The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest – A prospective, randomized trial

doi:10.1016/j.resuscitation.2010.11.006

Resuscitation

Volume 82, Issue 3, March 2011, Pages 257-262

https://doi.org/10.1016/j.resuscitation.2010.11.006 Get rights and content

Abstract

Aims

Chest compression quality is a determinant of survival from out-of-hospital cardiac arrest (OHCA). ERC 2005 guidelines recommend the use of technical devices to support rescuers giving compressions. This prospective randomized study reviewed influence of different feedback configurations on survival and compression quality.

Materials and methods

312 patients suffering an OHCA were randomly allocated to two different feedback configurations. In the limited feedback group a metronome and visual feedback was used. In the extended feedback group voice prompts were added. A training program was completed prior to implementation, performance debriefing was conducted throughout the study.

Results

Survival did not differ between the extended and limited feedback groups (47.8% vs 43.9%, p = 0.49). Average compression depth (mean ± SD: 4.74 ± 0.86 cm vs 4.84 ± 0.93 cm, p = 0.31) was similar in both groups. There were no differences in compression rate (103 ± 7 vs 102 ± 5 min(−1), p = 0.74) or hands-off fraction (16.16% ± 0.07 to 17.04% ± 0.07, p = 0.38). Bystander CPR, public arrest location, presenting rhythm and chest compression depth were predictors of short term survival (ROSC to ED).

Conclusions

Even limited CPR-feedback combined with training and ongoing debriefing leads to high chest compression quality. Bystander CPR, location, rhythm and chest compression depth are determinants of survival from out of hospital cardiac arrest. Addition of voice prompts does neither modify CPR quality nor outcome in OHCA. CC depth significantly influences survival and therefore more focus should be put on correct delivery. Further studies are needed to examine the best configuration of feedback to improve CPR quality and survival.

Registration

ClinicalTrials.gov (NCT00449969), http://www.clinicalTrials.gov.

Introduction

Success of pre-hospital cardio-pulmonary resuscitation (CPR) depends on many factors. Quality of chest compressions has been identified as one factor affecting survival after CPR. Kramer-Johansen et al. showed that deeper chest compressions were associated with improved short term survival (admission to hospital).¹ Christenson et al. demonstrated that compression fraction (time with compressions relative to total resuscitation duration) is an independent predictor of survival.² Automated feedback systems were able to improve the quality of resuscitation, but the ideal configuration of a feedback system has not yet been identified.¹

We investigated the effect of adding voice prompts to a metronome and visual depth feedback on the quality of chest compressions in a two arm, randomized, pre-hospital study. We hypothesized that the addition of this feedback-element would improve CPR quality and affect return of spontaneous circulation (ROSC).

Section snippets

Methods

The study was approved by the Ethics Committee of the Regional Medical Board of Registration (Ärztekammer Westfalen Lippe) and the University of Münster (Westfälische Wilhelms-Universität Münster, Record ID: 2006-671-f-S). The study was registered at clinicaltrials.gov with the identifier NCT00449969. The study population included all out-of-hospital arrests (unresponsive, pulseless and apneic and treated with either CPR or defibrillation) 18 years of age or older. Analysis was performed on 312

Results

The Utstein and demographic characteristics of the resuscitation attempts are comparable in both groups as presented in Table 2. Statistical comparisons were also made between these parameters for endpoint ROSC to ED vs non-ROSC to ED (Table 3).

We found no differences between the Limited and Extended feedback groups with regard to chest compression quality. The results are shown in Table 2. Overall performance deviated minimally from ERC 2005 guidelines for chest compression quality.

The almost

Discussion

Wik et al. in their landmark study of resuscitation quality (using ERC 2000 guidelines) published sobering data about CPR performance in professional rescue services. Only 28% of chest compressions were in the target range of 38–51 mm. The effective compression rate was only 64/min, and the hands-off fraction was 48%.³ These results prompted us to measure and improve the quality of chest compressions.

