Resuscitation 87 (2015) A1–A2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Improving CPR measurement: Are we there yet?
Keywords: Cardiac arrest Cardiopulmonary resuscitation Chest compression
Over the past decade, increasing data have supported the association between cardiopulmonary resuscitation (CPR) quality and survival from cardiac arrest.1–4 In response, the International Liaison Committee on Resuscitation and the American Heart Association have emphasized the importance of CPR quality in recent scientific statements and the consensus resuscitation guidelines.5,6 The quality of CPR encompasses a variety of quantifiable characteristics, including chest compression rate, depth, compression fraction, as well as ventilation rate and volume. Accelerometerbased technologies have been developed to monitor CPR quality and provide feedback in real-time during resuscitation efforts. Such tools have been incorporated into monitor/defibrillators as well as free-standing CPR sensing devices to improve compliance with CPR quality guidelines.7–9 However, accelerometer-based measurement of chest compression has been shown to overestimate compression depth, in varying amounts depending on the underlying surface on which CPR is performed. That is, performance of chest compressions on a victim lying on a highly deformable mattress will lead to greater overestimation of depth (and potentially incorrect feedback) compared to performance on a more firm transport gurney, for example. This measurement issue may have important clinical implications during CPR delivery, given the importance of sufficient chest compression depth.1,4,10,11 An alternative approach to chest compression measurement that addresses this issue has been studied during simulated resuscitation by Wutzler et al., in this issue of Resuscitation.12 The authors used a monitor/defibrillator that incorporates a chest compression sensor that exploits electromagnetic induction to determine the distance between two sensor pads, one placed under the patient and one on the sternum. In the study by Wutzler et al., health care providers performed CPR on manikins while CPR quality metrics were measured. The trial design randomized subjects to either initial performance of CPR without feedback, and then with feedback enabled, or vice versa. When audiovisual feedback was provided, the percentage of optimal chest compressions (with both correct rate and depth) improved from approximately 28% to 48%. This included both changes in compression rate and depth (for example, chest http://dx.doi.org/10.1016/j.resuscitation.2014.11.021 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
compressions at appropriate depth improved from 36% to 55%). It is important to note, however, that despite statistically significant impact on compression quality, CPR performance by the health care provider subjects remained highly variable; even with devicegenerated feedback, over 50% of delivered compressions did not satisfy guidelines recommended metrics for CPR quality, and a significant fraction of overall resuscitation time was spent performing suboptimal compressions. The findings of Wutzler et al., demonstrating improvements in some aspects of CPR performance with the use of feedback technology, are consistent with previous studies with other devices.8,13 Most recently, Bobrow et al. performed a prospective cohort study related to the implementation of real-time audiovisual feedback during pre-hospital cardiac arrest.8 They demonstrated improved CPR quality, improved compression fraction and increased survival after the introduction of audiovisual feedback. Of note, their work also involved an intensive educational component for providers in conjunction with feedback. Edelson et al.7 found similar results using CPR feedback and debriefing of providers in the hospital environment. Taken together, the current work and these prior studies are promising, but much work remains to be done, especially with regard to real-world implementation of CPR quality improvement. Solutions such as continuous learning programs, CPR “rolling refreshers” and post arrest debriefing may provide opportunities for improvement.7,14–16 For example, Wolfe et al. demonstrated that CPR feedback combined with structured postevent debriefing improved subsequent resuscitation performance and clinical outcomes in pediatric resuscitation care.15 Such interventions require considerable effort to implement, however, and methods to simplify and broadly implement such approaches will remain an important area for study. The variability seen in the delivery of CPR may reflect inherent difficulties in training and maintaining skills among a broad range of providers, with varying motivation and physical abilities. It is important to note that despite high-quality training, fatigue may cause the ability to perform high quality compressions to decay over time.17 Such observations have supported an alternative approach to CPR quality, namely the use of mechanical CPR devices. Mechanical devices lack human variability and allow the precise and consistent control of chest compression rate, depth and compression fraction, among other parameters. Clinical studies of mechanical CPR have yielded mixed results, but generally suggest that they are non-inferior to manual performance.18–20 Further investigations will be required to determine if mechanical CPR has
A2
Editorial / Resuscitation 87 (2015) A1–A2
clinical advantages in particular environments (e.g., prehospital care in suburban or rural settings with long transport times). A crucial limitation of both mechanical CPR and guidelinesbased manual CPR is the lack of adjustment to patient factors or physiologic response. That is to say, patients are left out of the resuscitation care equation. Much like other medical therapeutics, CPR may require “dosing” for patients of specific habitus, physiologic state, or chest wall characteristics. Initial laboratory investigations targeting physiologic measures during CPR (such as end-tidal CO2 or arterial pressure) have suggested that such an approach may indeed be possible.21,22 With the development of sophisticated tools to monitor CPR quality, such as the device evaluated by Wutzler et al., opportunities to study and improve CPR delivery are increasingly within reach. It is likely that through a variety of strategies, including audiovisual feedback, CPR debriefing, mechanical CPR, and broad system-wide emphasis on CPR training and delivery,23 health care providers will become increasingly empowered to provide high-quality resuscitation care. It will remain the responsibility of prehospital and hospital systems to provide robust implementation of these approaches to improve survival from cardiac arrest.
