Out of Hospital Cardiac Arrest

Task
Patient survival and quality of life post cardiac arrest have remained poor for many decades. Furthermore, the role of pharmacology in the management of cardiac arrest patients appears to be unclear. Hagihara et al (2012) elude to issues surrounding adrenaline use in reporting that the “prehospital use of adrenaline is significantly associated with increased chance of return of spontaneous circulation before hospital arrival but decreased chance of survival and good functional outcomes 1 month after the event”. This wicked problem may lead a reflective paramedic to question how out-of-hospital cardiac arrest (OOHCA) cases are managed.

Write a report that could be published in the Paramedics Australasia Response magazine to inform paramedics about the current evidence based principles of the paramedic management of cardiac arrest. In this report include:
A. The principles and rationale of the paramedic management of OOHCA,
B. The principles and rationale of the paramedic management of a patient with return of spontaneous circulation post OOHCA, and
C. A critique of one of the following new technologies being investigated:
a. ALMTM solution;
b. Active compression-decompression resuscitation or impedance threshold device ; or
c. Automated CPR devices.

Ref: Hagihara A. Hasegawa M. Abe T. Nagata T. Wakata Y. Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161-1168
The following report format must be followed. For back ground reading on report writing also refer to USC Academic Skills writing guides

The Report Format
Levels of Evidence
The main area to focus on when selecting a subject and preparing the report is the quality and quantity of the evidence you utilise to inform your argument. The highest level of evidence must be sought and collated to answer the question posed in the context of paramedic practice.

Your argument and supporting references should demonstrate that you have performed a comprehensive review of the available literature in the subject area and that your recommendations are based on sound interpretation of your research.

Your search strategy must discover and use the highest levels of evidence to support your argument. Refer to the ‘How do I judge research evidence’ section below for information on the hierarchy of the levels of evidence and for clarification on how to evaluate clinical research data.

In addition primary data must be used, for example epidemiological data must be obtained from an appropriate source such as Australian Institute of Health and Welfare (AIHW) and not obtained from text books or journal articles.

Audience
This report is being written to inform your professional peers. This is not being written for a particular ambulance service and a national perspective is necessary.

Report Format
Document type
To allow online feedback you must submit the report in MS Word supported by USC. Do not submit in PDF.
Title
A title that allows the reader to quickly identify the main focus of the report should be in bold at the top of the first page. Think of what you would put in the subject line of an email to ensure that it grabbed the reader’s attention.

Contents table
To make a table of contents in docx:
• Click on REFERENCES tab in word (found at the top of the page)
• Click on “table of contents” and select the style

To make headings which appear in the contents table:
• Highlight headings in your text and format using “styles” listed under the HOME tab.
• Note the contents table has to be updated manually by clicking on the reference table and the clicking on ‘update table’ at the top of the table and then choosing update entire field.
Search Strategy
A few sentences only to explain the search strategy you have used to find data and your inclusion criteria. You must include
• search terms;
• data bases used; and
• Inclusion / exclusion criteria for articles which were discovered in the original search results.

Introduction
The purpose of the introduction is to outline what the report will cover and how these issues/themes address the question. The introduction gives the reader the necessary background information to understand how your thesis is important to the practice of paramedicine. Depending on the type of report, the introduction may include:
• statement of the problem/s;
• description of the main aims of the report;
• an overview of previous research in this area and how this relates to the current problem.
• explanations of terminology;
• limitations of the report;
• an outline of material presented in the report and how this will be structured.

Body of the report
The body section expands and develops the material in a logical and coherent manner, reflecting the structure outlined in the Introduction. It contains a description of the findings and a discussion of them. It should also relate the findings to any theory of relevance. The following questions are examples of some of the types of questions the body of your report should seek to answer:
• What were the most significant findings or factors involved in topic/ the problem?
• Did the findings support the theory?
• Have you found some disagreement with the theory?
• Did you uncover any unexpected or new issue that needs to be considered?

This section is usually the longest part of the report so the material must be presented logically to make it is easy to read. The particular headings you use to organise the information in the body of your report and to make it logical will depend on the purpose of the report you are preparing. You should make sure the headings and sub-headings you choose are informative, and are related to the themes highlighted in the introduction.

Conclusion
The conclusion summarises the major inferences that can be drawn from the information presented in the report. It answers the questions raised by the original research problem or stated purpose of the report and states the conclusions reached. It also attempts to show ‘what it all means’: the significance of the findings reported and their impact.