In comparison to Wik's results compression depth and rate both with Limited and Extended

Conclusions

In our physician-based professional EMS system usage of feedback technology combined with training and debriefing improved chest compression quality, guideline adherence and high ROSC-rates. Even limited CPR feedback leads to high chest compression quality.

As previous studies described epidemiological aspects like bystander CPR, location, rhythm and chest compression depth are determinants of survival from out of hospital cardiac arrest.

Overall the single addition of voice prompts to the

Conflict of interest statement

The corresponding authors have no conflicts of interest.

Acknowledgements

Sources of funding: None.

The authors would like to thank Chief Benno Fritzen and Co-Chief Fritz Burrichter of Münster Fire Department for their great support. Without the support of Lothar Decker, Fritz Duesmann, Pascal Mombaur and Dirk Schwichtenhovel (Münster Fire Department) this study would not have been possible. In particular authors thank Christoph Fiessler for his outstanding support. We would like to thank all Münster firefighters/EMTs and emergency physicians for their participation

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Cited by (71)

Do automated real-time feedback devices improve CPR quality? A systematic review of literature
2021, Resuscitation Plus
Automated real-time feedback devices have been considered a potential tool to improve the quality of cardiopulmonary resuscitation (CPR). Despite previous studies supporting the usefulness of such devices during training, others have conflicting conclusions regarding its efficacy during real-life CPR. This systematic review aimed to assess the effectiveness of automated real-time feedback devices for improving CPR performance during training, simulation and real-life resuscitation attempts in the adult and paediatric population.
Articles published between January 2010 and November 2020 were searched from BVS, Cinahl, Cochrane, PubMed and Web of Science, and reviewed according to a pre-defined set of eligibility criteria which included healthcare providers and randomised controlled trial studies. CPR quality was assessed based on guideline compliance for chest compression rate, chest compression depth and residual leaning.
The selection strategy led to 19 eligible studies, 16 in training/simulation and three in real-life CPR. Feedback devices during training and/or simulation resulted in improved acquisition of skills and enhanced performance in 15 studies. One study resulted in no significant improvement. During real resuscitation attempts, three studies demonstrated significant improvement with the use of feedback devices in comparison with standard CPR (without feedback device).
The use of automated real-time feedback devices enhances skill acquisition and CPR performance during training of healthcare professionals. Further research is needed to better understand the role of feedback devices in clinical setting.
Effect of a resuscitation quality improvement programme on outcomes from out-of-hospital cardiac arrest
2021, Resuscitation
Many emergency medical service (EMS) agencies are implementing programmes to improve the quality and performance of resuscitation. We sought to examine the impact of a resuscitation quality improvement programme on outcomes following OHCA.
An interrupted time-series analysis of adult OHCA patients of medical aetiology. Patients treated after the implementation of a high-performance cardiopulmonary resuscitation (CPR) intervention between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on the risk-adjusted odds of survival were examined using logistic regression models, with and without adjustment for temporal trends.
A total of 8270 and 2330 patients were treated in the control and intervention periods, respectively. Patients in the intervention period were older and less likely to arrest in public, present with an initial shockable rhythm, and receive mechanical CPR. After adjustment for arrest factors and temporal trends, there was a significant increase in the level of monthly survival to hospital discharge (AOR 1.50; 95% CI: 1.10, 2.04; p = 0.01), event survival (AOR 1.34; 95% CI: 1.09, 1.65; p = 0.006) and return of spontaneous circulation (AOR 1.38; 95% CI: 1.14, 1.65; p = 0.001). After removing the non-significant temporal trend, there was a 33% increase (AOR 1.33; 95% CI: 1.11, 1.58; p = 0.002) in the risk-adjusted odds of survival over the 12-month intervention period. The average marginal effect of the intervention resulted in 8.7 (95% CI: 3.2, 14.1) additional survivors per million population.
A resuscitation quality improvement programme consisting of high-performance CPR was associated with a significant increase in survival following OHCA.
European Resuscitation Council Guidelines 2021: Basic Life Support
2021, Resuscitation
