Authors: Leia Kane, Toby Edmunds, Adam Campbell, Gareth Patton, Conal Mulholland, Tom Black, Lynn Stevenson, Ben Spowage-Delaney, Katie Roberts / Editors: Rajesh Chatha, Robert Hirst / Codes: MHC7, RP3, SLO10, SLO9 / Published: 10/11/2021

As many of us navigate a new curriculum, and with all of us feeling the immense pressures currently being faced, it seems apt that this month’s review topic is “Training and Wellbeing”.

We have been reminded that it is not only our own education that makes a difference to patient outcomes and that we do need to look after ourselves.  Laura Cottey, Tom Roberts, and the wider TERN have produced some important work in this area which we have intentionally not summarised.  We recommend you look at this in full here; and we consider our picks the best of the rest.

Be kind, be passionate, recover well and ask for help if you need it!


Effects of mobile mindfulness on emergency department work stress: A randomised controlled trial1

A two-arm randomised controlled trial in two Australian EDs recruiting from all ED staff groups in 2019-2020 aimed to determine whether a 4-week intervention of smartphone app guided mindfulness practice reduced stress levels in ED Staff. 

Participants were randomised to either an app group or a wait to treat group to practice daily 10 min app-guided mindfulness for 4 weeks. Online surveys were collected for both groups at three time periods: before, immediately after and 3 months after. The wait to treat group then received the same intervention, followed by surveys immediately after the intervention and 3 months later. 

Stress levels were measured using the Perceived Stress Scale. Secondary outcomes were measured using the Maslach Burnout Inventory, Mindfulness Attention Awareness Scale and Warwick-Edinburgh Mental Well-being Scale which are validated tools assessment tools. Both intention-to-treat and per-protocol analysis were performed and repeated measurement data were analysed by the linear mixed model.

Of 148 enrolled participants 98 completed all the surveys, but only 48% reported continuous use of the app. Based on the results of the intention-to-treat analysis, there was a statistically significant improvement of perceived stress levels, burnout, mindfulness and wellbeing levels from before intervention to 3 months later.

The delivery makes this intervention easily accessible to a wide number of ED staff members who may not have the time or inclination to access mindfulness training in other formats.  However, those who were recruited to the study were potentially more aware of and willing to engage with a strategy to address their stress levels. There were low levels of engagement with the intervention which means that those who did not have any benefit may not have been identified by the study. Importantly, the authors state that whilst they focused on encouraging individual wellbeing this should not replace the importance of other interventions addressing root causes of stress and burnout at the systematic level.

Bottom Line

Mindfulness training delivered via smartphone apps such as Headspace as used in this study have a benefit in reducing self-reported stress levels and burnout and may be one useful and easily accessible tool in helping to combat workplace stress in ED staff members.


  1. Xu HG, Eley R, Kynoch K, Tuckett A. Effects of mobile mindfulness on emergency department work stress: A randomised controlled trial.  Emerg Med Australas. 2021. doi: 10.1111/1742-6723.13836, 10.1111/1742-6723.13836

Addressing Post-pandemic Clinician Mental Health: A Narrative Review and Conceptual Framework2

This paper aims to synthesise research into 7 main themes regarding front-line clinician mental health needs post-pandemic. They matched this with current, readily available mental health resources found to be high yield and peer-reviewed these resources.

A narrative review was completed of 96 papers since the severe acute respiratory syndrome (SARS) outbreak in 2004 identified using keywords and then included only those which discussed: 1) prevalence of mental health symptoms during or after the pandemic and 2) individual, organizational-level, or societal-level responses to or assessment of mental health in health care workers. They peer-reviewed well-being resources from the Collaborative for Healing and Renewal in Medicine (CHARM) network.

Seven themes were identified in which uncertainty or lack of availability was found to worsen psychological wellbeing, separated into the three inclusion categories: 

First, development in the individual health care worker: 1) the need for resilience and stress reduction training. 

