Rescuer fatigue during cardiopulmonary resuscitation (CPR) is a likely contributor to variable CPR quality during clinical resuscitation efforts, yet investigations into fatigue and CPR quality degradation have only been performed in simulated environments, with widely conflicting results.
We sought to characterize CPR quality decay during actual in-hospital cardiac arrest, with regard to both chest compression (CC) rate and depth during the delivery of CCs by individual rescuers over time.
Using CPR-recording technology to objectively quantify CCs and provide audiovisual feedback, we prospectively collected CPR performance data from arrest events in two hospitals. We identified continuous CPR “blocks” from individual rescuers, assessing CC rate and depth over time.
135 blocks of continuous CPR were identified from 42 cardiac arrests at the two institutions. Median duration of continuous CPR blocks was 112 sec (IQR 101–122). CC rate did not change significantly over single rescuer performance, with an initial mean rate of 105 ± 11 / min, and a mean rate after 3 min of 106 ± 9 / min (p=NS). However, CC depth decayed significantly starting between 90 sec and 2 min, falling from a mean of 48.3 ± 9.6 mm to 46.0 ± 9.0 mm (p=0.0006) and to 43.7 ± 7.4 mm by 3 minutes (p=0.002).
During actual in-hospital CPR with audiovisual feedback, CC depth decay became evident after 90 sec of CPR, but CC rate did not change. These data provide clinical evidence for rescuer fatigue during actual resuscitations and support current guideline recommendations to rotate rescuers during CC delivery.
cardiopulmonary resuscitation; cardiac arrest; quality of care
Hands-Only cardiopulmonary resuscitation (CPR) is recommended for use on adult victims of witnessed out-of-hospital (OOH) sudden cardiac arrest or in instances where rescuers cannot perform ventilations while maintaining minimally interrupted quality compressions. Promotion of Hands-Only CPR should improve the incidence of bystander CPR and, subsequently, survival from OOH cardiac arrest; but, little is known about a rescuer's ability to deliver continuous chest compressions of adequate rate and depth for periods typical of emergency services response time. This study evaluated chest compression rate and depth as subjects performed Hands-Only CPR for 10 minutes. For comparison purposes, each also performed chest compressions with ventilations (30:2) CPR. It also evaluated fatigue and changes in body biomechanics associated with each type of CPR.
Twenty healthy female volunteers certified in basic life support performed Hands-Only CPR and 30:2 CPR on a manikin. A mixed model repeated measures cross-over design evaluated chest compression rate and depth, changes in fatigue (chest compression force, perceived exertion, and blood lactate level), and changes in electromyography and joint kinetics and kinematics.
All subjects completed 10 minutes of 30:2 CPR; but, only 17 completed 10 minutes of Hands-Only CPR. Rate, average depth, percentage at least 38 millimeters deep, and force of compressions were significantly lower in Hands-Only CPR than in 30:2 CPR. Rates were maintained; but, compression depth and force declined significantly from beginning to end CPR with most decrement occurring in the first two minutes. Perceived effort and joint torque changes were significantly greater in Hands-Only CPR. Performance was not influenced by age.
Hands-Only CPR required greater effort and was harder to sustain than 30:2 CPR. It is not known whether the observed greater decrement in chest compression depth associated with Hands-Only CPR would offset the potential physiological benefit of having fewer interruptions in compressions during an actual resuscitation. The dramatic decrease in compression depth in the first two minutes reinforces current recommendations that rescuers take turns performing compressions, switching every two minutes or less. Further study is recommended to determine the impact of real-time feedback and dispatcher coaching on rescuer performance.
The 2005 Emergency Cardiac Care guidelines for basic life support (BLS) recommend a compression to ventilation ratio of 30:2. The effect of the additional exertion required to deliver more chest compressions may present a considerable physical burden on the provider.
To compare cardiopulmonary resuscitation (CPR) performance and perceived exertion during compression to ventilation ratios of 15:2 and 30:2 with real-time feedback during two-rescuer CPR.
Eighteen BLS-certified healthcare providers each performed five minutes of chest compressions on a manikin with compression to ventilation ratios of 15:2 or 30:2 on two separate sessions. Heart rate, capillary lactate, and OMNI Rate of Perceived Exertion (RPE) were recorded before and after each session. Subjects were given continuous, automated, feedback via an accelerometer that measured rate, depth, duration, and release of compressions. Compression measurements and feedback messages were recorded continuously during each five minute session. Data were analyzed using descriptive statistics and t-test to compare groups. Repeated measures ANOVA was used to compare data over the five minute epoch.
