British Paramedic Journal

Real-time ventilation feedback devices for out-of-hospital cardiac arrest: A review of the literature

Cameron Barcroft, Caitlin Wilson, Andrew Crow — Mon, 01 Sep 2025 00:00:00 +0100

Real-time ventilation feedback devices for out-of-hospital cardiac arrests: a review of the literature

Cameron Barcroft¹, Andrew Crow ², Caitlin Wilson¹. ¹Yorkshire Ambulance Service, Wakefield, UK; ²University of Bradford, Bradford, UK.

Background: In the United Kingdom, ambulance services attempt resuscitation on 30,000 people per year, with fewer than 1 in 12 surviving and leaving hospital. Correct ventilation during out-of-hospital cardiac arrest (OHCA) is essential, as both hypo- and hyperventilation are linked to increased mortality. Despite this, ventilations are frequently given outside of recommended guidelines. Devices providing real-time feedback on ventilations aim to improve performance. While systematic reviews show that real-time feedback devices improve chest compression performance; evidence regarding ventilation feedback devices (VFDs) has not yet been synthesised. This literature review aimed to synthesise evidence on the effects of VFDs in OHCAs.

Methods: Databases searched in May 2024 included MEDLINE, CINAHL and Embase. Inclusion criteria were papers published after 1st January 2018, in English, involving adults, focused on clinical practice or simulated OHCA, and employing primary research and interventional study designs. The intervention criteria required a VFD that measured and provided feedback on both tidal volume and ventilation rate. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Methods for synthesis included a narrative summary of findings.

Results: The searches yielded 764 results. Five studies met the inclusion criteria: four simulation studies (Charlton et al., 2020; Gould et al., 2020; Lyngby et al., 2021; Scott et al., 2021) and one real-world study (Lee et al., 2023). The simulated studies confirmed that ambulance clinicians often did not meet advanced life support guidelines for ventilations. Introducing VFDs significantly improved compliance, accuracy, and precision of delivered ventilations in simulated OHCA scenarios. The real-world study did not find statistically significant effects and was of low quality.

Conclusion: The evidence suggests that VFDs are beneficial in simulated OHCA. However, effects on patient outcomes have not been adequately explored. Further research in clinical practice is necessary to establish the effectiveness of these devices in improving patient outcomes.

References:

Charlton, K., McClelland, G., Millican, K., Haworth, D., Aitken-Fell, P., & Norton, M. (2021). The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations. Resuscitation Plus, 6, 100130. mdc. https://doi.org/10.1016/j.resplu.2021.100130

Gould, J. R., Campana, L., Rabickow, D., Raymond, R., & Partridge, R. (2020). Manual ventilation quality is improved with a real-time visual feedback system during simulated resuscitation. International Journal of Emergency Medicine, 13(1), 18. https://doi.org/10.1186/s12245-020-00276-y

Lee, E. D., Jang, Y. D., Kang, J. H., Seo, Y. S., Yoon, Y. S., Kim, Y. W., Jeong, W. B., & Ji, J. G. (2023). Effect of a Real-Time Audio Ventilation Feedback Device on the Survival Rate and Outcomes of Patients with Out-of-Hospital Cardiac Arrest: A Prospective Randomized Controlled Study. Journal of Clinical Medicine, 12(18). mdc. https://doi.org/10.3390/jcm12186023

Lyngby, R. M., Clark, L., Kjoelbye, J. S., Oelrich, R. M., Silver, A., Christensen, H. C., Barfod, C., Lippert, F., Nikoletou, D., Quinn, T., & Folke, F. (2021). Higher resuscitation guideline adherence in paramedics with use of real-time ventilation feedback during simulated out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation Plus, 5, 100082. mdc. https://doi.org/10.1016/j.resplu.2021.100082

Scott, J. B., Schneider, J. M., Schneider, K., & Li, J. (2021). An evaluation of manual tidal volume and respiratory rate delivery during simulated resuscitation. The American Journal of Emergency Medicine, 45, 446–450.

