Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator,Feedback Device,and Survey Data

BackgroundHigh-quality cardiopulmonary resuscitation is foundational to cardiac arrest care. Visual feedback devices can improve chest compression quality, but are infrequently used. Quality improvement data were examined to determine whether handheld visual feedback and backboard use improved chest compression quality, whether resuscitation team size affected resuscitation indicators, and whether feedback sources are comparable.MethodsFrom August 2019 to December 2020, data from 50 resuscitations were collected using a handheld device (n = 35), defibrillator (n = 23), and surveys (n = 35) and shared with providers. Aggregated and individual case data, along with education and research, were distributed to staff as quality improvement measures.ResultsThe mean duration of resuscitation was 1080 compressions (SD = 858); there were no differences in the durations of resuscitations that did or did not use handheld feedback; 50% of resuscitations used handheld feedback and had more compressions at target rate (74.68% vs 42.18%, t₍₂₁₎ = 2.99, P = .007). Moreover, 25% of resuscitations used backboards; these had more chest compressions at target depth (72.92% vs 48.73%, t₍₂₅₎ = 2.08, P = .048). Team size was not associated with duration of resuscitation or chest compressions quality. There was no improvement in other quality indicators (leadership, family presence, or debriefing) during the data collection period. Feedback sources (defibrillator and feedback device) had good agreement and correlation (r = 0.77, P = .01).ConclusionsIncorporating handheld feedback and backboards improved chest compressions quality. Further work to improve the frequency of device use and to examine their relationship to patient-specific outcomes is needed. Study is needed to find interventions that improve other teamwork metrics, inclusion of family during the resuscitation, referral for tissue donation, and rates of postevent debriefing.     

Quality of chest compressions performed by inexperienced rescuers in simulated cardiac arrest associated with pregnancy

Objective

We aimed to compare the quality of chest compressions performed by inexperienced rescuers in different positions, notably supine and at a 30° inclined lateral position, to ascertain whether high-quality chest compression is feasible on a pregnant subject in cardiac arrest.

Subjects and methods

We performed a prospective, randomised crossover design study. Each participant performed 2-min chest compressions in two different positions on a mannequin: a supine position and a 30° left inclined lateral position. After 2 min of chest compression in one position, the participant took a rest for 10 min to minimise rescuer fatigue and then performed chest compression in the second position. Data on chest compression rate, mean chest compression depth, correct compression depth rate, correct recoil rate, and correct hand position rate were collected. To measure the angle between the rescuer's arm and the victim's chest surface, chest compressions were recorded with a video recorder. After each practice session, participants were asked to report the subjective difficulty of performing chest compressions using a visual analogue scale.

Results

All 32 participants successfully completed the study. The mean compression rate and depth were 121.0 per minute and 53.3 mm in the supine position and 118.8 per minute and 52.0 mm in the inclined lateral position, respectively (p = 0.978 and p = 0.260, respectively). Also, there were no differences in the correct compression depth rate, the correct hand position rate, or the correct recoil rate (p = 0.426, p = 0.467, and p = 0.260, respectively). However, the lowest and highest angles and the subjective difficulty of chest compression differed significantly (p < 0.001, p < 0.001, and p = 0.007, respectively).

Conclusions

Inexperienced rescuers appear to be capable of performing high-quality chest compressions in a 30° inclined lateral position on pregnant women in a simulated cardiac arrest state.     

Real-time feedback can improve infant manikin cardiopulmonary resuscitation by up to 79%—A randomised controlled trial

Setting

European and Advanced Paediatric Life Support training courses.

Participants

Sixty-nine certified CPR providers.

Interventions

CPR providers were randomly allocated to a ‘no-feedback’ or ‘feedback’ group, performing two-thumb and two-finger chest compressions on a “physiological”, instrumented resuscitation manikin. Baseline data was recorded without feedback, before chest compressions were repeated with one group receiving feedback.

Main outcome measures

Indices were calculated that defined chest compression quality, based upon comparison of the chest wall displacement to the targets of four, internationally recommended parameters: chest compression depth, release force, chest compression rate and compression duty cycle.