After performing external chest compressions for five minutes, peak heart rate (102±24 vs. 106±27), capillary lactate (2.2±0.95 vs. 2.2±0.96), and OMNI RPE (4.3±1.2 vs. 4.6±1.1) were higher were higher than baseline, but did not differ between 15:2 and 30:2. Compression rate (102 ± 24 vs.106 ± 27) and depth (38.8±3.6 vs. 38.2±2.9) did not differ between 15:2 and 30:2 groups or at any minute. Total chest compressions delivered were higher (p<0.05) in the 30:2 group (457±43) compared to 15:2 (379±28). The average no flow time was lower (p<0.05) in the 30:2 group (22±3.03) compared to the 15:2 group (33±2.64). Number of correction prompts (48±55 vs. 64±70) did not differ significantly between the 15:2 and 30:2 groups.
In a cohort of healthcare providers, increasing the CPR ratio from 15:2 to 30:2 did not change physical or perceived exertion during a five-minute bout of CPR when continuous, real-time feedback is provided. The 30:2 compression to ventilation ratio resulted in more chest compressions per minute without decreasing CPR quality.
Cardiopulmonary resuscitation; Guidelines; Compression to ventilation ratio; Manikin; Healthcare provider; Lactate
To investigate the effectiveness of brief bedside “booster” cardiopulmonary resuscitation (CPR) training to improve CPR guideline compliance of hospital-based pediatric providers.
Prospective, randomized trial.
General pediatric wards at Children’s Hospital of Philadelphia.
Sixty-nine Basic Life Support–certified hospital-based providers.
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated pediatric arrest. After a 60-sec pretraining CPR evaluation, subjects were randomly assigned to one of three instructional/feedback methods to be used during CPR booster training sessions. All sessions (training/CPR manikin practice) were of equal duration (2 mins) and differed only in the method of corrective feedback given to participants during the session. The study arms were as follows: 1) instructor-only training; 2) automated defibrillator feedback only; and 3) instructor training combined with automated feedback.
Measurements and Main Results
Before instruction, 57% of the care providers performed compressions within guideline rate recommendations (rate >90 min−1 and <120 min−1); 71% met minimum depth targets (depth, >38 mm); and 36% met overall CPR compliance (rate and depth within targets). After instruction, guideline compliance improved (instructor-only training: rate 52% to 87% [p .01], and overall CPR compliance, 43% to 78% [p < .02]; automated feedback only: rate, 70% to 96% [p = .02], depth, 61% to 100% [p < .01], and overall CPR compliance, 35% to 96% [p < .01]; and instructor training combined with automated feedback: rate 48% to 100% [p < .01], depth, 78% to 100% [p < .02], and overall CPR compliance, 30% to 100% [p < .01]).
Before booster CPR instruction, most certified Pediatric Basic Life Support providers did not perform guideline-compliant CPR. After a brief bedside training, CPR quality improved irrespective of training content (instructor vs. automated feedback). Future studies should investigate bedside training to improve CPR quality during actual pediatric cardiac arrests.
pediatric; cardiopulmonary resuscitation; quality appraisal
Good quality basic life support (BLS) improves outcome following cardiac arrest. As BLS performance deteriorates over time we performed a parallel group, superiority study to investigate the effect of feedback on quality of chest compression with the hypothesis that feedback delays deterioration of quality of compressions.
Participants attending a national one-day conference on cardiac arrest and CPR in Denmark were randomized to perform single-rescuer BLS with (n = 26) or without verbal and visual feedback (n = 28) on a manikin using a ZOLL AED plus. Data were analyzed using Rescuenet Code Review. Blinding of participants was not possible, but allocation concealment was performed. Primary outcome was the proportion of delivered compressions within target depth compared over a 2-minute period within the groups and between the groups. Secondary outcome was the proportion of delivered compressions within target rate compared over a 2-minute period within the groups and between the groups. Performance variables for 30-second intervals were analyzed and compared.
24 (92%) and 23 (82%) had CPR experience in the group with and without feedback respectively. 14 (54%) were CPR instructors in the feedback group and 18 (64%) in the group without feedback. Data from 26 and 28 participants were analyzed respectively. Although median values for proportion of delivered compressions within target depth were higher in the feedback group (0-30 s: 54.0%; 30-60 s: 88.0%; 60-90 s: 72.6%; 90-120 s: 87.0%), no significant difference was found when compared to without feedback (0-30 s: 19.6%; 30-60 s: 33.1%; 60-90 s: 44.5%; 90-120 s: 32.7%) and no significant deteriorations over time were found within the groups. In the feedback group a significant improvement was found in the proportion of delivered compressions below target depth when the subsequent intervals were compared to the first 30 seconds (0-30 s: 3.9%; 30-60 s: 0.0%; 60-90 s: 0.0%; 90-120 s: 0.0%). Significant differences were not found in secondary outcome and in other performance variables between the groups and over time
Quality of CPR was maintained during 2 minutes of continuous compressions regardless of feedback in a group of trained rescuers.