Next, development at the organisational level of the health care provider: 2) providing for clinicians’ basic needs (food, drink, adequate rest, quarantine-appropriate housing, transportation, childcare, PPE); 3) the importance of specialized training for pandemic-induced changes in job roles; 4) recognition and clear communication from leadership; 5) acknowledgment of and strategies for addressing moral injury; 6) the need for peer and social support interventions. 

Lastly, change within our society: 7) normalization and provision of mental health support programs.

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Bottom Line

This review provides a thought-provoking collection of goals, both for front line clinicians themselves to recognise and de-stigmatise the need for psychological support and what interventions may benefit them; and goals for system organisers to aim for to best support their teams post COVID-19 pandemic. 


  1. Schwartz R, Sinskey JL, Anand U, Margolis RD. Addressing Postpandemic Clinician Mental Health : A Narrative Review and Conceptual Framework. Ann Intern Med. 2020; 173(12): 981–8. doi: 10.7326/M20-4199.PMID: 32822206.

Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest3 

We know that timely and good quality chest compressions is associated with improved morbidity and mortality in cardiac arrest. Recent public health programmes have aimed to increase the frequency of layperson-bystander CPR in out of hospital cardiac arrest (OOHCA). This has been done through first aid and BLS courses and advertisements. The use of dispatcher assisted CPR has been used as a more cost effective, easier to maintain service. This study compared the two forms of training.

This is a cohort observational study, meaning a review of cases and no intervention (this allowed for waiving of the need for consent). It used a database of OOHCA in Sweden to compare dispatcher assisted CPR (DA-CPR) with both spontaneously initiated CPR (SP-CPR) and no CPR (NO-CPR). They looked at cases where OOHCA was witnessed and where CPR was performed by a layperson (non-healthcare professional). The primary endpoint was all cause mortality at 30 days.

They found that absolute survival improves from NO-CPR (7.1%) to DA-CPR (13.0%). However, SP-CPR had an even greater increased rate of survival at 18.3%.

This study addresses an important question around the appropriateness of investing in DA-CPR over public education to improve SP-CPR. The results showing an increase in absolute survival of 6 and 11% are impressive and the results remained statistically significant even when propensity-score-matched to account for difference between the groups. The large recruitment numbers (n=15471) were another strength which supports the importance of this study.

In evaluating the weaknesses of the study, the primary endpoint is a good starting point, but this does not tell the whole story; a patient centered outcome involving longer term neurological outcome may be more appropriate. When comparing unwitnessed cardiac arrest, the survival in all groups was less and there was no significant difference in outcome between the groups.

Bottom Line

In witnessed OOHCA, DA-CPR was associated with improved 30-day survival when compared with NO-CPR, however, DA-CPR was associated with worse survival than SP-CPR.


  1. Riva, Gabriel et al. “Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest.” Resuscitation. 2020; 157: 195-201. doi:10.1016/j.resuscitation.2020.08.125

Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals4

Following the London Transport Bombings, Manchester Arena Terrorist Attach and the Grenfell tower tragedy, the authors conducted separate surveys in 2006 and 2019 where they found there to be a gap in knowledge of key individuals in hospitals across England with regards to their major incident plans.

This paper describes a secondary analysis of the data collected in 2019 specifically comparing the responses from doctors working at major trauma centres (MTC) and other hospitals (non MTC).  

The study team contacted the on-call anaesthetic, emergency, general surgery and trauma and ortho registrars via switch board and asked three questions; a) Have you read your hospital’s MIP?, b) do you know where you can access your hospitals MIP guidelines?, and c) do you know what role you would play if a MIP came into effect while you were on call?

62.8% of contacted registrars consented to being included in the study.  In the primary analysis 50% had read at least part of the MIP, 46.8% were confident they knew where to find it and 36% knew of their role in the enactment plan. 