Results

Baseline data were consistent with other studies, with <1% of chest compressions performed by providers simultaneously achieving the target of the four internationally recommended parameters. During the ‘experimental’ phase, 34 CPR providers benefitted from the provision of ‘real-time’ feedback which, on analysis, coincided with a statistical improvement in compression rate, depth and duty cycle quality across both compression techniques (all measures: p < 0.001). Feedback enabled providers to simultaneously achieve the four targets in 75% (two-finger) and 80% (two-thumb) of chest compressions.

Conclusions

Real-time feedback produced a dramatic increase in the quality of chest compression (i.e. from <1% to 75–80%). If these results transfer to a clinical scenario this technology could, for the first time, support providers in consistently performing accurate chest compressions during infant CPR and thus potentially improving clinical outcomes.     

Effects of uninterrupted chest compressions on the rescuer's physical condition

Study objectiveRecent guidelines have emphasized the need for uninterrupted chest compressions. The purpose of this study was to evaluate the rescuer's tolerability of uninterrupted chest compressions.MethodsTwenty-five healthy subjects performed uninterrupted chest compressions for 7 minutes at a rate of 100 compressions per minute using a training manikin. The quality of chest compressions was assessed in terms of the total number and percentage of chest compressions, compression depth, recoil distance, and duty cycle. Correct chest compression was defined as a depth of 38 to 51 mm. Physiological and laboratory parameters were measured before and after the procedure. Fatigue was measured using a numerical rating scale. Data were compared before and after the procedure.ResultsThe participants were 10 emergency physicians and 15 medical students. The compression rate was nearly 100 compressions per minute. The number and percentage of correct compressions decreased gradually after 3 minutes. The compression depth decreased significantly after 2 minutes. The recoil distance and duty cycle were unchanged over 7 minutes. Systolic blood pressure, pulse rate, respiratory rate, numerical rating scale, serum lactate, adrenalin, and noradrenalin increased significantly after the procedure. Noradrenalin levels measured before the procedure were significantly and negatively correlated with the total number and percentage of correct compressions (r = −0.587, P = .004; r = −0.549, P = .008, respectively).ConclusionsPerforming uninterrupted chest compressions for 7 minutes is an arduous procedure. Higher noradrenalin levels before the procedure might be associated with incorrect chest compressions.     

Real-Time Cardiopulmonary Resuscitation Feedback and Targeted Training Improve Chest Compression Performance in a Cohort of International Healthcare Providers

BackgroundOptimal cardiopulmonary resuscitation (CPR) performance is the foundation of successful cardiac arrest resuscitation. However, health care providers perform inadequate compressions. Better training techniques and real-time CPR feedback may improve compression performance.ObjectiveWe sought to evaluate the impact of a targeted training program combined with real-time defibrillator CPR feedback on chest compression performance in an international cohort of health care providers.MethodsPhysicians, nurses, respiratory therapists, and technicians from 6 hospitals in 5 countries (Taiwan, Singapore, China, Bahrain, and Kuwait) participated in a standardized resuscitation workshop. Chest compression was measured before and after didactics and activation of CPR feedback. Compressions were performed for 1 min on standard CPR manikins placed on a hospital bed and backboard and measured using ZOLL R Series defibrillators. The percentage of compressions meeting target values for depth and rate were compared before and after the workshop and activation of real-time CPR feedback. No depth maximum was defined to allow for mattress compression.ResultsChest compressions were more likely to meet targets for depth (71–95%, odds ratio [OR] 8.61 [95% confidence interval {CI} 4.42–16.77], p < 0.001), rate (41–81%, OR 6.4 [95% CI 4.2–9.8], p < 0.001), and both depth and rate (5–42%, OR 2.4 [95% CI 6.7–22.9], p < 0.001) after the workshop and activation of real-time CPR feedback.ConclusionsA targeted training intervention combined with real-time CPR feedback improved chest compression performance among health care providers from various countries.     