Cardiopulmonary resuscitation (CPR); Basic life support (BLS); Advanced life support (ALS); Cardiac arrest; Resuscitation
Because mobile telephones may support video calls, emergency medical dispatchers may now connect visually with bystanders during pre-hospital cardio-pulmonary resuscitation (CPR). We studied the quality of simulated dispatcher-assisted CPR when guidance was delivered to rescuers by video calls or audio calls from mobile phones.
One hundred and eighty high school students were randomly assigned in groups of three to communicate via video calls or audio calls with experienced nurse dispatchers at a Hospital Emergency Medical Dispatch Center. CPR was performed on a recording resuscitation manikin during simulated cardiac arrest. Quality of CPR and time factors were compared depending on the type of communication used.
The median CPR time without chest compression (‘hands-off time’) was shorter in the video-call group vs. the audio-call group (303 vs. 331 s; P=0.048), but the median time to first compression was not shorter (104 vs. 102 s; P=0.29). The median time to first ventilation was insignificantly shorter in the video-call group (176 vs. 205 s; P=0.16). This group also had a slightly higher proportion of ventiliations without error (0.11 vs. 0.06; P=0.30).
Video communication is unlikely to improve telephone CPR (t-CPR) significantly without proper training of dispatchers and when using dispatch protocols written for audio-only calls. Improved dispatch procedures and training for handling video calls require further investigation.
Undressing the chest of a cardiac arrest victim may delay the initiation of chest compressions. Furthermore, expecting laypeople to undress the chest may increase bystander reluctance to perform cardiopulmonary resuscitation (CPR). Both of these factors might conceivably decrease survival following cardiac arrest. Therefore, the aim of this study was to examine if the presence or absence of clothes affected the quality of chest compressions during CPR on a simulator manikin.
Thirty laypeople and 18 firefighters were randomised to start CPR on the thorax of a manikin that was either clothed (three layers) or not. Data were obtained via recordings from the manikin and audio- and video-recordings. Measurements were: maximum compression depth; compression rate; percentage of compressions with correct hand positioning; percentage of compressions with complete release (≤ 10 mm), and percentage of compressions of the correct depth (range 40-50 mm). Laypeople were given a four-hour European Resuscitation Council standardised course in basic life support and tested immediately after. Firefighters were tested without additional training. Mock cardiac arrest scenarios consisted of three minutes of CPR separated by 15 minutes of rest.
No significant differences were found between CPR performed on an undressed manikin compared to a dressed manikin, for laypeople or firefighters. However, undressing the manikin was associated with a mean delay in the initiation of chest compressions by laypeople of 23 seconds (N = 15, 95% CI: 19;27).
In this simulator manikin study, there was no benefit gained in terms of how well CPR was performed by undressing the thorax. Furthermore, undressing the thorax delayed initiation of CPR by laypeople, which might be clinically detrimental for survival.
Performance of high quality CPR is associated with improved resuscitation outcomes. This study investigates code leader ability to recall CPR error during post-event interviews when CPR recording/audiovisual feedback-enabled defibrillators are deployed.
Patients and methods
Physician code leaders were interviewed within 24 h of 44 in-hospital pediatric cardiac arrests to assess their ability to recall if CPR error occurred during the event. Actual CPR quality was assessed using quantitative recording/feedback-enabled defibrillators. CPR error was defined as an overall average event chest compression (CC) rate <95/min, depth <38 mm, ventilation rate >10/min, or any interruptions in CPR >10 s. We hypothesized that code leaders would recall error when it actually occurred ≥75% of the time when assisted by audiovisual alerts from a CPR recording feedback-enabled defibrillators (analysis by χ2).
810 min from 44 cardiac arrest events yielded 40 complete data sets (actual and interview); ventilation data was available in 24. Actual CPR error was present in 3/40 events for rate, 4/40 for depth, 32/40 for interruptions >10 s, and 17/24 for ventilation frequency. In post-event interviews, code leaders recalled these errors in 0/3 (0%) for rate, 0/4 (0%) for depth, and 19/32 (59%) for interruptions >10 s. Code leaders recalled these CPR quality errors less than 75% of the time for rate (p = 0.06), for depth (p < 0.01), and for CPR interruption (p = 0.04). Quantification of errors not recalled: missed rate error median = 94 CC/min (IQR 93–95), missed depth error median = 36 mm (IQR 35.5–36.5), missed CPR interruption >10 s median = 18 s (IQR 14.4–28.9). Code leaders did recall the presence of excessive ventilation in 16/17 (94%) of events (p = 0.07).
