The Resuscitation Council is the United Kingdom body responsible for setting central standards for cardiopulmonary resuscitation guidelines — analogous to the American Heart Association’s role in setting the guidelines to ACLS (advanced cardiac life support) protocols.
To those not aware, cardiopulmonary resuscitation guidelines are the emergent steps taken when an individual’s heart stops beating, or if they are experiencing other life threatening cardiopulmonary anomalies.
The Resuscitation Council (UK) released iResus, a free iPhone medical app, in January 2010, aimed to help educate health care providers on ACLS guidelines. It includes adult and pediatric algorithms, with an interactive user interface.
Researchers in the UK wanted to see if the mobile app could be utilized to improve the performance of physicians in simulated emergencies. Low, Clark, Soar, et al (2011) performed a randomized control trial using the iResus app, and recently published their findings in the Journal Anaesthesia.
Their end conclusion further justifies the push for mobile medical apps at the point of care, and their research provided valuable data. However, there are aspects of the study that left us questioning certain protocols and practical utility of the medical app.
iResus, the app
iMedicalApps will have a detailed review of iResus in the future, but here are the basic contents of the application:
*Adult and Pediatric Guidelines
*Guidelines are stored in a central server, allowing the application to be automatically updated within the app, enabling the app to always have current guidelines
*8 different adult algorithms
*5 different pediatric algorithms
*Each algorithm is interactive, allowing you to easily choose different decision trees based on the particular situation
*Along with drug dosing information, associated text is also provided, such as “reversible causes” of the particular cardiac pathology (possibly the most useful part of this app)
Methods of the randomized control trial
The study was conducted in the Education Centre at the Royal United Hospital and took place over three evening sessions, from February to March 2010. While waiting in clinical workshops (to refresh knowledge of algorithms), participants were assigned to random groups.
Eligibility criteria: Resuscitation Council (UK) ALS trained Junior (residents and fellows) doctors, within 5 years of qualification, working in either the Royal United Hospital, Bath, or Southmead Hospital, Bristol. They were recruited via poster and e-mail, and were not blinded as to the purpose of the study. All participants were shown how to use the iResus app, how to navigate the app, but not shown the bradycardia algorithm, the basis for the assessment.
After randomization via opaque sealed envelopes, those in the intervention arm were given an iPhone with the iResus app, and those in the control arm did not have access to any aids.
Participants were then assessed using one of the Resuscitation Council’s cardiac simulation test — CASTest. This simulation tests the ability of the participant to perform resuscitation techniques during a simulated cardiac emergency using a mannequin with full defibrillation capacity. During this test the participant is provided with nurses and other house staff that would normally help during a patient’s resuscitation, helping to provide drugs and to perform CPR.
The participants were all given the same acute cardiac scenario, and then tested based on the CASTest scoring system. There were a total of 31 participants, with 15 randomly being assigned to the intervention group.
CASTest score for those junior doctors who used a smart phone was 84.5, compared to 72 in the control group. The P value was .02, showing a statistically significant difference between the intervention (iResus app) and control group.
Feedback from study participants
Interestingly enough, the participants of the study stated they would not be embarrassed to use the app in real clinical emergencies — they found the iResus app easy to use, and felt it increased confidence in their decision making ability.
Overall, we are fans of the methods used in this study, and it’s no exaggeration that we’re suckers for randomly controlled trials. The authors did a great job of using an analytical approach to show how the iResus app can be used to improve the performance of doctors trained in advanced life support in a simulated emergency.
We would have loved to see the investigators add another arm to the study and compare the iResus app with a standard card based cognitive aid, as opposed to a group with no cognitive aid at all. The researchers stated they choose not to do this since most physicians do not carry around resuscitation guidelines with them. However, doing this type of analysis would have truly shown if an interactive mobile device can outperform traditional cognitive aids. This type of analysis would have also shown if an interactive mobile aid serves as a better training tool than traditional paper based aids.
Some problems not addressed in the study are the practical problems that would arise with the use of an iPhone in the clinical setting, such as receiving a phone call, text message, or notification while using this application. In order to use this medical app in the clinical setting, the iPhone would have to be set to “Airplane” mode, or more practically, an iPod Touch would make a more suitable device for house officers to carry.
The next step in the process of studying the iResus app will be to see how it performs in an actual clinical setting, a study that will be significantly more difficult to perform. As the authors mentioned in the study, with the recent implementation of the World Health Organization surgical checklist, and other “no fail” professions such as pilots using checklists, the physician culture needs to stop being reluctant towards using cognitive aids for worry of seeming incompetent.
At the end of the day, interactive mobile aids such as this could improve outcomes, our ultimate end goal.
Authors: Low, Clark, Soar, Padkin, Stoneham, Perkins, Nolan
Journal: Anaesthesia, 2011, 66, pages 255-262
iResus medical app iTunes link: http://itunes.apple.com/us/app/iresus/id335355440?mt=8