Investigating prehospital troponin testing in the diagnosis of acute myocardial infarction: A systematic review

Jenny Alexanders, Sam McPherson, Andrew Letheren, Robert Oxley, Joe Saunders — Mon, 01 Sep 2025 00:00:00 +0100

Introduction

Chest pain is one of the most common conditions presenting to emergency departments, with over 1.3 million attendances according to 2022/2023 UK data (NHS Digital, 2023). The diagnosis of a myocardial infarction (MI) in prehospital settings is challenging, relying on careful history taking and echocardiograms (ECGs). Patients with ST-elevation are transferred to hospitals with Primary Percutaneous Coronary Intervention (PPCI) facilities, whilst those without ST-elevation are taken to local Emergency Departments (ED) for troponin testing. Point-of-Care (POC) troponin tests are now available in the field, presenting potential to diagnose MI in patients without ST elevation. This systematic review aims to investigate and determine whether POC troponin devices are effective in detecting patients with acute MI.

Method

This systematic review was performed in accordance with the PRISMA guidelines. A comprehensive search of the literature was created using the following databases: CINAHL, MEDLINE, EMBASE and DISCOVERY. Basic and advanced search strategies were used to identify papers using POC troponin testing in patients presenting in the prehospital setting with chest pain.

Results

A total of five articles were identified demonstrating that a variety of prehospital POC troponin testing devices can detect MI in patients presenting with chest pain. One limitation of POC testing was that some patients with negative troponin results in the prehospital setting were confirmed to have MI in the hospital setting.

Conclusion

Using POC troponin, raises the possibility of detecting an MI however cannot definitively exclude. Further research is required to investigate the reliability of POC troponin testing in cohorts without ST elevation in the prehospital environment, which may expedite transference to specialised PPCI hospitals over a local ED. The outcome of further research has the potential to positively impact outcomes of patients suffering with MI, and yield financial benefits via faster, more effective treatment.

Delayed Epinephrine Administration Prolongs Epinephrine-to-ROSC Interval in Out-of-Hospital Cardiac Arrest

Michael Hubble, Stephen Taylor, Melisa Martin, Sara Houston, Ginny Kaplan — Mon, 01 Sep 2025 00:00:00 +0100

Introduction: Previous investigations reveal protracted resuscitative efforts are associated with poorer long-term patient outcomes. Aside from certain patient characteristics and interventions such as shockable rhythms, bystander CPR, and early defibrillation, little is known about factors influencing resuscitation duration and time to return of spontaneous circulation (ROSC). We hypothesized that early public safety answering point (PSAP) call-receipt-to-pressor administration (PSAP-to-pressor) would decrease the pressor-to-ROSC interval and shorten low-flow duration.

Objective: To quantify the relationship between the PSAP-to-pressor and pressor-to-ROSC intervals.

Methods: We conducted a retrospective analysis using the 2020 ESO dataset containing calls from January-December 2020. Adults with non-traumatic, bystander-witnessed arrests were included. A Cox proportional hazard model was used to determine the association between PSAP-to-pressor interval and the pressor-to-ROSC interval while controlling for potential confounders. End-of-event was defined as ROSC, field termination-of-resuscitation, or hospital arrival without ROSC. Patients without ROSC upon hospital arrival were right censored.

Results: Overall, 10,093 patients had data sufficient for analysis. The mean age of the participants was 65.3(±15.5) years and 64.5% were males. Presumed cardiac etiology was present in 83.7% of arrests, 29.4% presented with a shockable rhythm, and 35.9% attained ROSC. The mean PSAP-to-pressor and pressor-to-ROSC intervals were 16.2(±5.0) and 14.6(±11.1) minutes, respectively. The mean time from the first epinephrine administration to end of event was 32.7(±1.0), 41.5(±1.2), and 51.6(±3.8) minutes for the 0–10-, 11–20-, and 21–30-minute PSAP-to-pressor intervals, respectively (p<0.001). After controlling for confounders, the PSAP-to-pressor time interval was associated with decreased hazard of ROSC (HR=0.97 per minute,p<0.001). When stratified by 10-minute increments with 0-10 minutes as reference, PSAP-to-pressor was negatively associated with ROSC for the 11-20(HR=0.86,p=0.002) and 21-30(HR=0.66,p<0.001) minute categories.

Conclusion: This retrospective analysis from a national database revealed that increasing delays to first epinephrine administration were associated with prolonged resuscitation duration after drug administration and decreasing hazard of ROSC.