Quality Comparison of the Manual Chest Compression and the Mechanical Chest Compression During Difficult Transport Conditions

BackgroundAlthough there are several studies comparing the quality of manual and mechanical chest compressions, we decided to conduct this study because results of previous studies were not sufficient for us to arrive at a definite conclusion.ObjectiveIn this study, our goal was to evaluate the quality of cardiopulmonary resuscitation (CPR) performed manually and by mechanical chest compression device (MCCD) when removing out-of-hospital cardiac arrest patients from their homes via stairs.MethodsA total of 20 paramedics participated in the study. The patient simulator manikin was moved down the stairs while each of 20 paramedics performed chest compressions, then it was moved down the stairs again 20 times while the MCCD performed chest compressions. Compression depth, compression rate, and hands-on times were recorded and the data were compared.ResultsThe median chest compression rate was 142.0 compressions/min (interquartile [25^th to 75^th percentile] range [IQR] 134.9–148.7 compressions/min) for the paramedics and 102.3 compressions/min for the MCCD (IQR 102.2–102.5 compressions/min) (p < 0.01). The median chest compression depth was 25.2 mm (IQR 23.2–30.9 mm) for the paramedics and 52.0 mm for the MCCD (IQR 51.4–52.6 mm) (p < 0.001). The rate of hands-on time for chest compressions performed by the paramedic participants was 92.0% (IQR 86.5–100%). Hands-on rate of the MCCD was 100% (p = 0.09).ConclusionsIn our study, while carrying the patient simulator manikin to the lower floor, it was found that the MCCD achieved high-quality CPR targets recommended by resuscitation guidelines in terms of compression rate, depth, and hands-on-time.     

One-hand chest compression and hands-off time in single-lay rescuer CPR—a manikin study

PurposeTo evaluate the effect of one-hand chest compression while continuously maintaining an open airway (OCOA) on rescue breath-associated hands-off time (RAHO) during single-lay rescuer cardiopulmonary resuscitation (CPR).MethodsIn this study, 193 CPR/automated external defibrillator certified lay rescuers were randomly allocated into 2 groups and were tested in a standard scenario using a mannequin. In control group (group A), the participants provided standard CPR. In group B, OCOA was performed by placing the heel of the strong hand in the center of the mannequin’s chest while maintaining an open airway using the other hand.ResultsMean RAHO was statistically significantly different between the two groups (group A: 8.38 ± 1.97 vs group B: 7.71 ± 2.43, P = .008). Only 13 (13.5%) group A and 25 (25.8%) group B providers ventilated the manikin with tidal volumes of 500 to 600 mL, while most participants caused hyperventilation. Although there were no significant differences in mean tidal volume between the groups, stomach inflation was greater in group A (< .001). Chest compressions were deeper in group A (P < .001), while chest recoil was significantly better in group B. In group B, there was a positive correlation between body mass index and compression depth (group A, P = .423; group B, P < .001).ConclusionsIn our study, OCOA resulted in shorter RAHO and less stomach inflation. Our results indicate that the airway should be maintained open during chest compressions, regardless of the technique. Larger studies are needed for the full clarification of OCOA.     

Does the use of BariBoard™ improve adequacy of chest compressions in morbid obesity? A pilot study using a simulation model

BackgroundObesity is a growing health problem worldwide. Morbid obesity has been associated with significant barriers to effective thoracic cage compression during cardiopulmonary resuscitation.ObjectiveThe BariBoard? purports to improve adequacy of chest compressions in morbidly obese patients. This study uses a simulation model to evaluate this.MethodsThis was a prospective blinded randomised-controlled crossover pilot trial using a simulation model of obesity. Participants, recruited from hospital departments and prehospital services, performed 2 minutes of continuous compressions on mannequins modified to emulate a morbidly obese patient. Participants were randomised by coin toss to a sequence of either control/intervention or intervention/control, with the BariBoard? in the intervention arm. Accelerometers measured chest wall movement during compressions. The primary endpoint was a composite measure of compression adequacy (rate, depth, and recoil). Secondary endpoints comprised the individual components of the composite outcome, as both dichotomous outcomes (adequate vs. inadequate) and continuous variables. All endpoints were adjusted for potential confounders.ResultsOf 205 participants recruited, 201 were analysed. There was a significant difference in the primary outcome between the control and intervention arms (13.4% vs. 4.5%, respectively, p = 0.001) and between the control and intervention arms for the secondary endpoints of adequate compression depth (31.3% vs. 15.9%, p < 0.001) and recoil (63.7% vs. 41.3%, p < 0.001). After adjustment for confounders and interactions, there was no difference in overall efficacy (odds ratio: 0.62, 95% confidence interval: 0.20–1.90, p = 0.40).ConclusionThis pilot study describes the successful assessment of a device using a simulation model of obesity. Within these constraints and after adjustment for confounders, use of the BariBoard ? did not improve efficacy of chest compressions.     