9.
10. 11. 12.
13.
14. 15. 16.
17.
18.
19.
Conflict of interest statement J. Nelson does not report any conflicts of interest; B.S. Abella receives research funding from the American Heart Association and Medtronic Foundation, and serves on the medical advisory boards of CardioReady and HeartSine Technologies. References 1. Wallace SK, Abella BS, Becker LB. Quantifying the effect of cardiopulmonary resuscitation quality on cardiac arrest outcome: a systematic review and metaanalysis. Circ Cardiovasc Qual Outcomes 2013;6:148–56. 2. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71:137–45. 3. Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012;125: 3004–12. 4. Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med 2012;40:1192–8. 5. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American heart association. Circulation 2013;128:417–35. 6. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive summary: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010;122:S250–75. 7. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008;168:1063–9. 8. Bobrow BJ, Vadeboncoeur TF, Stolz U, et al. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary
20.
21.
22.
23.
resuscitation quality and survival from out-of-hospital cardiac arrest. Ann Emerg Med 2013;62:47–56, e1. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: a systematic review. Resuscitation 2009;80:743–51. Nishisaki A, Nysaether J, Sutton R, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation 2009;80:540–5. Perkins GD, Mancini ME. Resuscitation training for healthcare workers. Resuscitation 2009;80:841–2. Wutzler A, Bannehr M, von Ulmenstein S, et al. Performance of chest compressions with the use of a new audio–visual feedback device: A randomized manikin study in healthcare professionals. Resuscitation 2014;87:81–5. Abella BS, Edelson DP, Kim S, et al. CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation 2007;73:54–61. Niles D, Sutton RM, Donoghue A, et al. “Rolling refreshers”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation 2009;80:909–12. Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Crit Care Med 2014;42:1688–95. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr 2013;167:528–36. Sugerman NT, Edelson DP, Leary M, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation 2009;80:981–4. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014;85:741–8. Gates S, Smith JL, Ong GJ, Brace SJ, Perkins GD. Effectiveness of the LUCAS device for mechanical chest compression after cardiac arrest: systematic review of experimental, observational and animal studies. Heart 2012;98:908–13. Ong ME, Quah JL, Annathurai A, et al. Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department. Resuscitation 2013;84:508–14. Sutton RM, Friess SH, Maltese MR, et al. Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest. Resuscitation 2014;85:983–6. Friess SH, Sutton RM, French B, et al. Hemodynamic directed CPR improves cerebral perfusion pressure and brain tissue oxygenation. Resuscitation 2014;85:1298–303. van Diepen S, Abella BS, Bobrow BJ, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project. Am Heart J 2013;166:647–53, e2.
Joshua Nelson Benjamin S. Abella ∗ Department of Emergency Medicine and the Center for Resuscitation Science, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA ∗ Corresponding author at: Department of Emergency Medicine, Center for Resuscitation Science, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA. E-mail address: [email protected] (B.S. Abella)
21 November 2014 22 November 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Improving CPR measurement: Are we there yet?
