京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22380号 / 社医博第102号 / 新制||社||医11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 小池 薫, 教授 今中 雄一 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

The standard first aid for a heart attack resulting in cardiopulmonary arrest is effective cardiopulmonary resuscitation (CPR). Chest compressions are most commonly performed on a flat surface with the rescuer kneeling next to the victim with one hand on top of the other on the sternum and elbows straight. This technique of being on the ground may be challenging for those without the mobility and strength to get up and down from the ground. In 2005, the American Heart Association (AHA) Guidelines listed “pedal”, or heel, compression as an acceptable alternative to standard chest compressions (Trenkamp & Perez, 2015). That same year, the recommended depth of a compression increased from 3.8 cm to 5.0 cm (Trenkamp & Perez, 2015). To attain such a depth, extra force and strength arerequired. The heel method may be especially reasonable for those rescuers who cannot attain the floor and those who do not have the cardiovascular or muscular strength to perform traditional chest compressions. The purpose of this study was to evaluate the effects of performance of hands only (HO) versus the combination (CO) of hands only plus pedal CPR on the electrocardiogram, including heart rate and heart rhythm. The subjects utilized in this investigation were six men and nine women between 56 and 71 years of age from San Luis Obispo County in California. Subjects underwent two trials with at least a 15 hour rest period in between but no more than one week. Subjects were randomly assigned to either the Combination (CO) trial or the Hands Only (HO) trial. When they came back for their second trial, they did the trial that they did not do the first time. On average, participants were able to sustain the combination of HO plus pedal CPR longer (9.47 minutes) than they were able to perform standard HO CPR (9.02 minutes) but this difference was not statistically significant (p=0.16). Mean maximum heart rate was 133 ± 23.7 bpm during the CO trial and 125.4 ± 21.9 bpm during the HO trial (p=0.12). Mean percentage of the HR reserve was 75.1% during the CO trial and 61.1% during the HO trial (p=0.09). Mean RPE was not significantly different between CO and HO trials (p=0.2124), nor between genders (p=0.42090). However, for both trials combined the mean RPE was significantly greater at 5 minutes of CPR (4.45 ± 0.53) than at 2 minutes of CPR (3.38 ± 0.31), (p It may take time for individuals to accept pedal CPR as a viable resuscitation method. With the majority of sudden cardiac arrests occurring in the home among older adults in society, it is important to recognize that pedal CPR is an acceptable method and that a rescuer may have this choice if they either need a break from standard CPR or if they can not attain the ground.

Human life is too precious to be lost. The rules of the first aid are not complicated. The knowledge of resuscitation is the basic principle of the first aid. You don't need only theoretical knowledge to do the right resuscitation. It is necessary to have a some practical experience. The experience of resuscitation is possible to get on a tutorial trainer manikin. This work considers a concept of system for analysing training of resuscitation by using computer. The first part of this thesis describes the right process of resuscitation by guidelines of European Resuscitation Council for Resuscitation 2005. The other part deals with possible ways of monitoring the correct procedure of instant resuscitation and the most common mistakes made by trainees during the training, are described in the following parts of this work. Component part of this thesis is summary of available resuscitation models. Last part is dedicated to the design of hardware and software for rating quality of resuscitation process. Resuscitation trainer manikin AmbuMAN from the company Ambu was also used. Among others contains "first aid" test as well.

The thesis focuses on analysis and design of a special hospital bed designed for the department of anesthesiology and resuscitation. The design was based on the rules set by the ČSN EN 60601-2-52 norm. The bed is adjusted for the use at the department of anesthesiology and resuscitation not only with its look but also with its functions. The design emphasizes the ergonomics of the bed, safety and the needs of the patient as well as of the staff and also an easy maintenance of the bed. Some of the main innovative elements are: basal stimulation system placed directly in the bed, used colors, more infusion-rack holders or a headboard fixed to the construction of the bed if not needed. The bed was designed especially to provide more comfort to the patient.

Emergency department nurses are faced with traumatic patient events while functioning as members of multidisciplinary teams. Critical incident debriefing has been shown to benefit health care professionals and patient clinical outcomes. The purpose of this quantitative correlational study was to examine the relationship between the use of formal post-resuscitation debriefings and perceptions of teamwork in emergency department nurses. The study also addressed the type and timing of debriefing to determine whether these factors impacted perceptions of teamwork. The nurse as wounded healer theory served as the theoretical framework. Data from the Nursing Teamwork Survey were collected from 68 emergency department nurses from across the United States. Data were analyzed using a statistical correlation coefficient. Results showed that when debriefings were done more frequently, were conducted using a formal debriefing method, and were held immediately after a situation, there was a positive correlation with higher levels of trust, team orientation, backup, shared mental model, and leadership. Findings may be used to increase utilization of debriefings and improve perceptions of teamwork among emergency department nurses, which may improve patient outcomes.