Despite assistance by CPR recording/feedback-enabled defibrillators, pediatric code leaders fail to recall important CPR quality errors for CC rate, depth, and interruptions during post-cardiac arrest interviews.
Pediatric; Code leader; CPR error
Cardiopulmonary resuscitation (CPR) is a series of life-saving actions that improve the chances of survival, following cardiac arrest. Successful resuscitation, following cardiac arrest, requires an integrated set of coordinated actions represented by the links in the Chain of Survival. The links include the following: immediate recognition of cardiac arrest and activation of the emergency response system, early CPR with an emphasis on chest compressions, rapid defibrillation, effective advanced life support, and integrated post-cardiac arrest care. The newest development in the CPR guideline is a change in the basic life support sequence of steps from "A-B-C" (Airway, Breathing, Chest compressions) to "C-A-B" (Chest compressions, Airway, Breathing) for adults. Also, "Hands-Only (compression only) CPR" is emphasized for the untrained lay rescuer. On the basis of the strength of the available evidence, there was unanimous support for continuous emphasis on high-quality CPR with compressions of adequate rate and depth, which allows for complete chest recoil, minimizing interruptions in chest compressions and avoiding excessive ventilation. High-quality CPR is the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation (ROSC). There is an increased emphasis on physiologic monitoring to optimize CPR quality, and to detect ROSC. A comprehensive, structured, integrated, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post-cardiac arrest care patients. The return to a prior quality and functional state of health is the ultimate goal of a resuscitation system of care.
Cardiopulmonary Resuscitation; Survival; Heart Massage
Cardiac arrest affects 30-35, 000 hospitalised patients in the UK every year. For these patients to be given the best chance of survival, high quality cardiopulmonary resuscitation (CPR) must be delivered, however the quality of CPR in real-life is often suboptimal. CPR feedback devices have been shown to improve CPR quality in the pre-hospital setting and post-event debriefing can improve adherence to guidelines and CPR quality. However, the evidence for use of these improvement methods in hospital remains unclear. The CPR quality improvement initiative is a prospective cohort study of the Q-CPR real-time feedback device combined with post-event debriefing in hospitalised adult patients who sustain a cardiac arrest.
The primary objective of this trial is to assess whether a CPR quality improvement initiative will improve rate of return of sustained spontaneous circulation in in-hospital-cardiac-arrest patients. The study is set in one NHS trust operating three hospital sites. Secondary objectives will evaluate: any return of spontaneous circulation; survival to hospital discharge and patient cerebral performance category at discharge; quality of CPR variables and cardiac arrest team factors. Methods: All three sites will have an initial control phase before any improvements are implemented; site 1 will implement audiovisual feedback combined with post event debriefing, site 2 will implement audiovisual feedback only and site 3 will remain as a control site to measure any changes in outcome due to any other trust-wide changes in resuscitation practice. All adult patients sustaining a cardiac arrest and receiving resuscitation from the hospital cardiac arrest team will be included. Patients will be excluded if; they have a Do-not-attempt resuscitation order written and documented in their medical records, the cardiac arrest is not attended by a resuscitation team, the arrest occurs out-of-hospital or the patient has previously participated in this study. The trial will recruit a total of 912 patients from the three hospital sites.
This trial will evaluate patient and process focussed outcomes following the implementation of a CPR quality improvement initiative using real-time audiovisual feedback and post event debriefing.
cardiac arrest; cardiopulmonary resuscitation; defibrillation; emergency medicine; guideline adherence; quality; resuscitation
Recently, it has been demonstrated that rescuers could safely provide a low, static downward force in direct contact with patients during elective cardioversion. The purpose of our experimental study was to investigate whether shock delivery during uninterrupted chest compressions may have an impact on cardiopulmonary resuscitation (CPR) quality and can be safely performed in a realistic animal model of CPR.
