Abstract Background and goal of study The relationship between chest compression rate and compression depth is unknown. In order to characterise this relationship, we performed an observational study ...in prehospital cardiac arrest patients. We hypothesised that faster compressions are associated with decreased depth. Materials and methods In patients undergoing prehospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, USA). Compression depth was compared for rates <80/min, 80–120/min and >120/min. A difference in compression depth ≥0.5 cm was considered clinically significant. Mixed models with repeated measurements of chest compression depth and rate (level 1) nested within patients (level 2) were used with compression rate as a continuous and as a categorical predictor of depth. Results are reported as means and standard error (SE). Results and discussion One hundred and thirty-three consecutive patients were analysed (213,409 compressions). Of all compressions 2% were <80/min, 62% between 80 and 120/min and 36% >120/min, 36% were <4 cm deep, 45% between 4 and 5 cm, 19% >5 cm. In 77 out of 133 (58%) patients a statistically significant lower depth was observed for rates >120/min compared to rates 80–120/min, in 40 out of 133 (30%) this difference was also clinically significant. The mixed models predicted that the deepest compression (4.5 cm) occurred at a rate of 86/min, with progressively lower compression depths at higher rates. Rates >145/min would result in a depth <4 cm. Predicted compression depth for rates 80–120/min was on average 4.5 cm (SE 0.06) compared to 4.1 cm (SE 0.06) for compressions >120/min (mean difference 0.4 cm, P < 0.001). Age and sex of the patient had no additional effect on depth. Conclusions This study showed an association between higher compression rates and lower compression depths. Avoiding excessive compression rates may lead to more compressions of sufficient depth.
Abstract Objectives To investigate whether repetitive sessions of formative self-testing (RFST) result in an equal cardiopulmonary resuscitation (CPR) skill level compared to repetitive sessions of ...formative self-testing with additional practice (RFSTAP). Methods In a non-inferiority trial, 196 third-year medical students were randomised to an RFST or RFSTAP group. Testing and practising took place in a self-learning station equipped with a manikin connected to a computer. Each cycle of RFST consisted of a 2-min CPR test followed by feedback and feedforward. In the RFSTAP group, additional practice consisted of CPR exercises with a computer voice feedback. To be successful, a combined score consisting of ≥70% compressions with a depth of ≥50 mm and ≥70% compressions with complete release (<5 mm) and a compression rate of 100–120 min−1 and ≥70% ventilations with a volume of 400–1000 ml had to be achieved within 6 weeks. Skill retention was measured after 6 months. The non-inferiority margin was predefined as a 10% difference in success rate. Results After six weeks the success rate in both groups was 96%: 99/103 (RFST) and 89/93 (RFSTAP). After 6 months, the success rate in the competent students was 26/96 (27%) for RFST and 32/86 (37%) for RFSTAP (three students dropped out in each group). The difference in the success rate between RFSTAP and RFST was 10% and 90% (CI −2 to 23%), respectively. As the upper bound exceeded 10%, non-inferiority was inconclusive. For each CPR skill separately, RFST was non-inferior for ventilation and complete release, superior for compression depth and inferior for compression rate. Conclusions RFST and RFSTAP were equally effective to refresh skills within 6 weeks. After 6 months, non-inferiority was inconclusive for the combined score. Our results indicate the potential of RFST to refresh CPR skills.
Abstract Introduction Current computerised self-learning (SL) stations for Basic Life Support (BLS) are an alternative to instructor-led (IL) refresher training but are not intended for initial skill ...acquisition. We developed a SL station for initial skill acquisition and evaluated its efficacy. Methods In a non-inferiority trial, 120 pharmacy students were randomised to IL small group training or individual training in a SL station. In the IL group, instructors demonstrated the skills and provided feedback. In the SL group a shortened Mini Anne™ video, to acquire the skills, was followed by Resusci Anne Skills Station™ software (both Laerdal, Norway) with voice feedback for further refinement. Testing was performed individually, respecting a seven week interval after training for every student. Results One hundred and seventeen participants were assessed (three drop-outs). The proportion of students achieving a mean compression depth 40–50 mm was 24/56 (43%) IL vs. 31/61 (51%) SL and 39/56 (70%) IL vs. 48/61 (79%) SL for a mean compression depth ≥40 mm. Compression rate 80–120/min was achieved in 49/56 (88%) IL vs. 57/61 (93%) SL and any incomplete release (≥5 mm) was observed in 31/56 (55%) IL and 35/61 (57%) SL. Adequate mean ventilation volume (400–1000 ml) was achieved in 29/56 (52%) IL vs. 36/61 (59%) SL. Non-inferiority was confirmed for depth and although inconclusive, other areas came close to demonstrate it. Conclusions Compression skills acquired in a SL station combining video-instruction with training using voice feedback were not inferior to IL training.
Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest ...encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome.
A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models.
Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician’s characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 2.13–6.64; P < .0001), a non-witnessed arrest (2.68 1.89–3.79; P < .0001), in older patients (2.94 2.18–3.96; P < .0001, for patients >79 years) and in case of a “poor” first physical impression of the patient (3.45 2.36–5.05; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 0.26−0.41; P < 0.0001 and 0.25 0.15−0.41; P < 0.0001, respectively), as were older patient age (0.25 0.14−0.44; P < 0.0001 for patients >79 years) and a “poor” first physical impression (0.26 0.19–0.35; P < 0.0001).
The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.
Abstract Aim In out of hospital cardiac arrest (OHCA) a single rescuer should start with cardiopulmonary resuscitation (CPR) immediately after calling the Emergency Medical Communication Centre ...(EMCC). The start of CPR may be delayed considerably if the total time to connect to the dispatcher at the EMCC (TT-EMCC) is prolonged. EUROCALL aimed to investigate the TT-EMCC and its components in several European regions using different calling procedures. Methods EUROCALL is a prospective, multicentre randomised study that was performed in April 2013. Conducted from a landline or a mobile phone, calls were randomly allocated to day and time of the call, and to those connecting directly to the EMCC (1-step procedure) and those that needed to be diverted before connecting to the EMCC (2-step procedure). Results Twenty-one EMCC’s from 11 countries participated in the study. For the 1878 1-step calls, median times were: time from dial to first ringtone 3.7 seconds (IQR 1.0-5.2) and time from first ringtone to response by call-taker 6.4 seconds (IQR 2.9 − 13.5). The median TT- EMCC was 11.7 seconds (IQR 8.7-18.5). For the 1550 2-step calls, median times were: time to first ringtone 4.0 seconds (IQR 2.4 − 5.2), from first ringtone to first call-taker 7 seconds (IQR 4.6 − 11.9) and from first call-taker to EMCC 18.7 seconds (IQR 13.4-29.9). Median TT-EMCC was 33.2 seconds (IQR 24.7-46.1) and was significantly longer than the TT-EMCC that was observed with the 1-step procedure (P < 0.0001). Significant differences existed among participating regions between and within different countries both for 1-step and 2-step procedures. No significant differences existed in TT-EMCC between landlines and mobile lines. Conclusion TT-EMCC was significantly shorter in a 1-step procedure compared to a 2-step procedure. We found regional differences between countries but also within countries. This may be relevant in cases of OHCA and other situations where patient outcome is critically time-dependent.
BACKGROUNDCardiopulmonary resuscitation (CPR) training at school is recommended. Limited school resources prevent implementation. The learning efficacy of low-cost training strategies is unknown.
...OBJECTIVETo evaluate the efficacy of different CPR learning strategies using low-cost didactic tools.
METHODSChildren (n=593, 15–16 years) were randomized to four training conditions(1) manikin+teacher instruction (control group), (2) manikin+video instruction, (3) foam dice+plastic bag+peer training+teacher instruction, and (4) foam dice+plastic bag+peer training+video instruction. After a 50 min training, a 3 min CPR test on a manikin was performed using SkillReporting Software (Laerdal, Norway), and repeated after 6 months. The data of children without previous CPR training were analysed. Analysis of variance and the χ-test assessed differences between groups.
RESULTSComplete data sets were available for 165 pupils. Initially, group 3 scored lower on the mean ventilation volume (P<0.05). The control group scored better than the alternative groups (P<0.05) on the mean compression rate. After 6 months, the differences disappeared. All groups scored equally on ventilation volume (P=0.12), compression depth (P=0.11), compression rate (P=0.10), correct hand position (P=0.46) and number of correct compressions (P=0.76). Ventilation volume was sufficient in 32% of the pupils, 18% had a correct compression depth and 59% had a correct compression rate.
CONCLUSIONTraining efficacy with low-cost equipment was not different from training with a manikin. The outcome for all training strategies was suboptimal. The basics of CPR can be taught with alternative equipment if manikins are not available.
Background: The implementation of general practitioner cooperatives (GPC) for out-of-hours (OOH) primary care, raises the question if the location of a GPC adjacent to a hospital reduces the OOH ...caseload of the emergency department (ED).
Methods: Two natural experiments were used in this before-after study, the effect of the implementation of two GPCs in two different regions on the out-of-hours caseload of the local EDs was compared. One GPC was located adjacent to the ED of a general hospital, the other was not. GPCs (or rota systems) and EDs in comparable regions were selected as control groups during the same study period. The study was performed in Flanders (Belgium) with no gatekeeping function for general practitioners (GPs).
Results: After implementation of the GPC there was a significantly increase in caseload at the GPC in the two regions, mainly due to an increase of consultations with small children. There were no significant changes in caseload at the ED services. Self-referrals' to the ED did not change significantly. For the GPs the number of home visits decreased during out-of-hours in one region.
Conclusion: In a country with no gatekeeping role for GPs, implementing a GPC increased the out-of-hours caseload of the GPCs. The caseload of the EDs stabilised during the study period.
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