Effect of a backboard on chest compression quality during in-hospital adult cardiopulmonary resuscitation: A randomised,single-blind,controlled trial using a manikin model

IntroductionChest compression quality during in-hospital resuscitation is often suboptimal on a soft surface. Scientific evidence regarding the effectiveness of a backboard is scarce. This single-blinded manikin study evaluated the effect of a backboard on compression depth, rate and chest recoil performed by nurses. Sex, BMI, age and clinical department were considered as potential predictors.MethodsUsing self-learning, nurses were retrained to achieve a minimal combined compression score at baseline. This combined score consisted of ≥70% compressions with depth 50–60 mm, ≥70% compressions with complete release (≤5mm) and a mean compression rate of 100–120 bpm. Subsequently, nurses were allocated to a backboard or control group and performed a two-minute cardiopulmonary resuscitation test. The main outcome measure was the difference in proportion of participants achieving a combined compression score of ≥70%.ResultsIn total 278 nurses were retrained, 158 nurses dropped out and 120 were allocated to the backboard (n = 61) or control group (n = 59). The proportion of participants achieving a combined compression score of ≥70% was not significantly different (p = 0.475) and suboptimal in both groups: backboard group 47.5% (backboard) versus 41.0% (control). Older age (≥51 years) was associated with a lower probability of achieving a combined compression score >70% [OR = 0.133; 95% confidence interval (CI), 0.037–0.479; p = 0.002].ConclusionUsing a backboard did not significantly improve compression quality in our study. Important decay of compression skills was observed in both groups, highlighting the importance of frequent retraining, particularly in some age groups.     

Perception of CPR quality: Influence of CPR feedback,Just-in-Time CPR training and provider role

AimMany healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions.MethodsWe conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm.ResultsParticipants overestimated achieving adequate chest compression depth (mean difference range: 16.1–60.6%) and rate (range: 0.2–51%), and underestimated chest compression fraction (0.2–2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p < 0.001). Accurate estimation of CPR quality was poor for chest compression depth (0–13%), rate (5–46%) and chest compression fraction (60–63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p = 0.043) when using real-time feedback.ConclusionHealthcare providers’ visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.     

The impact of quantitative feedback on the performance of chest compression by basic life support trained clinical staff

BackgroundThe quality of CPR is directly related to survival outcomes following sudden cardiac arrest but, CPR competency amongst nursing and medical staff is generally poor. The skills honed in CPR recertification training rapidly decline in quality, even as soon as eight weeks following the training. High frequency low dose training has been recommended to address this decay in skills. Automated training devices that provide feedback may be useful in conducting low dose training, which would assist hospitals to manage the often logistically difficult, and financially costly exercise of conducting training programs. Little evidence is published about the improvement in skills performance that can be derived from isolated feedback from these training devices.ObjectivesTo investigate whether the feedback from an automated training device can produce performance in a ‘low dose’ episode of re-training on chest compressions and compression depth for CPR.MethodsA repeated measures study was conducted assessing the compression rate and depth quality over 2 min using a Laerdal QCPR® simulation manikin capable of recording performance data. On-screen feedback was provided to participants between attempts. Convenience sampling recruited undergraduate and qualified nursing and medical staff who were engaged in a CPR recertification program at a major Australian private hospital.ResultsIn total, 150 participants were enrolled. Feedback from the automated training device was sufficient to produce a significant improvement in both chest compression rate (95% CI 13.3 to 19.7; p < 0.001) and depth (95% CI 5.9 to 9.7; p < 0.001) during the low dose training episode.ConclusionsThe feedback provided from an automated training device was sufficient to produce an improvement in performance in chest compressions in CPR. This demonstrates an alternate staff training model that could improve patient outcomes, and allow for higher frequency training whilst potentially reducing costs and the logistical problems many medical institutions face with staff training.     

