State of implementation of the Corona-Virus-Disease-2019 resuscitation guidelines

Abstract

Background

The present study evaluated the implementation of the European Resuscitation Council Corona-Virus-Disease 2019 (COVID-19) resuscitation guidelines in Germany 1 year after publication.

Aim of the work

To evaluate the practical implementation of the COVID-19 resuscitation guidelines in Germany one year after their publication.

Material and methods

In an online survey between April and May 2021 participants were asked about awareness of COVID-19 resuscitation guidelines, corresponding training, the resuscitation algorithm used and COVID-19 infections of emergency medicine personnel associated with COVID-19 resuscitation.

Results

A total of 961 (8%) of the 11,000 members took part in the survey and 85% (818/961) of questionnaires were fully completed. While 577 (70%) of the respondents were aware of the COVID-19 guidelines, only 103 (13%) had received respective training. A specific COVID-19 resuscitation algorithm was used by 265 respondents (32%). Adaptations included personal protective equipment (99%), reduction of staff caring for the patient, or routine use of video laryngoscopy for endotracheal intubation (each 37%), securing the airway before rhythm analysis (32%), and pausing chest compressions during endotracheal intubation (30%). Respondents without a specific COVID-19 resuscitation algorithm were more likely to use mouth-nose protection (47% vs. 31%; p < 0.001), extraglottic airway devices (66% vs. 55%; p = 0.004) and have more than 4 team members close to the patient (45% vs. 38%; p = 0.04). Use of an Filtering-Face-Piece(FFP)-2 or FFP3 mask (89% vs. 77%; p < 0.001; 58% vs. 70%; p ≤ 0.001) or performing primary endotracheal intubation (17% vs. 31%; p < 0.001) were found less frequently and 9% reported that a team member was infected with COVID-19 during resuscitation.

Conclusion

The COVID-19 resuscitation guidelines are still insufficiently implemented 1 year after publication. Future publication strategies must ensure that respective guideline adaptations are implemented in a timely manner.

Supplementary Information

The online version of this article (10.1007/s00101-022-01237-1) contains underlying questionnaire.

Introduction to the subject

Before the coronavirus disease 2019 (COVID-19) pandemic, the 2015 European Resuscitation Council (ERC) guidelines represented the gold standard of resuscitation in Europe. The COVID-19 pandemic in early 2020 challenged both clinical and prehospital emergency medical services to ensure adequate protection of personnel from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and optimal patient care at the same time. Therefore, several efforts were made to reduce aerosol-liberating procedures to protect prehospital responders.

Introduction and background

Before the COVID-19 pandemic, the 2015 European Resuscitation Council (ERC) guidelines represented the gold standard of resuscitation in Europe. [1, 2]. Because minimal no-flow time is a key prognostic factor in resuscitation, these guidelines focussed on early high-quality chest compressions, early defibrillation, bag-mask ventilation and extraglottic airway devices rather than endotracheal intubation. [1–10, 20].

The COVID-19 pandemic challenged prehospital emergency medical services to ensure adequate protection of personnel from SARS-CoV‑2 transmission and optimal patient care at the same time [11, 12]. Aerosols seem to be the main medium of transmission of SARS-CoV‑2. Aerosols are generated during chest compressions, mouth-to-mouth or bag-mask ventilation, and airway management. Therefore, several efforts were made to reduce aerosol-liberating procedures to protect prehospital responders. [13–17]. In April 2020 the ERC published adaptations to the basic and advanced cardiac life support algorithms for patients with suspected or proven COVID-19 infection with the primary intention to protect resuscitation providers. [11, 12]. For prehospital staff, additional problems arose due to the lack of personal protective equipment in the early phase of the pandemic and limited training opportunities due to imposed (social) distancing regulations [16, 17].

The present study evaluates the implementation status of the COVID-19 resuscitation guidelines in Germany, using an online survey. In addition, differences between resuscitation algorithms with and without COVID-19 adaptations were investigated and the stated infection rates between both groups were compared.

Study design and investigation methods

From 28 March 2021 to 14 May 2021, a web-based questionnaire (www.umfrageonline.com; enuvo GmbH, Pfäffikon, Switzerland) with 22 questions (see Supplementary Information) was distributed via the social media pages of the German Association of Emergency Medical Services (Deutscher Berufsverband Rettungsdienst e. V., DBRD). On 15 April 2021, a reminder was sent via the same social media pages. The DBRD was founded in 2006 and is the only association representing the emergency medical services professionals in Germany with approximately 11,000 members. Participation in the survey was voluntary and anonymous. Only fully completed questionnaires were included in the study. Incomplete questionnaires were excluded from the analysis. Data were evaluated after ethical approval by the ethics committee of the Westphalia-Lippe Medical Association of Muenster (2021-230-f-S) on 29 July 2021. This manuscript adheres to the applicable STROBE guidelines.