Bakgrund: En av de mest vanligt förekommande dödsorsakerna i Sverige är hjärtstopp. Under pågående återupplivningsförsök kan anhöriga närvara. Syfte: Beskriva sjuksköterskans uppfattning av anhörignärvaro vid återupplivningsförsök. Metod: Detta är en litteraturöversikt. Datainsamling genomfördes i databaserna Cinahl och PubMed. Det resulterade i 15 vetenskapliga artiklar som ligger till grund för resultatet. Analys har skett i tre olika steg.  Resultat: Fem huvudrubriker identifierades. Dessa är anhörigas närvaro, beslut om anhörignärvaro, anhörigas närvaro påverkar sjuksköterskans arbete, betydelsen för anhöriga att närvara samt anhörigas behov av stöd. Det framkom meningsskiljaktigheter hos sjuksköterskorna om anhöriga ska tillåtas närvara eller ej. Det framkom en ökad upplevd stress hos sjuksköterskor samt att anhöriga stör arbetet på olika sätt. Det framkom även fördelar för anhöriga om de närvarade.  Slutsats: Det finns meningsskiljaktigheter bland sjuksköterskorna om anhörignärvaro är fördelaktigt eller ej. Sjuksköterskorna påverkas negativt av anhörigas närvaro medan anhörigas sorgeprocess underlättas och de får även se att alla tillgängliga behandlingar är utförda. Vid anhörigas närvaro är det av stor vikt att personal avsätts i syfte att informera och bemöta deras behov. / Background: One of the most common causes of death in Sweden is cardiac arrest. Family members can be present during resuscitation. Aim: Describe nurses’ perception about family presence during resuscitation. Method: This is a literature review. Data collection was performed in the databases Cinahl and PubMed. 15 scientific articles form the basis of the result. The analysis process has been done in three stages.  Result: Five main themes were identified: Family presence, decisions regarding family presence, family presence affects the nurses’ work, the importance of family members to be present and family members need of support. Disagreements emerged among the nurses as to whether family members should be allowed to be present during resuscitation or not. Nurses experienced a higher level of stress if family members were present and family members interrupted the work in different ways. There were also benefits for family members if they were present during resuscitation.  Conclusions: There are differences of opinion if it’s beneficial or not to have family present during resuscitation. Family presence affect the nurses in a negative way while it appears to ease family members grieving process and they also have the opportunity to witness that every available treatment is performed. It’s important to have a staff member set aside to inform and answer family members needs if they are present during resuscitation.

Sjuksköterskors erfarenheter av när patienter får hjärtstopp Abstrakt Bakgrund: Hjärtstopp är den tredje vanligaste dödsorsaken i Europa och orsakas vanligen av att hjärtmuskeln drabbas av syrebrist. Vid hjärtstopp är adekvat hjärt- och lungräddning det enda som räddar patienten. Sjuksköterskan har där en viktig roll i omhändertagandet, vilket kan vara en krävande upplevelse.  Syfte: Att beskriva sjuksköterskors erfarenheter av när patienter får hjärtstopp.  Metod: En kvalitativ litteraturstudie baserat på åtta artiklar som analyserades med en modifierad innehållsanalys.  Resultat: Utifrån analysen utformades fyra kategorier och åtta subkategorier. Huvudkategorierna blev: Att vara medveten om sitt ansvar och att kunna samverka med andra. Att uppleva stress och samtidigt kunna hantera den akuta situationen. Att ställas inför etiska och känslomässiga utmaningar samt Att behöva stöd och kunna utvecklas professionellt.  Konklusion: Sjuksköterskor kan uppleva hjärtstopp som en komplex situation och fenomenet bör undersökas mer utav forskare i framtiden. Resultatet kan användas av sjukvårdens verksamheter för att förbereda och stötta sjuksköterskor och deras behov före, under och efter ett hjärtstopp och som i sin tur kan gynna patienternas vård. / Nurses experiences when patients are suffering cardiac arrests Abstract  Background: Cardiac arrest is the third leading cause of death in Europe, and is normally caused by a lack of oxygen in the heart muscle. Adequate cardiopulmonary resuscitation is the only viable treatment in order to save patients suffering cardiac arrests. The nurse has an important role in this situation, which can be a rather demanding experience.  Aim: To describe nurses experiences when patients are suffering cardiac arrests.  Methods: A qualitative literature review based on eight articles which were analyzed using a modified version of content analysis.  Result: Based on the analysis, four categories and eight subcategories were presented. The categories were: To know your responsibilities and be able to cooperating with others, To experience stress but still cope with the acute situation. To encounter ethical and emotional challenges and finally, To be in need of support and being able to develop in your profession.  Conclusion: Nurses can experience cardiac arrests as a complex situation, and the phenomenon needs to be explored further by researchers in the future. The result of this study can be used by the healthcare organisations to prepare and support the nurses and their needs before, during and after attending a cardiac arrest, which can promote the patient care.