Influence of chest compression rate guidance on the quality of cardiopulmonary resuscitation performed on manikins

AimsThe adequate chest compression rate during CPR is associated with improved haemodynamics and primary survival. To explore whether the use of a metronome would affect also chest compression depth beside the rate, we evaluated CPR quality using a metronome in a simulated CPR scenario.MethodsForty-four experienced intensive care unit nurses participated in two-rescuer basic life support given to manikins in 10 min scenarios. The target chest compression to ventilation ratio was 30:2 performed with bag and mask ventilation. The rescuer performing the compressions was changed every 2 min. CPR was performed first without and then with a metronome that beeped 100 times per minute. The quality of CPR was analysed with manikin software. The effect of rescuer fatigue on CPR quality was analysed separately.ResultsThe mean compression rate between ventilation pauses was 137 ± 18 compressions per minute (cpm) without and 98 ± 2 cpm with metronome guidance (p < 0.001). The mean number of chest compressions actually performed was 104 ± 12 cpm without and 79 ± 3 cpm with the metronome (p < 0.001). The mean compression depth during the scenario was 46.9 ± 7.7 mm without and 43.2 ± 6.3 mm with metronome guidance (p = 0.09). The total number of chest compressions performed was 1022 without metronome guidance, 42% at the correct depth; and 780 with metronome guidance, 61% at the correct depth (p = 0.09 for difference for percentage of compression with correct depth).ConclusionsMetronome guidance corrected chest compression rates for each compression cycle to within guideline recommendations, but did not affect chest compression quality or rescuer fatigue.     

A randomised control trial of prompt and feedback devices and their impact on quality of chest compressions—A simulation study

Aim

This study aims to compare the effect of three CPR prompt and feedback devices on quality of chest compressions amongst healthcare providers.

Methods

A single blinded, randomised controlled trial compared a pressure sensor/metronome device (CPREzy™), an accelerometer device (Phillips Q-CPR) and simple metronome on the quality of chest compressions on a manikin by trained rescuers. The primary outcome was compression depth. Secondary outcomes were compression rate, proportion of chest compressions with inadequate depth, incomplete release and user satisfaction.

Results

The pressure sensor device improved compression depth (37.24–43.64 mm, p = 0.02), the accelerometer device decreased chest compression depth (37.38–33.19 mm, p = 0.04) whilst the metronome had no effect (39.88 mm vs 40.64 mm, p = 0.802). Compression rate fell with all devices (pressure sensor device 114.68–98.84 min⁻¹, p = 0.001, accelerometer 112.04–102.92 min⁻¹, p = 0.072 and metronome 108.24 min⁻¹ vs 99.36 min⁻¹, p = 0.009). The pressure sensor feedback device reduced the proportion of compressions with inadequate depth (0.52 vs 0.24, p = 0.013) whilst the accelerometer device and metronome did not have a statistically significant effect. Incomplete release of compressions was common, but unaffected by the CPR feedback devices. Users preferred the accelerometer and metronome devices over the pressure sensor device. A post hoc study showed that de-activating the voice prompt on the accelerometer device prevented the deterioration in compression quality seen in the main study.

Conclusion

CPR feedback devices vary in their ability to improve performance. In this study the pressure sensor device improved compression depth, whilst the accelerometer device reduced it and metronome had no effect.     