Methods and Results
Twenty anesthetized swine were subjected to 7 minutes of ventricular fibrillation followed by CPR according to the 2010 American Heart Association Guidelines. Pregelled self-adhesive defibrillation electrodes were attached onto the torso in the ventrodorsal direction and connected to a biphasic defibrillator. Animals were randomized either to (1) hands-on defibrillation, where rescuers wore 2 pairs of polyethylene gloves and shocks were delivered during ongoing chest compressions, or (2) hands-off defibrillation, where hands were taken off during defibrillation. CPR was successful in 9 out of 10 animals in the hands-on group (versus 8 out of 10 animals in the hands-off group; not significant). In the hands-on group, chest compressions were interrupted for 0.8% [0.6%; 1.4%] of the total CPR time (versus 8.2% [4.2%; 9.0%]; P=0.0003), and coronary perfusion pressure was earlier restored to its pre-interruption level (P=0.0205). Also, rescuers neither sensed any kind of electric stimulus nor did Holter ECG reveal any serious cardiac arrhythmia.
Hands-on defibrillation may improve CPR quality and could be safely performed during uninterrupted chest compressions in our standardized porcine model.
cardiac arrest; cardiopulmonary resuscitation; chest compression; defibrillation; resuscitation
D-CPR (Defibrillator Cardiopulmonary Resuscitation) is a technique for optimal basic life support during cardiopulmonary resuscitation (CPR). Guidelines recommend that healthcare professionals can perform CPR with competence. How CPR training and provision is organized varies between hospitals, and it is our impression that in Sweden this has generally improved during the last 15-20 years. However, some hospitals still do not have any AED (Automated External Defibrillators). The aim was to investigate potential differences in practical skills between different healthcare professions before and after training in D-CPR.
Seventy-four healthcare professionals were video recorded and evaluated for adherence to a modified Cardiff Score. A Laerdal Resusci Anne manikin in connection to PC Skill reporting System was used to evaluate CPR quality. A simulated CPR situation was accomplished during a 5-10 min scenario of ventricular fibrillation. Paired and unpaired statistical methods were used to examine differences within and between occupations with respect to the intervention.
There were no differences in skills among the different healthcare professions, except for compressions per minute. In total, the number of compression per minute and depth improved for all groups (P < 0.001). In total, 41% of the participants used AED before and 96% of the participants used AED after the intervention (P < 0.001). Before intervention, it took a median time of 120 seconds until the AED was used; after the intervention, it took 82 seconds.
Nearly all healthcare professionals learned to use the AED. There were no differences in CPR skill performances among the different healthcare professionals.
Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.
HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.
Of 214 HCP trained, 40% resuscitate ≥1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p < 0.01; adult 28% vs. 48%, p < 0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p < 0.01) and 6 months (38% vs. 67%, p < 0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p = 0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.
HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.
Developing countries; Emergency training; Resuscitation education; CPR; Chest compression; Competence; Resource-limited setting; Basic life support; Cardiopulmonary resuscitation; Manikin
Shallow chest compressions and incomplete recoil are common during cardiopulmonary resuscitation (CPR) and negatively affect outcomes. A step stool has the potential to alter these parameters when performing CPR in a bed but the impact has not been quantified.
We conducted a cross-over design, simulated study of in-hospital cardiac arrest. Rescuers performed a total of four 2-min segments of uninterrupted chest compressions, half of which were on a step stool. Compression characteristics were measured using a CPR-sensing defibrillator and subjective impressions were obtained from rescuer surveys. Paired analyses were performed to measure the impact of the step stool, taking into account rescuer characteristics, including height.
Fifty subjects, of whom 36% were men, with a median height of 169.8 cm (range 148.6–190.5) volunteered to participate. Use of a step stool resulted in an average increase in compression depth of 4 mm (p<0.001) and 18% increase in incomplete recoil (p<0.001). However, unlike with incomplete recoil, the effect was more pronounced in rescuers in the lowest height tertile (9 ± 9 vs 2 ± 6 mm for those rescuers taller than 167 cm, p=0.006).
Using a step stool when performing CPR in a bed results in a trade-off between increased compression depth and increased incomplete recoil. Given the nonlinear relationship between the increase in compression depth and rescuer height, the benefit of a step stool may outweigh the risks of incomplete release for rescuers ≤167 cm in height. The benefit is less clear in taller rescuers.
cardiac arrest; chest compression; cardiopulmonary resuscitation
In real cardiopulmonary resuscitation (CPR), noise can arise from instructional voices and environmental sounds in places such as a battlefield and industrial and high-traffic areas. A feedback device using a flashing light was designed to overcome noise-induced stimulus saturation during CPR. This study was conducted to determine whether ‘flashlight’ guidance influences CPR performance in a simulated noisy setting.
Materials and methods
We recruited 30 senior medical students with no previous experience of using flashlight-guided CPR to participate in this prospective, simulation-based, crossover study. The experiment was conducted in a simulated noisy situation using a cardiac arrest model without ventilation. Noise such as patrol car and fire engine sirens was artificially generated. The flashlight guidance device emitted light pulses at the rate of 100 flashes/min. Participants also received instructions to achieve the desired rate of 100 compressions/min. CPR performances were recorded with a Resusci Anne mannequin with a computer skill-reporting system.