In addition to specific participant information (age, level of training, paramedic; emergency medical technician; emergency physician, and work experience), participants were asked the following questions:

• Whether they are aware of ERC advanced cardiac life support guidelines change for patients with suspected or proven COVID-19 infection.

• If the answer was “yes”, they were asked how they were informed about these changes (Internet; professional journals; information by the employer; colleagues; other), and what kind of training they had received (self-study; informational letter and theoretical instruction by employer; virtual training; other).

• Whether a regional resuscitation algorithm for patients with COVID-19 infection was used in their service, who decides to apply this algorithm and what criteria this decision was based on.

• How this algorithm differs from the resuscitation algorithm used previously (adjustment of personal protective equipment; timing of airway protection before rhythm analysis; no chest compressions until airway protection; endotracheal intubation as primary airway protection; routine use of the video laryngoscope during intubation; pausing chest compressions during airway protection; use of an automated chest compression device).

• If and what personal protective equipment was available (surgical face mask; FFP2 mask; FFP3 mask; protective goggles; visor/face shield; protective gown; full protective suit).

• How many emergency medicine service staff performed resuscitation.

• Which airway management strategy was used in COVID-19 resuscitation (bag-mask ventilation; laryngeal tube; laryngeal mask; endotracheal intubation).

• If they were aware of any staff in their service having acquired COVID-19 during a resuscitation or had been quarantined afterwards. The full questionnaire can be found in supplement 1.

Data were collected for statistical analysis in Microsoft Excel® version 2016 and Microsoft Word® version 2016 (Microsoft Germany GmbH, Munich, Germany), presented according to the participants’ responses into the groups with the use of a modified COVID-19 algorithm and without the use of a modified COVID-19 algorithm and statistically compared. Statistical analysis was performed with the χ²-test, significance level p ≤ 0.05, using SPSS V.20.0 (SPSS Inc.).

Results

A total of 968 emergency medical service staff took part in the survey of whom 818 (85%; average age 32 ± 9 years; average pre-hospital care experience 9.1 years) fully completed the questionnaire (paramedics 642, 78%; 95% confidence interval [95% CI] 75–81%; emergency medical technicians 166, 20%; 95% CI 18–23%; emergency physicians 10, 1%; 95% CI 0.6–2%). The ERC COVID-19 resuscitation guidelines were known to 577 (70%; 95% CI 67–74%) of the respondents. At the time of the survey, 103 (13%; 95% CI 10–15%) of the respondents reported that they had attended a training on COVID-19 resuscitation. Table 1 shows what kind of training was provided and how these participants were informed about the guideline changes.

Table 1.

Type of announcement and of training in the specifics of the COVID-19-adapted resuscitation guidelines in Germany

	Positive answer
	n	% (95% CI)
Are you aware of the changes in the European Resuscitation Council recommendations on resuscitation for COVID-19 infection?	577	70 (67–73)
How did you learn about these changes? (multiple answers possible)
Internet	390	67 (64–71)
Medical Journal	255	44 (40–48)
Information from employers	232	40 (36–44)
Colleagues	176	30 (27–34)
Others	73	13 (10–15)
If you had a special training, what type of information/training did you receive? (Multiple answers possible)
Information letter and theoretical instruction by the employer	60	58 (48–68)
Practical instruction & simulation by the employer	46	45 (35–55)
Self-study	40	39 (29–49)
Virtual training	30	29 (21–39)
Others	11	11 (5–18)
Free text details	e‑learning
	Advanced cardiac life support course
	Education to paramedic
	Training by colleagues without employer involvement

95% CI 95% confidence interval

The criteria used for decision making and the specifics of the COVID-19 resuscitation algorithm applied by the respondents in the group of participants with a special COVID-19 resuscitation algorithm are shown in Table 2. Within the study group of participants using a dedicated COVID-19 resuscitation algorithm in patients with suspected or proven infection (n = 265, 32%; 95% CI 29–36%), 160 (60%; 95% CI 54–66%) used defined criteria to trigger the algorithm Of these respondents 260 (98%; 95% CI 96–99%) answered that they decide on their own whether or not to apply this COVID-19 algorithm and 61 (23%; 95% CI 18–28%) replied that the Emergency Operation Center takes this decision.

Table 2.