The high impulse,palm lift technique for chest compression: Prospective,experimental, pilot study

BackgroundThe classic technique of high quality chest compression (HQCC) during cardiopulmonary resuscitation (CPR) is based on the International Liaison Committee on Resuscitation (ILCOR) guidelines which specify that the rescuer's hands should maintain constant contact with the chest surface but should not lean upon it, in order to provide full chest recoil. Since end–tidal CO2 (EtCO2) values have been shown to be a reliable indicator of CPR quality, we examined a method where classic HQCC was modified by a high impulse and palm lifting (HIPL) technique which merged rapid forceful compression with disconnection of the rescuer's palm from the patient's sternum during the recoil phase. The object of the study was to detect any differences in HIPL EtCO2 values in comparison with those from classic HQCC.MethodsWe report a prospective pilot study in which we compared EtCO2 readings achieved during 2 min of classic HQCC technique with readings after implementing 2 min of the HIPL technique during out-of-hospital CPR, provided by medical emergency response teams for cases of cardiac arrest.ResultsEtCO2 values obtained from16 cases who received HQCC followed by HIPL compressions showed a significant difference (p = 0.037) between the two techniques. Mean ± SD EtCO2 values after 2 min of each technique were: HQCC: 18 ± 9 mmHg; HIPL: 27 ± 11 mmHg; followed by a further 2 min of HQCC: 19 ± 11 mmHg. Linear regression showed that the differences in EtCO2 were associated with non - significant changes in ventilation rate (p = 0.493) and chest compression rate (p = 0.889).ConclusionsThe results obtained suggest that modifying HQCC with the HIPL technique led to a significant increase in EtCO2 values in comparison with classic HQCC, indicating an improvement in circulation during CPR. We think that these encouraging early results warrant a larger multi – centre study of HIPL.     

The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest

IntroductionMost manikin and clinical studies have found decreased quality of CPR during transport to hospital. We wanted to study quality of CPR before and during transport for out-of-hospital cardiac arrest patients and also whether quality of CPR before initiation of transport was different from the quality in patients only receiving CPR on scene.Materials and methodsQuality of CPR was prospectively registered with a modified defibrillator for consecutive cases of out-of-hospital cardiac arrest in three ambulance services during 2002–2005. Ventilations were registered via changes in transthoracic impedance and chest compressions were measured with an extra chest compression pad placed on the patients’ sternum. Paired t-tests were used to analyse quality of CPR before vs. during transport with ongoing CPR. Unpaired t-tests were used to compare CPR quality prior to transport to CPR quality in patients with CPR terminated on site.ResultsQuality of CPR did not deteriorate during transport, but as previously reported overall quality of CPR was substandard. Quality of CPR performed on site was significantly better when transport was not initiated with ongoing CPR compared to episodes with initiation of transport during CPR: fraction of time without chest compressions was 0.45 and 0.53 (p < 0.001), compression depth 37 mm and 34 mm (p = 0.04), and number of chest compressions per minute 61 and 56 (p = 0.01), respectively.ConclusionCPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation.     

Wearing a N95 mask increases rescuer's fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation

ObjectivesN95 mask is essential for healthcare workers dealing with the coronavirus disease 2019 (COVID-19). However, N95 mask causes discomfort breathing with marked reduction in air exchange. This study was designed to investigate whether the use of N95 mask affects rescuer's fatigue and chest compression quality during cardiopulmonary resuscitation (CPR).MethodsAfter a brief review of CPR, each participant performed a 2-minute continuous chest compression on a manikin wearing N95 (N95 group, n = 40) or surgical mask (SM group, n = 40). Compression rate and depth, the proportions of correct compression rate, depth, complete chest recoil and hand position were documented. Participants' fatigue was assessed using Borg score.ResultsSignificantly lower mean chest compression rate and depth were both achieved in the N95 group than in the SM group (p < 0.05, respectively). In addition, the proportion of correct compression rate (61 ± 19 vs. 75 ± 195, p = 0.0067), depth (67 ± 16 vs. 90 ± 14, p < 0.0001) and complete recoil (91 ± 16 vs. 98 ± 5%, p = 0.0248) were significantly decreased in the N95 group as compared to the SM group. At the end of compression, the Borg score in the N95 group was significantly higher than that in the SM group (p = 0.027).ConclusionWearing a N95 mask increases rescuer's fatigue and decreases chest compression quality during CPR. Therefore, the exchange of rescuers during CPR should be more frequent than that recommended in current guidelines when N95 masks are applied.     