Keywords: Cardiac arrest Cardiopulmonary resuscitation Chest compression
Over the past decade, increasing data have supported the association between cardiopulmonary resuscitation (CPR) quality and survival from cardiac arrest.1–4 In response, the International Liaison Committee on Resuscitation and the American Heart Association have emphasized the importance of CPR quality in recent scientific statements and the consensus resuscitation guidelines.5,6 The quality of CPR encompasses a variety of quantifiable characteristics, including chest compression rate, depth, compression fraction, as well as ventilation rate and volume. Accelerometerbased technologies have been developed to monitor CPR quality and provide feedback in real-time during resuscitation efforts. Such tools have been incorporated into monitor/defibrillators as well as free-standing CPR sensing devices to improve compliance with CPR quality guidelines.7–9 However, accelerometer-based measurement of chest compression has been shown to overestimate compression depth, in varying amounts depending on the underlying surface on which CPR is performed. That is, performance of chest compressions on a victim lying on a highly deformable mattress will lead to greater overestimation of depth (and potentially incorrect feedback) compared to performance on a more firm transport gurney, for example. This measurement issue may have important clinical implications during CPR delivery, given the importance of sufficient chest compression depth.1,4,10,11 An alternative approach to chest compression measurement that addresses this issue has been studied during simulated resuscitation by Wutzler et al., in this issue of Resuscitation.12 The authors used a monitor/defibrillator that incorporates a chest compression sensor that exploits electromagnetic induction to determine the distance between two sensor pads, one placed under the patient and one on the sternum. In the study by Wutzler et al., health care providers performed CPR on manikins while CPR quality metrics were measured. The trial design randomized subjects to either initial performance of CPR without feedback, and then with feedback enabled, or vice versa. When audiovisual feedback was provided, the percentage of optimal chest compressions (with both correct rate and depth) improved from approximately 28% to 48%. This included both changes in compression rate and depth (for example, chest http://dx.doi.org/10.1016/j.resuscitation.2014.11.021 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
compressions at appropriate depth improved from 36% to 55%). It is important to note, however, that despite statistically significant impact on compression quality, CPR performance by the health care provider subjects remained highly variable; even with devicegenerated feedback, over 50% of delivered compressions did not satisfy guidelines recommended metrics for CPR quality, and a significant fraction of overall resuscitation time was spent performing suboptimal compressions. The findings of Wutzler et al., demonstrating improvements in some aspects of CPR performance with the use of feedback technology, are consistent with previous studies with other devices.8,13 Most recently, Bobrow et al. performed a prospective cohort study related to the implementation of real-time audiovisual feedback during pre-hospital cardiac arrest.8 They demonstrated improved CPR quality, improved compression fraction and increased survival after the introduction of audiovisual feedback. Of note, their work also involved an intensive educational component for providers in conjunction with feedback. Edelson et al.7 found similar results using CPR feedback and debriefing of providers in the hospital environment. Taken together, the current work and these prior studies are promising, but much work remains to be done, especially with regard to real-world implementation of CPR quality improvement. Solutions such as continuous learning programs, CPR “rolling refreshers” and post arrest debriefing may provide opportunities for improvement.7,14–16 For example, Wolfe et al. demonstrated that CPR feedback combined with structured postevent debriefing improved subsequent resuscitation performance and clinical outcomes in pediatric resuscitation care.15 Such interventions require considerable effort to implement, however, and methods to simplify and broadly implement such approaches will remain an important area for study. The variability seen in the delivery of CPR may reflect inherent difficulties in training and maintaining skills among a broad range of providers, with varying motivation and physical abilities. It is important to note that despite high-quality training, fatigue may cause the ability to perform high quality compressions to decay over time.17 Such observations have supported an alternative approach to CPR quality, namely the use of mechanical CPR devices. Mechanical devices lack human variability and allow the precise and consistent control of chest compression rate, depth and compression fraction, among other parameters. Clinical studies of mechanical CPR have yielded mixed results, but generally suggest that they are non-inferior to manual performance.18–20 Further investigations will be required to determine if mechanical CPR has
A2
Editorial / Resuscitation 87 (2015) A1–A2
clinical advantages in particular environments (e.g., prehospital care in suburban or rural settings with long transport times). A crucial limitation of both mechanical CPR and guidelinesbased manual CPR is the lack of adjustment to patient factors or physiologic response. That is to say, patients are left out of the resuscitation care equation. Much like other medical therapeutics, CPR may require “dosing” for patients of specific habitus, physiologic state, or chest wall characteristics. Initial laboratory investigations targeting physiologic measures during CPR (such as end-tidal CO2 or arterial pressure) have suggested that such an approach may indeed be possible.21,22 With the development of sophisticated tools to monitor CPR quality, such as the device evaluated by Wutzler et al., opportunities to study and improve CPR delivery are increasingly within reach. It is likely that through a variety of strategies, including audiovisual feedback, CPR debriefing, mechanical CPR, and broad system-wide emphasis on CPR training and delivery,23 health care providers will become increasingly empowered to provide high-quality resuscitation care. It will remain the responsibility of prehospital and hospital systems to provide robust implementation of these approaches to improve survival from cardiac arrest.