Criteria and specifics of the COVID-19 resuscitation algorithm in the group of participants with a special COVID-19 resuscitation algorithm

	Positive answer
What criteria do you use to decide if the adapted resuscitation algorithm should be applied? (multiple answers possible) (n = 160 respondents)	n	% (95% CI)
Current positive COVID-19 test (smear/polymerase chain reaction) of the patient	153	96 (91–98)
Members of the household with a current positive COVID-19 test (smear test/polymerase chain reaction)	151	94 (90–97)
Respiratory symptoms (shortness of breath, cough, cold)	150	94 (88–97)
History of fever	131	82 (75–87)
Increased incidence on site	59	37 (29–45)
Emergency medicine service operations in nursing homes	61	38 (31–46)
How does your standard resuscitation algorithm differ from your COVID-19 algorithm? (Multiple answers possible) (n = 265 respondents)
Adaptation of personal protective equipment	262	99 (97–100)
Reducing the number of helpers	99	37 (32–43)
Regular use of the video laryngoscope for intubation	99	37 (32–43)
Securing the airway before rhythm analysis	84	32 (26–38)
Pausing chest compressions whilst securing the airway	80	30 (25–36)
Endotracheal tube as primary airway	74	28 (23–34)
Use of an automated chest compression device	45	17 (13–22)
No chest compressions until airway is secured	24	9 (6–13)

95% CI 95% confidence interval

Table 3 and Fig. 1 show the procedural details of COVID-19 resuscitations in the two groups (participants without vs. with use of a modified COVID-19 algorithm). Significant differences were identified regarding the use of face masks, the maximum number of staff on the patient and the kind of airway management provided.

Table 3.

Special features of resuscitation at the time of the COVID-19 pandemic

	Overall (n = 818)		Participants without a special COVID-19 algorithm (n = 553)		Participants with a special COVID-19 algorithm (n = 265)
	n	% (95% CI)	n	% (95% CI)	n	% (95% CI)
What personal protective equipment is available to paramedics in your ambulance service area during resuscitation of a patient with COVID-19 infection? (multiple answers possible)
Mouth-nose protection	339	41 (38–44)	258	47 (42–51)	81*	31 (25–36)
FFP2 mask	698	85 (82–87)	495	89 (87–92)	203*	77 (71–82)
FFP3 mask	509	62 (58–65)	323	58 (54–62)	186*	70 (64–76)
Protective goggles	804	98 (96–98)	542	98 (96–99)	262	99 (97–100)
Visor/face shield	450	55 (51–58)	292	53 (49–57)	158	60 (53–66)
Protective gown	696	85 (81–86)	478	86 (83–89)	218	82 (77–87)
Full protective suit	620	75 (72–78)	428	77 (74–81)	192	72 (67–78)
How many staff members are on the patient during the resuscitation?
At most 1	2	0.3 (0.0–1)	1	0.2 (0.0–1)	1	0.4 (0.0–2)
At most 2	52	6 (5–8)	30	5 (4–8)	22	8 (5–12)
At most 3	210	26 (22–28)	139	25 (22–29)	71	27 (22–32)
At most 4	204	25 (22–28)	133	24 (21–28)	71	27 (22–32)
≥ 4	350	43 (29–46)	250	45 (41–49)	100***	38 (32–44)
What airway management do you primarily use in COVID-19 resuscitation?
Bag-mask ventilation	119 (14)	14 (12–17)	85	15 (12–19)	34	13 (9–17)
Extraglottic airway	476 (58)	58 (55–62)	364	66 (62–70)	147**	55 (49–62)
Laryngeal tube	404 (49)	49 (46–53)	292	53 (49–57)	112**	42 (36–48)
Laryngeal mask	107 (13)	13 (11–16)	72	13 (10–16)	35	13 (9–18)
Tracheal intubation	178 (22)	22 (19–25)	96	17 (14–21)	82*	31 (25–37)
Only chest compressions until the emergency physician arrives	10 (1)	1 (0.6–2)	8	1 (0.6–2)	2	1 (0.0–3)

95% CI 95% confidence interval, FFP filtering face piece

*p ≤ 0.001

**p ≤ 0.004

***p = 0.04

****p = 0.03

Fig. 1.

Significant differences of special features of resuscitation at the time of the COVID-19 pandemic (x-axis = respondents; y-axis = special features of resuscitation). FFP filtering face piece, * p ≤ 0.001, ** p ≤ 0.004, *** p = 0.04

Overall, 73 (9%; 95% CI 8–12%) respondents were aware of staff in their service that had acquired COVID-19 whilst attending to an out-of-hospital cardiac arrest (participants without a special COVID-19 algorithm: 54 out of 553, 9%; 95% CI 7–12%, participants with a special COVID-19 algorithm: 19 out of 265, 7%; 95% CI 4–11%, p > 0.05).

