulation (ROSC) and neurological outcome at 24 hours compared to ventilations or CC alone [16, 21]. Animal studies comparing various C:V ratios including 2:1 C:V, 4:1 C:V, 9:3 C:V, and 15:2 C:V to 3:1 C:V reported no difference in ROSC, survival or any other outcomes [82–84]. These studies suggest that during neonatal CPR, higher C:V ratios do not improve outcomes, and potentially a higher ventilation rate is needed. Similarly, Schmölzer et al. compared 3:1 C:V CPR with continuous CC with asynchronous ventilations (CCaV) using 90 CC and 30 non-synchronized inflations. The study reported similar time to ROSC (143 and 114 sec for 3:1 and CCaV, respectively), and survival (3/8 and 6/8, respectively) [85] suggesting no

Most recently, a new technique providing CC during a sustained inflation (SI) (CC + SI) has been proposed, which significantly improved hemodynamics, minute ventilation, and time to ROSC compared to the 3:1 C:V ratio during resuscitation of asphyxiated newborn piglets [86]. While this first study used a CC rate of 120/min (in the CC + SI group) instead of the recommended 90/min, further studies using CC rates of 90/min in the same animal model

advantages of using CCaV compared to 3:1 C:V.

hemorrhage, or presumed sepsis with secondary surfactant consumption.

8. Chest compressions

#### 6. Ventilation modes

When infants fail to initiate spontaneous breathing, the current neonatal resuscitation guidelines recommend mask PPV using any above described ventilation devices coupled with a face mask or a nasal prong [4–6]. The purpose of PPV is to establish FRC, deliver an adequate VT to facilitate gas exchange, and stimulate breathing while minimizing lung injury [2]. The current neonatal resuscitation guidelines further recommend to use a peak inflation pressure of around 30 cm H2O, a positive end expiratory pressure of 5 cm H2O when using a T-Piece or a flow-inflating bag, and a gas flow rate of 10 L/min and 21% oxygen [4–6]. Oxygen should only be increased if the infant requires chest compression (see the paragraph below), the heart rate does not increase despite adequate ventilation, or if SpO2 is below the recommend target range [4–6]. If infants have adequate spontaneous respiration, but remain cyanotic (e.g., SpO2 is below the recommend target range [4–6]) during the initial stabilization, CPAP using pressures between 5 and 8 cm H2O should be provided using a T-Piece or a flow-inflating bag (see the paragraph about ventilation devices).

There is no need for any other ventilation modalities (e.g., high frequency ventilation or mechanical ventilation) in the delivery room, which should be done in the NICU.

#### 7. Surfactant administration

During fetal development, surfactant production starts at around 24–26 weeks' gestation with a continuous increase in production up to 36 weeks' gestation. At that time, the surfactant production is similar to that of adults. Term infants rarely require surfactant in the delivery room and surfactant should be given only after the infants have been admitted to the NICU. Using this approach will allow for a more gentle intubation with recued stress for the resuscitation team. Potential indications for surfactant administration include transient tachypnea of the newborn, meconium aspiration syndrome, respiratory distress syndrome, pulmonary hemorrhage, or presumed sepsis with secondary surfactant consumption.

#### 8. Chest compressions

5.3. Oropharyngeal airway

30 Special Topics in Resuscitation

6. Ventilation modes

the paragraph about ventilation devices).

7. Surfactant administration

In 1907, Sir Fredrick Hewitt presented the first known artificial oral "air-way" to alleviate upper airway obstruction, a common problem during general anesthesia [31]. In 1933, Arthur Guedel presented "the Guedel oropharyngeal airway" [37], designed to hold the tongue away from the back of the pharynx, thus providing a clear channel for respired gases [70]. An oropharyngeal airways may be used to open the airway in floppy newborn infants, or if mask ventilation is ineffective [71–74]. In addition, various surveys evaluating neonatal resuscitation practice reported that Guedel airways are part of the neonatal resuscitation equipment [50, 75]. Guedel airways for newborn infants come in traditional sizes of 000, 00, and 0. However, oropharyngeal airways during neonatal resuscitation have not been systematically studied, and only one trial is currently ongoing comparing an oropharyngeal airway for prevention of airway obstruction during PPV in preterm infants <34 weeks' gestation in the DR [49]. Until

further evidence is available, oropharyngeal airway should be used with caution.

When infants fail to initiate spontaneous breathing, the current neonatal resuscitation guidelines recommend mask PPV using any above described ventilation devices coupled with a face mask or a nasal prong [4–6]. The purpose of PPV is to establish FRC, deliver an adequate VT to facilitate gas exchange, and stimulate breathing while minimizing lung injury [2]. The current neonatal resuscitation guidelines further recommend to use a peak inflation pressure of around 30 cm H2O, a positive end expiratory pressure of 5 cm H2O when using a T-Piece or a flow-inflating bag, and a gas flow rate of 10 L/min and 21% oxygen [4–6]. Oxygen should only be increased if the infant requires chest compression (see the paragraph below), the heart rate does not increase despite adequate ventilation, or if SpO2 is below the recommend target range [4–6]. If infants have adequate spontaneous respiration, but remain cyanotic (e.g., SpO2 is below the recommend target range [4–6]) during the initial stabilization, CPAP using pressures between 5 and 8 cm H2O should be provided using a T-Piece or a flow-inflating bag (see

There is no need for any other ventilation modalities (e.g., high frequency ventilation or

During fetal development, surfactant production starts at around 24–26 weeks' gestation with a continuous increase in production up to 36 weeks' gestation. At that time, the surfactant production is similar to that of adults. Term infants rarely require surfactant in the delivery room and surfactant should be given only after the infants have been admitted to the NICU. Using this approach will allow for a more gentle intubation with recued stress for the resuscitation team. Potential indications for surfactant administration include transient tachypnea of

mechanical ventilation) in the delivery room, which should be done in the NICU.