The theoretical part of this thesis titled "Organization of Advanced Life Support Provider Course in the Czech Republic" deals with adult education from different perspectives. Firstly, it briefly discusses the history of adult education and then deals with emerging trends in human resource management and knowledge management (e.g. management by competencies, learning organization, etc.) in relation to education. Then clearly describes the area of adult education with a focus on training and mainly training of health care professionals. The last part of theoretical block describes the Advanced Life Support Provider course and teaching methods that are used during the course. The practical part presents the action research project, which includes quantitative methods, which represents two questionnaire surveys relates to the satisfaction of the course participants with the organization and practical usage of the taught techniques. The results of these surveys are high rate of satisfaction with ongoing organisation of the courses and also high rate of practical usage of the taught techniques. The qualitative method aimed at creating a handbook for the organization of the ALS courses in the Czech Republic and its implementation in practice. It has focused on the acquisition of specific know-how from...

Bakgrund: Ambulanspersonal har ett ansvar i sitt beslutsfattande om hjärt-lungräddning, att inte bara rädda liv utan återställa ett liv med kvalité. Beslutsstöd som är medicinsk grundade guidar beslutsfattandet prehospitalt för att inte orsaka skada, onödigt lidande och skapa förutsättning att avsluta på plats. Men trots det så ställs ambulanspersonalen för en rad etiska utmaningar där de kan ställas mellan att göra gott och göra rätt. Ett hjärtstopp sker plötsligt och ambulanspersonalen arbetar ofta i situationer där information om händelse och patienten är bristfällig, vilket försvårar tillämpningen av beslutstöden och skapar etiska dilemman. Syftet: Att beskriva etiska utmaningar för ambulanspersonal vid beslut om att påbörja, förlänga, avstå eller avsluta hjärt-lungräddning vid hjärtstopp utanför sjukhus. Metod: En litteraturöversikt med en systematisk sökstrategi. Datan insamlades via databaserna Cinahl och Pubmed. Totalt inkluderades 16st vetenskapliga artiklar till studien tio är kvalitativa, tre mixad metod och tre kvantitativa studier som kvalitetsgranskades. Litteraturen sammanställdes genom en integrerad analys. Resultat: Studiens resultat presenteras i tre huvudrubriker ”Etiska utmaningar i yrkesrollen”, ”Etiska utmaningar i att påbörja och förlänga hjärt-lungräddning” och ”Etiska utmaningar i att avstå eller avsluta hjärt-lungräddning” med respektive underkategorier. I resultatet framkommer att beslutsfattandet kunde påverkas av etiska utmaningar i omgivningen, i relation till anhöriga och kollegor. Känslor som rädsla och oro påverkade beslutsfattandet och resulterade i förlängd hjärt-lungräddning. Slutsats: Beslut vid hjärt-lungräddning påverkas av etiska utmaningar och gör att ambulanspersonalens beslut baserades på andra grunder än evidens och medicinska kunskaper. De etiska utmaningar som ambulanspersonalen ställs inför uppkommer från både inre utmaningar hos ambulanspersonal och yttre utmaningar i omgivningen. Det framkom att erfarenhet och högre utbildningsgrad skapar mer trygghet i beslutsfattandet och följsamhet till riktlinjer. / Background: Ambulance personnel have a responsibility in their decision-making about cardiopulmonary resuscitation, to not only save lives but to restore a quality life. Medical based guidelines support decision making prehospital to not cause harm, unnecessary suffering and create the conditions for termination. But despite that, the ambulance staff are faced with several ethical challenges where they can be faced between doing good and doing the right thing. A cardiac arrest occurs suddenly and the ambulance personnel often work in situations where information about the event and the patient is deficient, which makes it difficult to apply the decision support and creates ethical dilemmas. Aim: To describe ethical challenges for ambulance personnel when deciding to start, extend, refrain or end cardiopulmonary resuscitation in the event of cardiac arrest outside a hospital. Method: A literature review with a systematic search strategy. The data were collected through Cinahl and Pubmed databases. A total of 16 articles were included in the study, ten qualitative, three mixed methods and three quantitative studies were quality reviewed. The literature was compiled through an integrated analysis. Results: The results of the study are presented in three main headings "Ethical challenges in the professional role", "Ethical challenges in starting and extending cardiopulmonary resuscitation" and "Ethical challenges in refraining or ending cardiopulmonary resuscitation" with subcategories. The results show that decision making could be influenced by ethical challenges in the environment, in relation to relatives and colleagues. Emotions such as fear and anxiety affected decision making and resulted in extended cardiopulmonary resuscitation. Conclusion: Decisions in cardiopulmonary resuscitation are influenced by ethical challenges and means that the ambulance personnels decisions are based on other grounds than evidence and medical knowledge. The ethical challenges that ambulance personnel faced arise from both internal challenges among ambulance personnel and external challenges in the environment. It emerge that experience and a higher degree of education creates more security in decision-making and adherence to guidelines.