There were significant differences between the control and flashlight groups in mean compression rate (MCR), MCR/min and visual analogue scale. However, there were no significant differences in correct compression depth, mean compression depth, correct hand position, and correctly released compression. The flashlight group constantly maintained the pace at the desired 100 compressions/min. Furthermore, the flashlight group had a tendency to keep the MCR constant, whereas the control group had a tendency to decrease it after 60 s.
Flashlight-guided CPR is particularly advantageous for maintaining a desired MCR during hands-only CPR in noisy environments, where metronome pacing might not be clearly heard.
Cardiopulmonary resuscitation; chest compression; flashlight; noise; stroke; imaging; CT/MRI; ultrasound; trauma; acute coronary syndrome; airway; anaesthesia—general; emergency care systems
The optimal age to begin CPR training is a matter of debate. This study aims to determine if elementary schoolchildren have the capacity to administer CPR efficiently.
This quasi-experimental study took place in a Quebec City school. Eighty-two children 10 to 12 years old received a 6-hour CPR course based on the American Heart Association (AHA) Guidelines. A comparison group of 20 adults who had taken the same CPR course was recruited. After training, participants’ performance was evaluated using a Skillreporter manikin. The primary outcome was depth of compressions. The secondary outcomes were compression rate, insufflation volume and adherence to the CPR sequence. Children’s performance was primarily evaluated based on the 2005 AHA standards and secondarily compared to the adults’ performance.
Schoolchildren did not reach the lower thresholds for depth (28.1 +/− 5.9 vs 38 mm; one-sided p = 1.0). The volume of the recorded insufflations was sufficient (558.6 +/222.8 vs 500 ml; one-sided p = 0.02), but there were a significant number of unsuccessful insufflation attempts not captured by the Skillreporter. The children reached the minimal threshold for rate (113.9 +/−18.3 vs 90/min; one-sided p < 0.001). They did not perform as well as the adults regarding compression depth (p < 0.001), but were comparable for insufflation volume (p = 0.83) and CPR sequence.
In this study, schoolchildren aged 10–12 years old did not achieve the standards for compression depth, but achieved adequate compression rate and CPR sequence. When attempts were successful at generating airflow in the Skillreporter, insufflation volume was also adequate.
Child; Cardiopulmonary resuscitation/standards; Cardiopulmonary resuscitation/methods; Education; School health services; Age factors
Successful resuscitation from cardiac arrest requires the delivery of high-quality chest compressions, encompassing parameters such as adequate rate, depth, and full recoil between compressions. The lack of compression recoil (“leaning” or “incomplete recoil”) has been shown to adversely affect hemodynamics in experimental arrest models, but the prevalence of leaning during actual resuscitation is poorly understood. We hypothesized that leaning varies across resuscitation events, possibly due to rescuer and/or patient characteristics and may worsen over time from rescuer fatigue during continuous chest compressions.
This was an observational clinical cohort study at one academic medical center. Data were collected from adult in-hospital and Emergency Department arrest events using monitor/defibrillators that record chest compression characteristics and provide real-time feedback.
We analyzed 112,569 chest compressions from 108 arrest episodes from 5/2007 to 2/2009. Leaning was present in 98/108 (91%) cases; 12% of all compressions exhibited leaning. Leaning varied widely across cases: 41/108 (38%) of arrest episodes exhibited <5% leaning yet 20/108 (19%) demonstrated >20% compression leaning. When evaluating blocks of continuous compressions (>120 sec), only 4/33 (12%) had an increase in leaning over time and 29/33 (88%) showed a decrease (p<0.001).
Chest compression leaning was common during resuscitation care and exhibited a wide distribution, with most leaning within a subset of resuscitations. Leaning decreased over time during continuous chest compression blocks, suggesting that either leaning may not be a function of rescuer fatiguing, or that it may have been mitigated by automated feedback provided during resuscitation episodes.
cardiopulmonary resuscitation; cardiac arrest; sudden death; chest compression; quality of care
To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, high-frequency training program (booster training) would improve CPR skill retention.
PATIENTS AND METHODS:
CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support–certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥ 90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30.
MEASUREMENTS AND MAIN RESULTS:
Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval [CI]: 1.1–4.5; P = .02) more likely after 2 trainings and 2.9 times (95% CI: 1.4–6.2; P = .005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 [95% CI: 0.17–0.97]; P = .043).
Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
pediatric; cardiopulmonary resuscitation; quality appraisal
Telephone-CPR (T-CPR) can increase rate of bystander CPR as well as CPR quality. Instructions for T-CPR were developed when most callers used a land line. Telephones today are often wireless and can be brought to the patient. They often have speaker function which further allows the rescuer to receive instructions while performing CPR.
We wanted to measure adult lay people’s ability to activate the speaker function on their own mobile phone.
Elderly lay people, previously trained in CPR, were contacted by telephone. Participants with speaker function experience were asked to activate this without further instructions, while participants with no experience were given instructions on how to activate it. Participants were divided in three groups; Group 1: Can activate the speaker function without instruction, Group 2: Can activate the speaker function with instruction, and Group 3: Unable to activate the speaker function. Time to activation for group 1 and 2 was compared using Mann-Whitney U-test.
Seventy-two elderly lay people, mean age 68 ± 6 years participated in the study. Thirty-five (35)% of the participants were able to activate the speaker function without instructions, 29% with instructions and 36% were unable to activate the speaker function. The median time to activate the speaker function was 8s and 93s, with and without instructions, respectively (p < 0.01).
One-third of the elderly could activate speaker function quickly, and two-third either used a long time or could not activate the function.
Cardiopulmonary resuscitation (CPR) improves outcomes after cardiac arrest. Much of the lay public is untrained in CPR skills. We evaluated the effectiveness of a compression-only CPR video self-instruction (VSI) with a personal manikin in the lay public.
Adults without prior CPR training in the past year or responsibility to provide medical care were randomized into one of three groups: 1) Untrained before testing, 2) 10-minute VSI in compressions-only CPR (CPR Anytime, American Heart Association, Dallas, TX), or 3) 22-minute VSI in compressions and ventilations (CPR Anytime). CPR proficiency was assessed using a sensored manikin. The primary outcome was composite skill competence of 90% during five minutes of skill demonstration. Evaluated were alternative cut-points for skill competence and individual components of CPR. 488 subjects (143 in untrained group, 202 in compressions-only group and 143 in compressions and ventilation group) were required to detect 21% competency with compressions-only versus 7% with untrained and 34% with compressions and ventilations.
Analyzable data were available for the untrained group (n = 135), compressions-only group (n = 185) and the compressions and ventilation group (n = 119). Four (3%) achieved competency in the untrained group (p-value = 0.57 versus compressions-only), nine (4.9%) in the compressions-only group, and 12 (10.1%) in the compressions and ventilations group (p-value 0.13 vs. compressions-only). The compressions-only group had a greater proportion of correct compressions (p-value = 0.028) and compressions with correct hand placement (p-value = 0.0004) compared to the untrained group.
VSI in compressions-only CPR did not achieve greater overall competency but did achieve some CPR skills better than without training.
Public; Cardiopulmonary resuscitation; Cardiac arrest; Education; Randomized trial
Immediate start of basic cardiopulmonary resuscitation (CPR) and early defibrillation have been highlighted as crucial for survival from cardiac arrest, but despite new knowledge, new technology and massive personnel training the survival rates from in-hospital cardiac arrest are still low. National guidelines recommend regular intervals of CPR training to make all hospital personnel able to perform basic CPR till advanced care is available. This study investigates CPR training, resuscitation experience and self-confidence in skills among hospital personnel outside critical care areas.
A cross-sectional study was performed at three Norwegian hospitals. Data on CPR training and CPR use were collected by self-reports from 361 hospital personnel.
A total of 89% reported training in CPR, but only 11% had updated their skills in accordance with the time interval recommended by national guidelines. Real resuscitation experience was reported by one third of the respondents. Both training intervals and use of skills in resuscitation situations differed among the professions. Self-reported confidence decreased only after more than two years since last CPR training.
There is a gap between recommendations and reality in CPR training among hospital personnel working outside critical care areas.
Methods: Untrained subjects were asked to perform CPR on a manikin with and without the assistance of audio prompts. All subjects were then trained in CPR, and retested them eight weeks later.
Results: Untrained subjects who performed CPR first without audio prompts performed poorly, with only (mean (SD)) 24.5% (32%) of compressions at the correct site and depth, a mean compression rate of 52 (31) per minute, and with 15% (32%) of ventilatory attempts adequate. Repeat performance by this group with audio prompts resulted in significant improvements in compression rate (91(12), p = 0.0002, paired t test), and percentage of correct ventilations (47% (40%), p = 0.01 paired t test), but not in the percentage correct compressions (23% (29%)). Those who performed CPR first with audio prompts performed significantly better in compression rate (87 (19), p = 003, unpaired t test), and the percentage of correct ventilations (51 (34), p = 0.003 unpaired t test), but not in the percentage of correct compressions (18 (27)) than those without audio prompts. After training, CPR performance was significantly better than before training, but there was no difference in performance with or without audio prompts, although 73% of subjects commented that they felt more comfortable performing CPR with audio prompts.