Overall, 205 (25%; 95% CI 22–28%) of the participants answered that emergency medical service staff in their area had been quarantined for an average of 11.2 days related to resuscitation of a patient with proven or suspected COVID-19 infection (participants without a special COVID-19 algorithm: 135 out of 553, 24%; 95% CI 21–28%, participants with a special COVID-19 algorithm: 73 out of 265, 27%; 95% CI 22–33%, p > 0.05).

Discussion

This study investigates the level of implementation of the COVID-19 resuscitation guidelines in Germany using an online survey of German emergency medical services professionals. Surprisingly, one third of the respondents were not aware of the COVID-19 adaptations to the 2015 ERC guidelines. Only 1 in 10 participated in teaching or training 1 year after the guideline adaptation. Only half of these sessions included practical training. A modified COVID-19 resuscitation algorithm was used by nearly one third of the respondents. The main adaption was adjusting personal protective equipment. Further adjustments in nearly one third were reducing the number of staff on the patient, the routine use of the video laryngoscopy, securing the airway before rhythm analysis and pausing chest compression during endotracheal intubation. Respondents who used a modified algorithm were significantly more likely to use an FFP3 mask and endotracheal intubation, whereas respondents who did not use a modified algorithm were significantly more likely to use a mouth-nose protection or FFP2 mask, a larger number of staff on the patient and an extraglottic airway device. No significant differences in the number of COVID-19 infections were observed between the groups.

Guideline implementation

Because guideline changes only become effective when they are implemented consistently into daily practice, appropriate practical and refresher training is of particular importance to ensure high quality resuscitation [18, 19]. To promote guideline implementation, the ERC carefully plans the publication of new guideline recommendations, publishes the recommendations in different languages to overcome language barriers, provides training material and makes recommendations for training and guideline implementation [18]. Our data suggest that the chosen ways of information utilized in Germany have not led to a sufficient spread of information so far, which is of particular concern in an ongoing pandemic [11, 12]. Social distancing has led to cancellations of teaching, which might have hampered the dissemination of the COVID-19 resuscitation algorithm.

As it remains unclear how the COVID-19 pandemic will develop in the face of emerging mutations, it seems sensible to optimize the dissemination of guidelines to active staff. Possibly, the deficits in dissemination and implementation of modified guideline recommendations may be optimized by, e.g. mandatory online training, quiz questions etc., implemented by local authorities and leadership in each emergency service to ensure dissemination of knowledge rather than relying on voluntary training. In addition to free publication via the internet, direct e‑mailing of emergency service staff has been shown to be effective [23]. Simulation-based training in the context of blended learning is superior to e‑learning alone and might be a useful alternative to traditional classroom education. To reduce the need for face-to-face teaching, virtual reality may also play a role in future training concepts [24–27].

Personal protective equipment

Airborne transmission through aerosol was suspected early after the COVID-19 pandemic had emerged [13–17]. As potentially infectious aerosols are released during resuscitation, the ERC guidelines were adapted on the basis of an expert consensus with the aim to minimize the liberation and exposure of rescuers and emergency medical service staff to contagious aerosols [11, 12, 28]. In this context it is even more surprising that, with no regard to the fact we are speaking about resuscitation, a large proportion of emergency staff seems to underuse personal protective equipment such as mouth-nose protection or FFP2 mask during their routine work on ambulance duties. This sheds new light on the particular importance of raising the awareness of active emergency medical service personnel on the adequate attention to personal protective equipment.

In addition to wearing adequate personal protective equipment, emphasis was also placed on reducing the number of staff present while performing airway management [11, 12]. On the one hand, COVID-19-associated morbidity and mortality of rescuers should be prevented and on the other hand the functionality of the emergency medical service should be ensured by preventing contact-related infections of staff and quarantines [11, 12, 17]. Whilst protective face masks were widely adopted other recommendations were not well implemented as reduction of staff for instance. This could be due to insufficient dissemination of information about the guideline adaptations and because of reduced practical training opportunities (see Table 2). The changes made to the resuscitation guidelines and subsequent adherence to the guidelines which mainly focus on staff protection, while conceding potentially worse patient outcomes, as well as a deficit in training may have contributed to the increase in out-of-hospital cardiac arrest mortality rates seen during the COVID-19 pandemic [21, 22].