The European Resuscitation Council has produced these basic life support guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include cardiac arrest recognition, alerting emergency services, chest compressions, rescue breaths, automated external defibrillation (AED), CPR quality measurement, new technologies, safety, and foreign body airway obstruction.
Ultrasound-Guided Chest Compressions in Out-of-Hospital Cardiac Arrests
2020, Journal of Emergency Medicine
Citation Excerpt :
A better strategy includes a real-time monitoring system of chest compression quality during CPR to maximize the hemodynamic effect of compression according to the patient's response, for a strategy of a personalized CPR (1–5). Current monitoring systems as CPR feedback/prompt devices are useful, but in clinical practice, they have not shown a true superiority in performance compared with conventional CPR (6–8). End-tidal carbon dioxide (ETCO2) is the only noninvasive parameter for monitoring the hemodynamic effect of CPR in OHCA: there is a very strong correlation between ETCO2 and cardiac output, coronary perfusion, and cerebral blood flow (9–12).
There is a significant variability in survival rates for cardiopulmonary resuscitation (CPR) in out of-hospital cardiac arrest (OHCA), and some data indicate that ultrasound improves CPR.
We evaluated the feasibility of ultrasound for monitoring chest compressions in OHCA.
We planned a prospective study in patients with an ultrasound-integrated CPR for OHCA. Chest compressions were performed on the intermammillary line (IML), but the position was changed according to the quality of the heart squeezing, evaluated by ultrasound. End-tidal carbon dioxide (ETCO₂) was used as the control parameter. Then we compared the area with the highest squeezing with the position of the heart in the chest computed tomography (CT) scans of 20 hospitalized patients.
Chest compressions were good, partial, and inadequate on the IML in 58.4%, 48.9%, and 2.8% of cases, respectively. These percentages were 75%, 25%, and 0% after these modifications: none (47.2%), increased depth (8.3%), hands moved on the lower third of the sternum (27.8%), on left parasternal line of the lower part of the sternum (13.9%), and on the center of the sternum (1 case). Accordingly, ETCO₂ improved significantly (20.37 vs. 37.10, p < 0.0001). The CT scans showed that the larger biventricular area (BVA) was under the parasternal line of the lower third of the sternum, and the mean distance IML-BVA was 5.7 cm.
Our study has demonstrated that CPR in OHCA can be improved using ultrasound and changing the position of the hands. This finding was connected with the ETCO₂ and confirmed by chest CT scans.
Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
2020, Resuscitation
This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.
Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.
The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.
Frequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR)
2020, Mayo Clinic Proceedings
To characterize what proportion of all randomized controlled trials (RCTs) among patients experiencing cardiac arrest find that an established practice is ineffective or harmful, that is, a medical reversal.
We reviewed a database of all published RCTs of cardiac arrest patient populations between 1995 and 2014. Articles were classified on the basis of whether they tested a new or existing therapy and whether results were positive or negative. A reversal was defined as a negative RCT of an established practice. Further review and categorization were performed to confirm that reversals were supported by subsequent systematic review, as well as to identify the type of medical practice studied in each reversal. This study was conducted from October 2017 to June 17, 2019.
We reviewed 92 original articles, 76 of which could be conclusively categorized. Of these, 18 (24%) articles examined a new medical practice, whereas 58 (76%) tested an established practice. A total of 18 (24%) studies had positive findings, whereas 58 (76%) reached a negative conclusion. Of the 58 articles testing existing standard of care, 44 (76%) reversed that practice, whereas 14 (24%) reaffirmed it.
Reversal of cardiopulmonary resuscitation practices is widespread. This investigation sheds new light on low-value practices and patterns of medical research and suggests that novel resuscitation practices have low pretest probability and should be empirically tested with rigorous trials before implementation.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.11.006.

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Clinical paperThe addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest – A prospective, randomized trial☆

Abstract

Aims

Materials and methods

Results

Conclusions

Registration

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Ann Emerg Med

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation

Circulation

Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest

JAMA

Clinical paper
The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest – A prospective, randomized trial☆