A Qualitative Exploration of Behaviours and Lifestyle Factors Impacting Levels of Vitamin D within a UK Ambulance Service Workforce (EVOLVED)

Mon, 01 Sep 2025 00:00:00 +0100

Introduction: Vitamin D deficiency can impact health and wellbeing and may affect workplace performance. Shift, indoor and night working, alongside variable awareness of vitamin D, likely puts ambulance staff at an increased risk of deficiency. Screening in one ambulance service identified 46% of staff had insufficient or deficient vitamin D levels (i.e., 50.0nmol/L or less, as defined by National Institute for Health and Care Excellence). The aim of the EVOLVED study was to explore the behaviours and lifestyle factors of ambulance service staff with a range of vitamin D levels and understand the work and personal impacts.
Methods: A purposive sample of 40 ambulance staff were recruited over four months and invited to a one-hour, online, semi-structured interview. Interviews explored behaviours and lifestyle factors of those above and below the recommended adequate vitamin D levels and included questions about the impacts of vitamin D level on personal and professional wellbeing, with the opportunity to suggest possible improvements. Interview transcription analysis was undertaken using an intuitive thematic analysis strategy.
Results: Participants were aged between 21 and 61 years and worked in varying roles, including control room (n=9), operational (n=20) and support staff (n=11) and included those from diverse ethnic backgrounds, to represent Trust demographics. Five themes were identified: Reaction to result; diet; deficiency symptoms and impacts; impact of work on maintaining adequate vitamin D levels; and activity levels.
Discussion: A lack of awareness of vitamin D related issues was identified, alongside a variety of improvement suggestions, including participants emphasising the importance of awareness, to allow staff to take responsibility to promote their own health and wellbeing. Strategies to promote awareness of vitamin D should be considered to improve staff wellbeing in this area. Participants positively perceived research exploring staff health and wellbeing, highlighting this as an area for future research.

Cables ties as a method of suicide

Gary Shaw, Lee Thompson, Graham McClelland — Mon, 01 Sep 2025 00:00:00 +0100

Calls of despair: A retrospective cohort study of Yorkshire Ambulance Service data

Verity Bellamy, Holly Wilcock, Caitlin Wilson, Ruth Crabtree — Mon, 01 Sep 2025 00:00:00 +0100

Introduction: Deaths of Despair (DoD)—encompassing fatalities from suicide, drug overdoses, and alcohol-related causes—represent a growing public health crisis. Socioeconomic vulnerability and healthcare disparities are well-documented drivers of DoD. While healthcare contacts preceding despair-related deaths have been studied extensively, the role of ambulance services is underexplored. This study aimed to address this gap by utilising ambulance service data to provide insights into "calls of despair" received by a UK ambulance service over 12 months.

Methods: This exploratory, retrospective study analysed 2023 data from Yorkshire Ambulance Service (YAS), which serves urban and rural areas with varying levels of deprivation. Calls were included if they involved suicidal ideation and/or drug or alcohol misuse. Data were sourced from Computer-Aided Dispatch and Electronic Patient Records and analysed to describe call characteristics, demographic profiles, geographic distribution, temporal trends, and repeat caller patterns.

Results: In 2023, YAS received 40,870 calls of despair. Nearly half of calls originated from the most deprived quintile. Urban areas had more than double the rate of calls compared to rural areas. Over half (54%) of calls involved drug and alcohol misuse, while 43% were related to suicidal ideation. Females were more likely to call for substance misuse (58%) than suicide (46%), and young females (<25 years) represented a disproportionate share of calls. Only 43% of calls resulted in hospital conveyance, suggesting ambulance services capture crises not reflected in hospital datasets. Repeat callers were common, with 119 individuals making over 10 calls each.

Discussion: The findings highlight the utility of ambulance service data in understanding despair-related crises, particularly among socioeconomically disadvantaged and young populations. Ambulance data offers a valuable lens for public health monitoring, capturing acute needs often absent in traditional healthcare datasets. These insights emphasise the need for targeted interventions and cross-sectoral approaches to address the underlying drivers of despair.

High-fidelity simulation in healthcare education: Design and delivery considerations for optimising teaching and learning in higher education.