Effect of synchronous online vs. face-to-face cardiopulmonary resuscitation training on chest compression quality: A pilot randomized manikin study

ObjectivesThe aim of the study was to compare the effect of synchronous online and face-to-face cardiopulmonary resuscitation (CPR) training on chest compressions quality in a manikin model.MethodsA total of 118 fourth-year medical students participated in this study.The participants were divided into two groups: the online synchronous teaching group and the face-to-face group. Then, the participants were further randomly distributed to 1 of 2 feedback groups: online synchronous teaching and training with feedback devices (TF, n = 30) or without feedback devices (TN, n = 29) and face-to-face teaching and training with feedback devices (FF, n = 30) or without feedback devices (FN, n = 29). In the FN group and FF group, instructors delivered a 45-min CPR training program and gave feedback and guidance during training on site. In the TN group and TF group, the participants were trained with an online lecture via Tencent Meeting live broadcasting. Finally, participants performed a 2-min continuous chest compression (CC) during a simulated cardiopulmonary arrest scene without the audiovisual feedback (AVF) device. The outcome measures included CC depth, CC rate, proportions of appropriate depth (50–60 mm) and CC rate (100–120/min), percentage of correct hand location position, and percentage of complete chest recoil.ResultsThere was little difference in the CC quality between the synchronous online training groups and the face-to-face training groups. There was no statistically significant difference in CC quality between the TN group and FN group. There were also no statistically significant differences between the TF and FF groups in terms of correct hand position, CC depth, appropriate CC depth, complete chest recoil or CC rate. However, the FF group had a higher appropriate CC rate than the TF group (p = 0.045). In the face-to-face training groups, the AVF device group had a significantly greater CC depth, appropriate CC depth, CC rate, and appropriate CC rate. However, there was a lack of statistically significant differences in terms of correct hand position (p = 0.191) and appropriate CC depth (p = 0.123). In the synchronous online training groups, the AVF device had little effect on the CC rate (p = 0.851) and increased the appropriate CC rate, but the difference was not statistically significant (p = 0.178).ConclusionsSynchronous online training with an AVF device would be a potential alternative approach to face-to-face chest compression training. Synchronous online training with AVF devices seems to be a suitable replacement for face-to-face training to offer adequate bystander CPR chest compression training.     

Visual assessment of CPR quality during pediatric cardiac arrest: Does point of view matter?

AimIn many clinical settings, providers rely on visual assessment when delivering feedback on CPR quality. Little is known about the accuracy of visual assessment of CPR quality. We aimed to determine how accurate pediatric providers are in their visual assessment of CPR quality and to identify the optimal position relative to the patient for accurate CPR assessment.MethodsWe videotaped high-quality CPR (based on 2010 American Heart Association guidelines) and 3 variations of poor quality CPR in a simulated resuscitation, filmed from the foot, head and the side of the manikin. Participants watched 12 videos and completed a questionnaire to assess CPR quality.ResultsOne hundred and twenty-five participants were recruited. The overall accuracy of visual assessment of CPR quality was 65.6%. Accuracy was better from the side (70.8%) and foot (68.8%) of the bed when compared to the head of the bed (57.2%; p < 0.001). The side was the best position for assessing depth (p < 0.001). Rate assessment was equivalent between positions (p = 0.58). The side and foot of the bed were superior to the head when assessing chest recoil (p < 0.001). Factors associated with increased accuracy in visual assessment of CPR quality included recent CPR course completion (p = 0.034) and involvement in more cardiac arrests as a team member (p = 0.003).ConclusionHealthcare providers struggle to accurately assess the quality of CPR using visual assessment. If visual assessment is being used, providers should stand at the side of the bed.     

