Newswise — New research indicates that CPR performed outside the hospital and in the hospital often does not meet or adhere to standard guidelines, according to 2 studies in the January 19 issue of JAMA.
The importance of CPR (cardiopulmonary resuscitation) for survival of cardiac arrest patients has been demonstrated, according to background information in the article. There are indications that the quality of CPR performance influences the outcome. When tested on mannequins, CPR quality performed by lay rescuers and health care professionals tends to deteriorate significantly within a few months after training, but little is known about the quality of actual clinical performance of CPR on patients.
CPR guidelines recommend target values for chest compressions, ventilations, and CPR-free intervals allowed for rhythm analysis and defibrillation. There is little information on adherence to these guidelines during advanced cardiac life support during out-of-hospital cardiac arrest.
In the first study, Lars Wik, M.D., Ph.D., of Ulleval University Hospital, Oslo, Norway and colleagues examined the performance of paramedics and nurse anesthetists during out-of-hospital advanced cardiac life support (ACLS) by continuously monitoring all chest compressions and ventilations during resuscitation episodes using online defibrillators. The study included 176 adult patients with out-of-hospital cardiac arrest treated by paramedics and nurse anesthetists in Stockholm, Sweden, London, and Akershus, Norway, between March 2002 and October 2003. The defibrillators were modified to measure chest compressions and ventilations, in addition to standard event and electrocardiographic recordings.
The primary outcome measure was adherence to international guidelines for CPR. Target values for compression rate were 100 to 120/min; for depth, 38 to 52 mm; and for ventilation rate, 2 ventilations for every 15 compressions before intubation and 10/min to 12/min after intubation.
The researchers found that chest compressions were not given 48 percent of the time without spontaneous circulation; this percentage was 38 percent when subtracting the time necessary for electrocardiographic analysis and defibrillation. Combining these data with an average compression rate of 121/min when compressions were given resulted in an average compression rate of 64/min. Average compression depth was 34 mm, 28 percent of the compressions had a depth of 38 mm to 51 mm, and the compression part of the duty cycle was 42 percent. An average of 11 ventilations were given per minute. Sixty-one patients (35 percent) had return of spontaneous circulation, and 5 of 6 patients discharged alive from the hospital had normal neurological outcomes.
"Whether some of these deficiencies can be improved by specific focus during training needs attention. Through better understanding of the mistakes made in a real-life cardiac arrest situation, training courses might be designed to focus on these aspects. Another approach would be to develop online tools that prompt the rescuer to improved performance. Audiotapes giving instructions on chest compression rate have been reported to improve the compression rate during cardiac arrest in patients," the authors write.
"If our study represents how CPR is delivered during resuscitation from out-of-hospital cardiac arrest in other communities, there is a great opportunity to improve CPR quality and, hopefully, patient survival by focusing on delivery of chest compressions of correct depth and rate, with minimal 'hands-off' periods," the researchers conclude.(JAMA. 2005;293:299-304. Available post-embargo at http://JAMA.com)
Editor's Note: For funding and financial disclosure information, please see the JAMA article.
Quality of In-Hospital CPR May Fail To Meet Guidelines
In the second report, Benjamin S. Abella, M.D., M.Phil., of the University of Chicago Hospitals, Chicago, and colleagues conducted a study to determine whether well-trained hospital staff perform CPR compressions and ventilations according to guideline recommendations.
According to background information in the article, survival from cardiac arrest remains low despite the introduction of CPR over 50 years ago. The delivery of CPR, with correctly performed chest compressions and ventilations, exerts a significant survival benefit. Conversely, interruptions in CPR or failure to provide compressions during cardiac arrest have been noted to have a negative impact on survival in animal studies. Consensus guidelines clearly define how CPR is to be performed, but the parameters of CPR in actual practice are not routinely measured, nor has the quality been known. Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines.
This study examined in-hospital cardiac arrests at the University of Chicago Hospitals from December 11, 2002 until April 5, 2004. Using a monitor/defibrillator with novel additional sensing capabilities, the researchers recorded parameters of CPR quality including chest compression rate, compression depth, ventilation rate and the fraction of arrest time without chest compressions (no-flow fraction; NFF).
Data were collected from 67 in-hospital arrests. The researchers found that analysis of the first 5 minutes of each resuscitation by 30 second segments revealed that chest compression rates were less than 90 compressions per minute in 28.1 percent of segments. Compression depth was too shallow for 37.4 percent of compressions. Ventilation rates were high, with 60.9 percent of segments containing a rate of more than 20/min. A total of 27 patients (40.3 percent) achieved return of spontaneous circulation and 7 (10.4 percent) were discharged from the hospital.
"There are several potential practical solutions for helping to improve poor CPR quality. The first involves mechanical devices that can provide chest compressions reliably at a set rate and depth. These devices may generate better hemodynamic characteristics than manual chest compressions. Another solution is to improve monitoring and feedback to reduce human error during manual CPR, by using devices such as [a certain type of] CO2 monitors and 'smart defibrillators', which can measure CPR characteristics and provide audio feedback to alert rescuers to errors such as incorrect chest compression or ventilation rate," the authors write. (JAMA. 2005;293:305-310. Available post-embargo at http://JAMA.com)
Editor's Note: For funding and financial disclosure information, please see the JAMA article. Editorial: Cardiopulmonary Resuscitation in the Real World - When Will the Guidelines Get the Message?
In an accompanying editorial, Arthur B. Sanders, M.D., and Gordon A. Ewy, M.D., of the University of Arizona College of Medicine, Tucson, comment on the studies in this week's JAMA on CPR.
""¦ the clinical data, including the 2 studies in this issue of JAMA, imply that current resuscitation guidelines are not being followed, and other observational studies indicate that performing high-quality CPR is important for resuscitation success. Clearly, the quality of real-world CPR must be improved. In the past such inadequacies have been dismissed as an education/training problem. This assumed that health care professionals and laypersons do not adequately learn and retain CPR skills, which leads to medical errors when CPR is performed. But perhaps it is not a question of how well rescuers are being taught and learn the material. In reality, the training courses for health care professionals get more complex with each revision of the guidelines. Some of the skills taught, such as 2 breaths in 5 seconds, are impossible to deliver."
"Many patients in cardiac arrest do not receive high-quality CPR, and this observation may affect the success of the resuscitation efforts. This represents a shortcoming of the guidelines development process and current training systems. The CPR and Emergency Cardiovascular Care (ECC) Guidelines are too complex, resulting in patients not receiving known benefits such as chest compressions for extended periods. It is time to reconsider some of the policies and processes used in guidelines development such as the inclusion of previous recommendations without evidence to support them. It is time to simplify the CPR guidelines and educational programs so that all patients who sustain cardiac arrest can receive optimal treatment. It is time to give rescuers and health care professionals the knowledge and skills that can be readily used in the real world to improve the resuscitation of patients in cardiac arrest," they conclude. (JAMA. 2005;293:363-365. Available post-embargo at http://JAMA.com)
Editor's Note: Drs. Sanders and Ewy have served as members of the Emergency Cardiac Care Committee, have been involved in the development of previous versions of the ECC and CPR Guidelines, and will participate in the 2005 International Consensus on Science Conference and in development of the 2005 guidelines.
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