Jon Newton — Mon, 01 Sep 2025 00:00:00 +0100

High-Fidelity Simulation (HFS) is a recognised teaching and learning tool within higher education and one capable of facilitating skill retention and knowledge retrieval. Successfully achieving these outcomes relies on effective design, delivery, and debriefing; yet a limited range of publications draw together these fundamental components. To support healthcare educators orchestrate HFS with greater impact and influence, careful consideration of the following five areas will provide scope to optimise teaching and learning outcomes: (1.) create a believable scenario (2.) integrate the principles of ‘fidelity harmony’ (3.) select an appropriate modality (4.) integrate a clear pedagogic stance; and (5) amalgamate concepts of experiential learning theory into the briefing and debriefing. When dynamically incorporated, important gaps between theory and practice will be bridged, and learner experience significantly enhanced.

Developments in public health paramedicine: exploring the professional practice of ambulance clinicians in palliative and end-of-life care in a remote and rural setting

Lisa Kamphausen, Els Freshwater — Mon, 01 Sep 2025 00:00:00 +0100

Professional practice in paramedicine is evolving rapidly, and with this evolution comes a growing ability, and responsibility, for paramedics to contribute to public health. Palliative and end-of-life care (PEOLC) public health is one such area where paramedicine has begun to contribute substantially and might still have significant untapped potential.

The following explores developments in PEOLC paramedicine in Highland, Scotland, an area classified as remote and rural, characterised by low population density, widely spaced communities and susceptibility to health inequalities created by access to healthcare, especially to specialist services. The role of paramedicine in PEOLC is examined in the context of public health priorities and policy, while considering the ability of paramedics to influence behaviour and reduce health inequalities.

Critical analysis of a selection of relevant literature was used to identify interventions through which paramedicine can make improvements to the experience of death and dying on a population level, and lead to substantial healthcare cost savings. These interventions range from reducing end-of-life hospital admissions through effective use of advance statements, just-in-case medications and independent prescribing, and local referral pathways, to effectively managing palliative emergencies amenable to treatment in hospital.

Paramedicine could thus play a significant role in making policy ambitions in PEOLC a reality, and conversely, achieving PEOLC policy ambitions might be difficult without support from paramedicine. Greater recognition of the growing role paramedics play in community healthcare provision and better integration of paramedicine into primary and secondary healthcare systems could facilitate turning more PEOLC public health theory into practice. The information collated in this discussion reinforces the need to reflect this potential in research funding allocation, in social and government policy development, and in clinical practice decisions made by each individual paramedic.

Exploratory study comparing a single episode of feedback with regular feedback and no feedback on BVM ventilation during a simulated cardiac arrest over a six-month time frame.

Mon, 01 Sep 2025 00:00:00 +0100

Introduction
Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality in the UK, with survival rates remaining low despite advancements in resuscitation techniques. The European Resuscitation Council (ERC) and Resuscitation Council UK guidelines recommend controlled ventilation during cardiopulmonary resuscitation (CPR), yet studies show that ambulance clinicians often fail to meet these standards. In particular, hyperventilation has been linked to worse outcomes. This protocol describes a study that will explore the impact of different applications of real-time ventilation feedback on the quality of ventilations during CPR in a simulated environment.

Methods
This exploratory simulation study will assess the effectiveness of real-time feedback on the quality of ventilations delivered by ambulance clinicians. Participants from North East Ambulance Service (NEAS) NHS Foundation trust will be randomly assigned to three arms receiving either a single episode of feedback, regular feedback or no feedback (used as a control group). Each arm will complete four simulated OHCA scenarios over six months, and their ventilation quality will be assessed at each session. The primary outcome will be the quality of ventilations, measured by rate and tidal volume, at the six-month mark. Secondary outcomes include trends in ventilation quality over time, compression quality, and participant characteristics.

Discussion
This study aims to explore whether regular feedback improves the quality of ventilations during CPR and if feedback sessions influence skill retention over a six-month period. Findings could inform training strategies, highlighting the role of real-time feedback in maintaining high-quality CPR skills. With a lack of prior research on ventilation skill maintenance in the United Kingdom, this study is expected to provide valuable insights into optimising clinical performance.