Conclusions: For untrained subjects, the quality of CPR may be improved by using this device, while for trained subjects the willingness to perform CPR may be increased.
Bystander resuscitation plays an important role in lifesaving cardiopulmonary resuscitation (CPR). A significant reduction in the "no-flow-time", quantitatively better chest compressions and an improved quality of ventilation can be demonstrated during CPR using supraglottic airway devices (SADs). Previous studies have demonstrated the ability of inexperienced persons to operate SADs after brief instruction. The aim of this pilot study was to determine whether an instruction manual consisting of four diagrams enables laypersons to operate a Laryngeal Mask Supreme® (LMAS) in the manikin.
An instruction manual of four illustrations with speech bubbles displaying the correct use of the LMAS was designed. Laypersons were handed a bag containing a LMAS, a bag mask valve device (BMV), a syringe prefilled with air and the instruction sheet, and were asked to perform and ventilate the manikin as displayed. Time to ventilation was recorded and degree of success evaluated.
A total of 150 laypersons took part. Overall 145 participants (96.7%) inserted the LMAS in the manikin in the right direction. The device was inserted inverted or twisted in 13 (8.7%) attempts. Eight (5.3%) individuals recognized this and corrected the position. Within the first 2 minutes 119 (79.3%) applicants were able to insert the LMAS and provide tidal volumes greater than 150 ml (estimated dead space). Time to insertion and first ventilation was 83.2 ± 29 s. No significant difference related to previous BLS training (P = 0.85), technical education (P = 0.07) or gender could be demonstrated (P = 0.25).
In manikin laypersons could insert LMAS in the correct direction after onsite instruction by a simple manual with a high success rate. This indicates some basic procedural understanding and intellectual transfer in principle. Operating errors (n = 91) were frequently not recognized and corrected (n = 77). Improvements in labeling and the quality of instructional photographs may reduce individual error and may optimize understanding.
The usefulness of basic cardiopulmonary resuscitation (CPR) training in school systems has been questioned, considering that young students may not have the physical or cognitive skills required to perform complex tasks correctly. In the study conducted by Fleishhackl and coworkers, students as young as 9 years were able to successfully and effectively learn basic CPR skills, including automated external defibrillator deployment, correct recovery position, and emergency calling. As in adults, physical strength may limit the depth of chest compressions and ventilation volumes given by younger individuals with low body mass index; however, skill retention is good. Training all persons across an entire community in CPR may have a logarithmic improvement in survival rates for out-of-hospital cardiac arrest because bystanders, usually family members, are more likely to know CPR and can perform it immediately, when it is physiologically most effective. Training captured audiences of trainees, such as the entire work-force of the community or the local school system, are excellent mechanisms to help achieve that goal. In addition to better retention with new half hour training kits, a multiplier effect can be achieved through school children. In addition, early training not only sets the stage for subsequent training and better retention, but it also reinforces the concept of a social obligation to help others.
Background and Objective
Cardiopulmonary Resuscitation (CPR) with adequate chest compression depth appears to improve first shock success in cardiac arrest. We evaluate the effect of simplification of chest compression instructions on compression depth in dispatcher-assisted CPR protocol.
Data from two randomized, double-blinded, controlled trials with identical methodology were combined to obtain 332 records for this analysis. Subjects were randomized to either modified Medical Priority Dispatch System (MPDS) v11.2 protocol or a new simplified protocol. The main difference between the protocols was the instruction to “push as hard as you can” in the simplified protocol, compared to “push down firmly 2 inches (5cm)” in MPDS. Data were recorded via a Laerdal® ResusciAnne® SkillReporter™ manikin. Primary outcome measures included: chest compression depth, proportion of compressions without error, with adequate depth and with total release.
Instructions to “push as hard as you can”, compared to “push down firmly 2 inches (5cm)”, resulted in improved chest compression depth (36.4 vs 29.7 mm, p<0.0001), and improved median proportion of chest compressions done to the correct depth (32% vs <1%, p<0.0001). No significant difference in median proportion of compressions with total release (100% for both) and average compression rate (99.7 vs 97.5 per min, p<0.56) was found.
Modifying dispatcher-assisted CPR instructions by changing “push down firmly 2 inches (5cm)” to “push as hard as you can” achieved improvement in chest compression depth at no cost to total release or average chest compression rate.
Bystander CPR; Cardiac arrest; Chest compression