Airway management

The importance of airway management for the prognosis of out-of-hospital cardiac arrest has been the subject of various studies in recent years [29]. While using bag-mask ventilation or an extraglottic airway was associated with a better outcome of out-of-hospital cardiac arrest, possibly by reducing the no-flow time, endotracheal intubation came back into focus because of its lower potential for aerosol liberation. This makes a sufficiently blocked endotracheal tube and the use of an adequate viral filter the gold standard for preventing aerosol liberation [1–4], which explains the significantly higher rate of endotracheal intubation in the group of participants using a COVID-19 algorithm [11, 12, 29, 30].

The use of video laryngoscopy is currently recommended for endotracheal intubation of patients with proven or suspected COVID-19 [11, 12]. In addition to a significant improvement of the intubation conditions and an increased first-pass success, video laryngoscopy in this context allows an increased distance of the intubator from the patient’s face, reducing aerosol exposure [29, 30]. Despite these advantages, the majority of respondents in both groups reported using an extraglottic airway as the primary airway device during resuscitation in COVID-19 patients (see Table 3). A possible cause could be that German emergency medical service staff, who are mostly not trained in endotracheal intubation still used extraglottic airways in line with their (not adapted) protocols. However, from a resource perspective it is not feasible to equip every ambulance with a video laryngoscope and train every paramedic accordingly. Hence, it appears reasonable to investigate simple protective measures that can be implemented in the reality of care more easily: Covering the patient’s face with a protective film after insertion of the extraglottic airway, as used in anesthesia or intensive care, could possibly contribute to improving safety by reducing aerosol liberation and should be investigated in future studies to achieve an optimal compromise between resuscitation quality and provider safety [11, 12, 29].

Early defibrillation

The importance of performing early defibrillation has been demonstrated in numerous studies and is also an essential component of the COVID-19 resuscitation guidelines. Assuming that defibrillation is not associated with increased aerosol generation, it is of note that one third of the participants in the group using a modified COVID-19 resuscitation algorithm reported performing airway protection before rhythm analysis [11, 12]. Training should explicitly emphasize the importance of early defibrillation also in patients with proven or suspected COVID-19.

COVID-19 infections after resuscitation

There were no significant differences in the need for and duration of quarantine or in the number of COVID-19 infections between both groups known to the participants as a result of COVID-19 resuscitation. Despite potential limitations of this survey it is possible that the measures implemented for provider protection by means of appropriate protective masks and airway protection and the progress in vaccination coverage are effective to prevent SARS-CoV‑2 transmission in prehospital emergency personal. In this context, further studies should attempt to optimize the resuscitation algorithm, focusing on minimization of no-flow time.

Limitations

This study was conducted as a voluntary online survey, with the risk of responder bias and the sample not being representative (selection bias) because the estimated rate of participation was about 8%. While most of the members of the German Association of Emergency Medical Services are not physicians, in Germany professional resuscitation is often conducted together with emergency physicians. Therefore, the study design may limit the validity of the presented results. Typically, respondents to online surveys are more prone to have an intrinsic drive for the topic at hand, therefore were more on the side of those who were aware of the new guidelines. Therefore, this study may overestimate the level of implementation. However, overall the distribution of participants in the present study reflects the distribution of emergency medical service locations in Germany and allows a limited review of the current state of guideline implementation during the COVID-19 pandemic.

Conclusions and/or practical recommendations

• One year after publication the respective adaptations of the ERC COVID-19 resuscitation guidelines are still insufficiently implemented. This may lead to an increased risk of exposure for emergency medical service staff.

• Experiences from the COVID-19 pandemic show that alternative strategies for teaching and training in resuscitation, using modern techniques and digitalization, e.g. blended learning methods or virtual reality, may prove useful in future pandemics.

• As the majority of respondents are using extraglottic airway in out-of-hospital cardiac arrest, the prevention of aerosol liberation through extraglottic airways should be investigated and addressed to optimize the compromise between resuscitation quality and provider safety.

Author Contribution

Gerrit Jansen, Nils Kappelhoff, Frank Flake, Rainer Borgstedt, Sebastian Rehberg, Sean S. Scholz, Karl C. Thies have given substantial contributions to the conception and the design of the manuscript, to acquisition, analysis and interpretation of the data. All authors have participated in drafting the manuscript and revised it critically. All authors read and approved the final version of the manuscript.

Declarations

Conflict of interest

S. Rehberg is a medical advisor for Fresenius Kabi Germany, has received honoraria and travel expenses from Amomed Pharma and Orion Pharma. G. Jansen, N. Kappelhoff, F. Flake, R. Borgstedt, S.S. Scholz and K.-C. Thies declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.