Elsevier

Resuscitation

Volume 84, Issue 8, August 2013, Pages 1125-1130
Resuscitation

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

https://doi.org/10.1016/j.resuscitation.2013.03.029Get rights and content

Abstract

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.

Introduction

Survival rates following paediatric cardiac arrest are extremely low.1, 2, 3, 4 A return of spontaneous circulation (ROSC) is achieved in approximately 60% of paediatric patients following in-hospital cardiac arrest, with newborns and infants (i.e. <1 year olds) having the greatest likelihood of neurologically-intact survival (∼20%).1, 2 By direct comparison, only 2–9% of such patients will achieve neurological survival if they suffer an out-of-hospital cardiac arrest.3, 4, 5, 6, 7, 8, 9

The importance of high quality chest compressions during infant cardiopulmonary resuscitation (CPR) is recognised by both the European and UK Resuscitation Councils.10, 11 Recent publications, however, describe the poor chest compression performance of Advanced Paediatric Life Saver (APLS)-certified instructors during simulated infant CPR, typified by inconsistent chest compression depths, excessive compression rates and prolonged compression duty cycles.12, 13, 14, 15 Even when utilising a manikin with enhanced “physiological” characteristics, APLS-certified instructors could still only achieve an overall chest compression quality <1% when compared to the targets of the four internationally recommended parameters (chest compression depth, chest compression rate, duty cycle, release force; summarised in Online Table 1 and schematically in Fig. 1).15

Whilst the effect of instantaneous performance feedback during adult CPR has previously been reported, this study is the first to investigate the hypothesis that instantaneous feedback will improve the performance of chest compression quality during simulated, infant CPR.

Section snippets

Methods

Sixty-nine European Paediatric Life Support (EPLS) and/or APLS certified CPR providers were recruited from seven EPLS/APLS training courses, and were evaluated when performing two-thumb (TT) and two-finger (TF) technique chest compressions during simulated, chest compression-only, infant CPR. The flow of participants through the study is described in Fig. 2. Providers were excluded if there was >4 years since certification.

This study utilised a commercially available CPR manikin (Laerdal® ALS

Results

The demographics of the 69 APLS and/or EPLS certified CPR providers that participated in this study are available in Online Table 2.

. Study demographics.

Discussion

This study is unique in demonstrating how ‘real-time’ feedback during simulated infant CPR leads to a dramatic improvement in quality, with 75% (TF) and 80% (TT) of chest compressions simultaneously achieving the four, internationally recommended targets. This compares to an overall quality <1% when performing chest compressions without feedback.

Providers achieved relatively high CD quality (∼20%) versus other data when performing chest compressions without feedback (Online Table 4),14 although

Conclusion

The study demonstrated that the provision of real-time feedback during simulated infant CPR coincided with a dramatic improvement in overall infant chest compression quality (from 1% to 75–80%). Should these result transfer to clinical practice, then this technology will enable CPR providers to perform the vast majority of chest compressions to within the targets of internationally recommended parameters, thereby having great potential to influence survival following infant cardiac arrest.

Conflict of interest statement

Dr. Ian Maconochie is Co-chair of the Paediatric Task Force for ILCOR 2015, and a member of the European and the UK Resuscitation Councils. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgements

The authors would like to thank the EPLS training course organisers and NHS Trusts for hosting and helping organise this research, and the CPR providers that consented to participate in this study.

References (25)

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    Another important aspect observed in the studies explored in this review was related to how the outcome measures were reported, which may have impacted the differences seen in results. Data from 13 studies were presented using a percentage, which represented compliance with resuscitation guidelines.18,26,27a,27b,29a,29b –33,35,37,38 All 13 studies had chest compression rate and chest compression depth as outcome measures and seven of those included residual leaning as well.

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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.029.

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