9.
10. 11. 12.
13.
14. 15. 16.
17.
18.
19.
Conflict of interest statement J. Nelson does not report any conflicts of interest; B.S. Abella receives research funding from the American Heart Association and Medtronic Foundation, and serves on the medical advisory boards of CardioReady and HeartSine Technologies. References 1. Wallace SK, Abella BS, Becker LB. Quantifying the effect of cardiopulmonary resuscitation quality on cardiac arrest outcome: a systematic review and metaanalysis. Circ Cardiovasc Qual Outcomes 2013;6:148–56. 2. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71:137–45. 3. Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012;125: 3004–12. 4. Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med 2012;40:1192–8. 5. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American heart association. Circulation 2013;128:417–35. 6. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive summary: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010;122:S250–75. 7. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008;168:1063–9. 8. Bobrow BJ, Vadeboncoeur TF, Stolz U, et al. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary
20.
21.
22.
23.
resuscitation quality and survival from out-of-hospital cardiac arrest. Ann Emerg Med 2013;62:47–56, e1. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: a systematic review. Resuscitation 2009;80:743–51. Nishisaki A, Nysaether J, Sutton R, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation 2009;80:540–5. Perkins GD, Mancini ME. Resuscitation training for healthcare workers. Resuscitation 2009;80:841–2. Wutzler A, Bannehr M, von Ulmenstein S, et al. Performance of chest compressions with the use of a new audio–visual feedback device: A randomized manikin study in healthcare professionals. Resuscitation 2014;87:81–5. Abella BS, Edelson DP, Kim S, et al. CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation 2007;73:54–61. Niles D, Sutton RM, Donoghue A, et al. “Rolling refreshers”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation 2009;80:909–12. Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Crit Care Med 2014;42:1688–95. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr 2013;167:528–36. Sugerman NT, Edelson DP, Leary M, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation 2009;80:981–4. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014;85:741–8. Gates S, Smith JL, Ong GJ, Brace SJ, Perkins GD. Effectiveness of the LUCAS device for mechanical chest compression after cardiac arrest: systematic review of experimental, observational and animal studies. Heart 2012;98:908–13. Ong ME, Quah JL, Annathurai A, et al. Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department. Resuscitation 2013;84:508–14. Sutton RM, Friess SH, Maltese MR, et al. Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest. Resuscitation 2014;85:983–6. Friess SH, Sutton RM, French B, et al. Hemodynamic directed CPR improves cerebral perfusion pressure and brain tissue oxygenation. Resuscitation 2014;85:1298–303. van Diepen S, Abella BS, Bobrow BJ, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project. Am Heart J 2013;166:647–53, e2.
Joshua Nelson Benjamin S. Abella ∗ Department of Emergency Medicine and the Center for Resuscitation Science, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA ∗ Corresponding author at: Department of Emergency Medicine, Center for Resuscitation Science, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA. E-mail address: [email protected] (B.S. Abella)
21 November 2014 22 November 2014