ED and anaesthetic registrars showed greater preparedness across all questions. In the secondary analysis the authors found there to be only a marginal precedence of MTC over non MTC.

The authors conclude the MIP training could be included in medical inductions. 

Bottom Line

While we can’t argue MIP training could be included at inductions for relevant speciality trainees it would have been interesting to include consultants, senior nurses and relevant AHPs in this study.


  1. Mawhinney, Jamie A et al. “Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals.” Emergency Medicine Journal. 2020; ; 38(10): 765-768. doi:10.1136/emermed-2020-209767

Randomized Trial of Therapy Dogs Versus Deliberative Colouring (Art Therapy) to Reduce Stress in Emergency Medicine Providers5

Burnout and cognitive stress is an increasing concern within healthcare, particularly within Emergency Medicine staff. 

This paper looked at the perceived and manifested stress levels in ED workers after 5 minutes of interaction with a therapy dog versus deliberative colouring of a mandala or no intervention. It was hypothesized that interaction with the therapy dog while on ED shift would decrease stress levels in both physicians and nurses. 

This was a prospective randomised control trial performed in a single centre with 127 participants of which five withdrew voluntarily due to the shift being too busy. Participants provided three self-reported assessments of stress and saliva samples at the start (T1), middle (T2) and end (T3) of the shift, with randomisation occurring 30 minutes before T2. The visual analogue scale (VAS), modified perceived stress scale, FACES scale and salivary cortisol were used to assess stress levels at each time point. 

Participants randomised to interaction with the therapy dog had a significant reduction in self-reported anxiety (via the VAS score) compared to the colouring group and control. There was no significant difference in the FACES scale between control vs colouring or control vs dog group. Salivary cortisol reduced at T2 and T3 in both the dog therapy and colouring compared to the control group. 

Bottom Line

A 5-minute interaction with a therapy dog and handler during an ED shift can have a significant impact on reducing perceived and manifested stress levels in emergency medicine staff.

[Editor: personally, I’d love to see this intervention become more widespread!]


  1. Kline, Jeffrey A et al. “Randomized Trial of Therapy Dogs Versus Deliberative Coloring (Art Therapy) to Reduce Stress in Emergency Medicine Providers.” Academic Emergency Medicine. 2020;  27(4): 266-275. doi:10.1111/acem.13939

Barriers and facilitators for in-hospital resuscitation: A prospective clinical study6

This is a mixed methods prospective cohort study aiming to assess and understand the challenges with non-technical skills during in hospital cardiac arrest.

Data was collected after each cardiac arrest event via a survey to each team member assessing perceived resuscitation quality, teamwork, communication, barriers, and facilitators. It included data from all in hospital cardiac arrests from hospitals in the Central Denmark region where a cardiac arrest team attended (6 centres).  The data was collected over a 4-year period.

The survey used was split into three key parts. The first to assess the quality of the resuscitation, the second to assess if the respondent had challenges during the resuscitation, and the third include respondent demographics.

The results showed 924 resuscitation attempts allowing 3698 survey responses.  Quantitive aspects of the questionnaires were reported using descriptive statistics.  A coding framework was developed and applied to create qualitative data for review using thematic analysis.

The data collected shows that the most frequent challenges were overcrowding (27%) and poor ergonomics/choreography of people in the room (17%). Narrative comments aligned into 24 unique barrier and facilitator themes in 4 domains; 6 related to treatment (most commonly CPR, the rhythm check, and equipment), 7 for teamwork (most commonly role allocation, crowd control, collaboration with ward staff), 6 for leadership (most common being a visible and distinct leader, multiple leaders, leader experience) and 5 for communication (most common closed loops, atmosphere in room, speaking clearly).

Bottom Line

This study gives an insight into the complexity of delivery high quality resuscitation and suggests some of the potential barriers faced by resuscitation teams in hospital.  It allows a contextualisation of CPR and resuscitation guidelines for teams to consider the barriers and facilitators they may have within their own units.