Bakgrunden belyser att barnsjukvården arbetar utefter ett familjecentrerat förhållningssätt där familjen ses som en enhet. Separation av barn och föräldrar har negativa konsekvenser. Vårdpersonalen syn på föräldrars närvaro världen över är tveksamma till att låta föräldrar att närvara vid återupplivning av deras barn.  Syftet var att beskriva föräldrars upplevelse av att närvara vid deras barn återupplivning. Den valda metoden för denna studie var litteraturöversikt med systematisk metod. Sökningarna genomfördes i databaserna PubMed och CINAHL. Totalt inkluderades 16 vetenskapliga artiklar varav 12 kvaliativa studier, tre kvantitativa studer och en mixad studie. Efter kvalitesgranskningen var nio av god kvalité och sju av hög kvalitet. De inkluderade artiklarna analyserades i en integrerad metod.  Resultatet kategoriseras i fyra huvudkategorier "Föräldrar emotionella uttryck", "föräldras behov vid återupplivning", Föräldras relation till vårdpersonal" och "Närvaro vid ååterupplivning". Familjer Beskriver det inte bara som av högsta vikt at få närvara utan även som deras otvetydig rättighet, ett naturligt och instinktivt ansvar som förelder. Det är kritiskt för anhöriga att få basal och konkret information kring barnets tillstånd och att vårdpersonalen som ger dessa uppdateringar vet vad som pågår. Familjers närvaro vid återupplivning ger sällan avbrott i det medicinska teamets arbete.  Slutsats från studie var att majoriteten av föräldrarna vill närvara vid återupplivningen av deras barn. Närvaron påverkar föräldrar i efterhand positivt då det underlättar för sorgearbetet. Därtill är det av vikt att anhöriga erbjuds adekvat stöd och blir tillhandahållna kontinuerlig adekvat information angående barnets tillstånd för att bidra till att föräldrarna ska känna sig mer trygga i situationen. / The background highlights that pediatric care works from a family-centered point of view where the family is seen as a unit. Separation of children and their parents has negative consequences. Worldwide nurses' view of parents' presence during resuscitation of their children is hesitant. The purpose of this study was to describe parents´ experience of attending their child´s resuscitation. The chosen method for this study was a literature review with systematic method. The searches were performed in the PubMed and CINAHL databases. A total of 16 articles were included, of which 12 qualitative studies, 3 quantitative studie and 1 mixed study. After the quality review, nine were of good quality and seven of high quality. The included articles were analyzed in an integrated method. The results are categorized into four main categories: “Parents´ emotional expression”, “Parents´ need during resuscitation”, “Parents´relationship to care staff” and “Attendance in resuscitation”. Families do not only describe it as the utmost importance to be present but also as their unequivocal right, an innate and instinctive responsibility as a parent. It is critical for relatives to receive basic and concrete information about the child's condition and furthermore that the care staff who provide these updates has knowledge regarding the resuscitation of the parents´child. The presence of families in resuscitation seldom interrupts the work of the medical team. The conclusion from the study was that the majority of parents want to attend the resuscitation of their children. The presence has a positive effect on parents afterwards as it facilitates the mourning. In addition, it is important that relatives are offered emotional support and are provided with continuous adequate information regarding the child's condition in order to help the parents feel more secure in the situation.