An investigation of thrust,depth and the impedance cardiogram as measures of cardiopulmonary resuscitation efficacy in a porcine model of cardiac arrest

ObjectiveOptimising the depth and rate of applied chest compressions following out of hospital cardiac arrest is crucial in maintaining end organ perfusion and improving survival. The impedance cardiogram (ICG) measured via defibrillator pads produces a characteristic waveform during chest compressions with the potential to provide feedback on cardiopulmonary resuscitation (CPR) and enhance performance. The objective of this pre-clinical study was to investigate the relationship between mechanical and physiological markers of CPR efficacy in a porcine model and examine the strength of correlation between the ICG amplitude, compression depth and end-tidal CO₂ (ETCO₂).MethodsTwo experiments were performed using 24 swine (12 per experiment). For experiment 1, ventricular fibrillation (VF) was induced and mechanical CPR commenced at varying thrusts (0–60 kg) for 2 min intervals. Chest compression depth was recorded using a Philips QCPR device with additional recording of invasive physiological parameters: systolic blood pressure, ETCO2, cardiac output and carotid flow. For experiment 2, VF was induced and mechanical CPR commenced at varying depths (0–5 cm) for 2 min intervals. The ICG was recorded via defibrillator pads attached to the animal's sternum and connected to a Heartsine 500P defibrillator. ICG amplitude, chest compression depth, systolic blood pressure and ETCO₂ were recorded during each cycle. In both experiments the within-animal correlation between the measured parameters was assessed using a mixed effect model.ResultsIn experiment 1 moderate within-animal correlations were observed between physiological parameters and compression depth (r = 0.69–0.77) and thrust (r = 0.66–0.82). A moderate correlation was observed between compression depth and thrust (r = 0.75). In experiment 2 a strong within-animal correlation and moderate overall correlations were observed between ICG amplitude and compression depth (r = 0.89, r = 0.79) and ETCO₂ (r = 0.85, r = 0.64).ConclusionIn this porcine model of induced cardiac arrest moderate within animal correlations were observed between mechanical and physiological markers of chest compression efficacy demonstrating the challenge in utilising a single mechanical metric to quantify chest compression efficacy. ICG amplitude demonstrated strong within animal correlations with compression depth and ETCO₂ suggesting its potential utility to provide CPR feedback in the out of hospital setting to improve performance.     

Effects of cardiopulmonary resuscitation on direct versus video laryngoscopy using a mannequin model

IntroductionDuring the last decade, guidelines for cardiopulmonary resuscitation has shifted, placing chest compressions and defibrillation first and airway management second. Physicians are being forced to intubate simultaneously with uninterrupted, high quality chest compressions. Using a mannequin model, this study examines the differences between direct and video laryngoscopy, comparing their performance with and without simultaneous chest compressions.MethodsFifty emergency medicine physicians were randomly assigned to intubate a mannequin six times, using direct laryngoscopy (DL) and with two video laryngoscopy (VL) systems, a C-MAC traditional Macintosh blade and a GlideScope hyperangulated blade, with and without simultaneous chest compressions. A total of 300 intubations were completed and variables including intubation times, accuracy, difficulty, success rates and glottic views were recorded.ResultsThe C-MAC VL system resulted in quicker intubations compared to DL (p = 0.007) and the GlideScope VL system (p = 0.039) during active chest compressions. Compared to DL, intubations were rated easier for both the C-MAC (p < 0.0001) and the GlideScope (p < 0.0001). Intubation failure rates were also higher when DL was used compared to either the C-MAC or GlideScope (p = 0.029). VL devices provided a superior overall Cormack-Lehane grade view compared to DL (p < 0.0001). The presence of chest compressions significantly impaired Cormack-Lehane views during direct laryngoscopy (p = 0.007). Chest compressions made the intubation more difficult under DL (p = 0.002) and when using the C-MAC (p = 0.031). Chest compressions also made ETT placement less accurate when using DL (p = 0.004).ConclusionUsing a mannequin model, the C-MAC conventional VL blade resulted in decrease intubation times compared with DL or the GlideScope hyperangulated VL blade system. Overall, VL out performed DL in terms of providing a superior glottic view, minimizing failed attempts, and improving physician's overall perception of intubation difficulty. Chest compressions resulted in worse Cormack-Lehane views and higher rates of inaccurate endotracheal tube placement with DL, compared to VL.