  1. Lauridsen KG, Krogh K, Müller SD, Schmidt AS, Nadkarni VM, Berg RA, Bach L, Dodt KK, Maack TC, Møller DS, Qvortrup M, Nielsen RP, Højbjerg R, Kirkegaard H, Løfgren B. Barriers and facilitators for in-hospital resuscitation: A prospective clinical study. Resuscitation. 2021; 164: 70-78. doi: 10.1016/j.resuscitation.2021.05.007. Epub 2021 May 24. PMID: 34033863.

What happens in the shock room stays in the shock room? A time-based audio/video audit framework for trauma team performance analysis7

This observational study in a Level 1 European trauma centre examined the use of audio and visual recording of the resuscitation of trauma patients according to ATLS guidelines. Data was collected on a series of camara and a sound detection system. 162 trauma team activations took place with 143 were analysed; some recordings were not successful. They reviewed the videos against an 11-point ATLS checklist of skills to be performed in the primary survey as well as the T-NOTECHS non- technical evaluation score.

Thy found 68.5% of the cases had a completed primary survey checklist as approved by ATLS. They were able to ‘very precisely’ document times taken to complete each task. Some skills were achieved quickly, such as a second IV access was established in 97% of cases within 2.92minutes. Other procedures such as chest drain and CT scan took longer; over 40min to obtain. 

The non-technical assessment identified the teams to be average with communication and leadership but well above average for co-operation score. They did admit this score had limitations due to the lack of objective skills markers. 

Bottom Line

This study demonstrated it was feasible to obtain precise information of events during trauma care using in-situ audio and visual recording for subsequent review. This could be useful tool to support audit, clinical governance and education. 


  1. Aukstakalnis V, Dambrauskas Z, Stasaitis K, Darginavicius L, Dobozinskas P, Jasinskas N, Vaitkaitis D. What happens in the shock room stays in the shock room? A time-based audio/video audit framework for trauma team performance analysis. Eur J Emerg Med. 2020;; 27(2): 121-124. doi: 10.1097/MEJ.0000000000000627. PMID: 31490786; PMCID: PMC7050797.

Combatting COVID-19: is ultrasound an important piece in the diagnostic puzzle?8

This literature review examines the use of point of care lung ultrasound (LUS) in the diagnosis and management of suspected COVID 19 patients. Due to the rapidly changing nature of information at the time of writing the authors used a novel approach to data collection. This included crowd sourcing information from global expert user groups, social media, specialist websites and none peer reviewed evidence, in addition to a peer reviewed literature search. 

Lung imaging can be useful in the diagnosis and prognostication of COVID-19 but the review identified CXR can miss up to 40% of confirmed cases. 

The review suggested that CT scanning had a sensitivity of between 88-97% for identifying COVID-19. However, in the hands of an experienced operator, they found evidence suggesting LUS can be 100% sensitive and 78.6% specific when compare with CT scan for detecting COVID 19 disease. 

The authors list possible LUS finding suggestive of COVID 19 pneumonitis and explore its limitations. They suggest LUS could a useful additional tool for decision making in a range of situations:

  • In clinically well patients with risk factors for severe COVID disease, abnormal LUS could identify those needing closer monitoring.
  • While LUS would not be appropriate during resuscitation for the diagnosis of COVID 19 POCUS could be used to identify other illnesses such as PE, tamponade and hypovolaemia in critically ill patients. 

The authors provide suggestions for optimising technique and a scanning protocol. 

Bottom Line

There is an emerging evidence base that, with appropriate training, LUS can be a useful additional diagnostic tool in the management of suspected COVID 19 patients in the ED. This article offers practical advice on how this can be done. 


  1. McDermott, Cian et al. “Combatting COVID-19: is ultrasound an important piece in the diagnostic puzzle?.” Emergency Medicine Journal. 2020; 37:10: 644-649. doi:10.1136/emermed-2020-209721