The conclusion/s presented in a report must be related to and justifiable by the material which appears in the report. The conclusion must not introduce any new material. It should report on all the conclusions that the evidence dictates as it is NOT the job of a conclusion to gloss over areas that are incomplete or don’t seem to fit the evidence presented. Doing this would indicate writer bias and means that your conclusion may mislead the reader.

Conclusions are quite often read before the main text of the report and hence, should summarise the main points clearly. This section also may include:
• reference to original aim(s) and objective(s) of report,
• application(s) of results,
• limitations and advantages of the findings,
• objective opinion, evaluation or judgement of the evidence

Quite often the present tense is used in the conclusion. The conclusions may also be ordered in several ways. The main conclusion may be stated first followed by less important ones or the conclusions may be presented in the same order as the arguments in the report. Although the structure of the conclusion may vary, it must be logical. It should not, however, tell the reader what to do. This job is performed by the recommendations section.

Recommendations
Recommendations should emerge from the conclusions of the report. Recommendations tell the reader what to do: what decision to make and what course of action to take, what alternative solution is superior or what further work needs to be undertaken. Although subjective, that is the recommendations arise from your opinion and judgements, the recommendation section should never contain any new evidence and should arise from the information presented in the body and conclusion sections.

Recommendations should be feasible and appropriate to the problem. The recommendations section provides your opinion on the course of action to be taken, you should not, therefore, hedge your bets by recommending all possible actions. Sometimes it may be the case that you recommend that no action be taken as this, in your opinion, is the best course of action to take.

Recommendations are written for action so they should be as concrete and specific as possible and let your reader know why you are recommending an action by supplying the reasons for your decision drawn from the conclusions of the report.

References
Throughout the text of the report references are included when a definitive statement is made or an idea is stated which is not the author’s own original idea. A reference is the bracketed piece of information within the text of your writing that provides an acknowledgment that attributes the idea or information to its rightful owner.
It is essential to include a reference list which is a list of all the references cited in the text of your report. The prescribed referencing style is Vancouver. Conducting a literature review
You will need to get your head around how you perform a literature review to discover the evidence base for your report
Consider the following steps in a literature review
Define the topic / question
Population What population am I looking at – adults, children, Australian, international?
Intervention What is the intervention or illness I am reviewing?
Control/comparison Is there a control group or a comparison group I need to include
Outcomes What outcomes should I be including in the review
Time line How long do I have to do this in

Develop a search strategy
Databases What databases will I search – libcat, EBSCO, Web of Science etc.
Keywords What key words will I input and how will I choose further key words to refine the output
Publication years How far back should I search?
Levels of evidence How do I find the highest levels of evidence? Aim to include evidence from the tip of the hierarchy pyramid below. Do not include text books in the reference list.
Scoping a review.
Start thinking about the following questions:
• What do I need to cover given the scope of my topic, my level of study and the time I have available to write my report?
• What bodies of literature will I review?
• Focus on key experts and groups who have contributed significantly to the topic being reported on.
• Cover the most recent, relevant publications available. Avoid text books, they are for background reading only!

Categorizing
Categorize the literature found
• Determine the level of evidence found, is it the highest possible? Read the reference lists of articles to find further sources of evidence.
• Mind map to link the research into categories to help you to break down more precisely what needs to be covered.

Putting it together
Consider the following questions when determining what you need to do:
• Do I have a thorough critical understanding of the literature? Do I need to read more or discuss with a critical friend
• What are the key issues essential to put in my report? Have these become clear so far in my search of data bases? Have I reached saturation point – nothing new is being found?
• How do I discriminate carefully between what is known, not known, uncertain (evidence base)? And
• Do I have a picture of what the gaps are in the literature that I have I evaluated?

Structuring a review
• Organize your review around key themes and concepts, consider the following questions:
• What has been studied and how do individual studies contribute to the body knowledge?
• What is known, unknown, uncertain, opinion, and consensus? This needs to be made clear in the report.
• What are there any limitations in the research?
• If there are controversies in the topic area, how are these being resolved?
• What are the implications of your findings?
• Infer what the literature is telling you about the topic and draw these into recommendations based in logical reasoning.

Positioning
• Position your research in the field of paramedicine. Make the report and recommendations specific to paramedic practice.

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