Simulation and educationDoes Dual Operator CPR help minimize interruptions in chest compressions?☆
Introduction
Several factors may affect the quality of CPR. Performance of chest compressions is known to be tiring. It has been shown that rescuer fatigue occurs within 1 min of chest compressions and that fatigue results in less efficacious chest compressions.[1], [2], [3] Hightower et al.1 found that the percentage of adequate compressions decreased from 93 to 39% after 3 min and only 18% were satisfactory after 5 min. Performance of CPR by a single rescuer may also be affected by pauses between compressions (also known as the no-flow duration). Interruption in chest compressions reduces coronary perfusion pressure and the chance of successful defibrillation.
Guidelines 2005 increased the compression to ventilation ratio from 15:2 to 30:2 for Dual Operator CPR with the aim of reducing interruptions. In addition, if two rescuers are present, then the problems of fatigue and increased no-flow duration can be minimized. If the tiring compressions are shared between two or more rescuers then fatigue may be less of an issue. Furthermore, if one rescuer can perform chest compressions immediately after the other performs rescue breaths then it is possible to reduce the ‘no-flow duration’. Although not the primary aim of a study in 2004, Handley and Handley suggested that 2 person CPR was more efficient than Single Operator CPR in avoiding long pauses for ventilation,4 effectively resulting in a reduced ‘no-flow duration’.
European Resuscitation Council (ERC) Guidelines in 20005 and 20056 offer different suggestions on how to approach the situation if 2 rescuers are present. The former ERC Guidelines 2000 suggest that when two or more trained rescuers are present they should perform Dual Operator CPR. This is when one rescuer performs chest compressions whilst the other performs rescue breaths, swapping if required (see Fig. 1). ERC Guidelines 2005 recommend that when two or more rescuers are present Single Operator CPR should be performed, where one rescuer swaps with the other every 1–2 min. Both sets of guidelines stress that any changeover of rescuers should be undertaken with a minimum of delay. However, despite changing the guidelines between 2000 and 2005 there seems to have been no published research comparing the two methods. There have been studies examining how best to provide advanced resuscitation with multiple professional providers; in the pre-hospital setting7 and the in-hospital advanced life support setting,8 but none of these have focused on the provision of Basic Life Support alone or examined the effect on interruptions in chest compressions.
The aim of the present study was to determine if Dual Operator CPR, performed by a team of trained first responders reduces no-flow duration compared to Single Operator CPR with two rescuers.
Section snippets
Setting
The study was carried out at the University of Birmingham Medical School, UK. We recruited 58 Basic Life Support (BLS) instructors that taught BLS on a peer-led BLS and Automated External Defibrillator (AED) course. Ethical approval was granted by the South Birmingham Research Ethics Committee. Verbal consent was obtained from the candidates.
Study design
The present study was a randomised controlled crossover trial. All candidates were randomly allocated to work in pairs. The pairs were then randomised into
Results
58 candidates were assessed for eligibility and 8 were excluded before randomisation (n = 8 due to personal commitments making them unable to attend CPR assessments). At initial CPR assessment there were 50 candidates (Dual Operator group n = 26, Single Operator group n = 24). At the crossover assessment 1 week after the initial assessment there were no candidates lost to follow-up (Dual Operator group n = 26, Single Operator group n = 24). Fig. 2 shows the flow of candidates through the study.
Discussion
The principal finding of this study was that Dual Operator CPR achieved a statistically significant reduction in no-flow duration when compared with Single Operator CPR (28.53% versus 31.62%, P ≤ 0.001). However, the magnitude of the improvement (3%) was small and would be unlikely to have any major effect on patient outcome were they to be reproduced in an actual resuscitation attempt. There were no other clinically significant differences in CPR (rescue breath or chest compression) performance
Conclusion
Dual Operator CPR provides marginal improvement in minimizing interruptions in chest compressions when compared to Single Operator CPR performed by BLS resuscitation teams. There are no other differences in the performance of CPR between Dual Operator and Single Operator CPR when 2 rescuers are present. There seems little advantage in adding teaching of Dual Operator CPR to trained first responder/BLS CPR programs in view of the added complexities.
Conflict of interest
None declared.
Acknowledgements
Thanks to Rebecca Taylor, Andy Owen, Laura Kocierz and the RMD teachers for participating. Finally to Professor Julian Bion and Dr Jon Hulme for their continued support. Funding: the manikins in this study were paid for by a grant from the Resuscitation Council (UK). GDP is supported by a Department of Health NIHR Clinician Scientist Award.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.04.048.