Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: A prospective cohort study

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Use of CPR feedback devices to treat out-of-hospital cardiac arrest in Germany: Associated with improved ROSC-rates, but infrequent usage, in a registry-based analysis of 107,548 cases

INTRODUCTION

Out-of-hospital cardiac arrest is a leading cause of mortality in Europe. Quality cardiopulmonary resuscitation, particularly of chest compressions, is crucial. Real-time audiovisual feedback (RTAVF) devices aim to enhance chest compression quality. Recent studies on these tools have reported improved outcomes for in-hospital but not for out-of-hospital cardiac arrest. This registry-based, retrospective study investigated the use of feedback-devices by emergency medical services personnel to treat out-of-hospital cardiac arrest in Germany and assessed its effect on return of spontaneous circulation (ROSC).

METHODS

We analyzed 107,548 records from the German Resuscitation Registry between 2015 and 2022 and compared patient outcomes of patients treated with feedback devices or not. ROSC rates both at any time and at hospital admission were compared to expected rates based on the "Rosc After Cardiac Arrest" (RACA) score. Furthermore, a generalized linear mixed methods model was calculated to receive an adjusted effect for those devices.

RESULTS

Feedback-devices were used in 17.5% of cases overall, rising from 7.1% (2015) to 23.2% (2022). Patients resuscitated with feedback devices had a 2.6% higher rate of hospital admission with spontaneous circulation (35.9% vs. 33.3%). In both groups, the ROSC rates were higher than predicted by the RACA score. After multivariable adjustment we found a minor effect for RTAVF use on any ROSC (odds ratio 1.09, 95% confidence interval 1.04-1.14), but no effect on the ROSC rate on admission (odds ratio 0.98, 95% confidence interval 0.93-1.03).

CONCLUSION

We could show a minor association between the use of feedback devices and any ROSC, but not for ROSC on hospital admission, in out-of-hospital cardiac arrest patients in a generalized linear mixed model. Further research should address implementation strategies, sustainability and evaluate its effectiveness for other applications.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

The Role of Different Feedback Devices in the Survival of Patients in Cardiac Arrest: Systematic Review with Meta-Analysis

Background: Cardiac arrest is a critical condition affecting approximately 1 in every 1000 people in Europe. Feedback devices have been developed to enhance the quality of chest compressions during CPR, but their clinical impact remains uncertain. This study aims to evaluate the effect of feedback devices on key clinical outcomes in adult patients experiencing both out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). The primary objective is to assess their impact on the return of spontaneous circulation (ROSC); secondary objectives include the evaluation of neurological status and survival to discharge. Methods: A systematic review was conducted following PRISMA guidelines, utilizing databases including PubMed, Scopus, Web of Science, and Embase. Studies published between 2000 and 2023 comparing CPR with and without the use of feedback devices were included. A fixed-effects network meta-analysis was performed for ROSC and survival, while a frequentist meta-analysis was conducted for neurological outcomes. Results: Twelve relevant studies met the inclusion criteria. The meta-analysis results showed that the use of audiovisual feedback devices significantly increases the likelihood of ROSC (OR 1.26, 95% CI 1.13-1.41, p < 0.0001) and survival (OR 1.52, 95% CI 1.27-1.81, p < 0.0001) compared to CPR without feedback. However, the effect of metronomes did not reach statistical significance. Conclusions: Feedback devices, particularly audiovisual ones, are associated with improved clinical outcomes in cardiac arrest patients. Their use should be encouraged in both training settings and real-life emergency scenarios to enhance survival rates and ROSC. However, further studies are needed to confirm long-term impacts and to explore the potential benefits of metronomes.

Designing Chinese hospital emergency departments to leverage artificial intelligence-a systematic literature review on the challenges and opportunities

Artificial intelligence (AI) has witnessed rapid advances in the healthcare domain in recent years, especially in the emergency field, where AI is likely to radically reshape medical service delivery. Although AI has substantial potential to enhance diagnostic accuracy and operational efficiency in hospitals, research on its applications in Emergency Department building design remains relatively scarce. Therefore, this study aims to investigate Emergency Department facility design by identifying the challenges and opportunities of using AI. Two systematic literature reviews are combined, one in AI and the other in sensors, to explore their potential application to support decision-making, resource optimisation and patient monitoring. These reviews have then informed a discussion on integrating AI sensors in contemporary Emergency Department designs for use in China to support the evidence base on resuscitation units, emergency operating rooms and Emergency Department Intensive Care Unit (ED-ICU) design. We hope to inform the strategic implementation of AI sensors and how they might transform Emergency Department design to support medical staff and enhance the patient experience.

Compliance with CPR quality guidelines and survival after 30 days following out-of-hospital cardiac arrest. A retrospective study

BACKGROUND

Our study assessed the quality of cardiopulmonary resuscitation (CPR) given by emergency medical services in Southern Ostrobothnia Finland, as is advised in the international guidelines. The goal was to evaluate the current quality of CPR given to patients who suffered an out-of-hospital cardiac arrest and to examine possible measures for improving emergency medical services.

METHODS

A retrospective study was conducted on out-of-hospital cardiac arrest patients in Southern Ostrobothnia, Finland, during a three-year period. Confounding caused by each patient's individual medical history was addressed by calculating Charlson Comorbidity Index (CCI), a score describing individual's risk for death in 10 years. The Utstein analysis and the CPR metrics were acquired from the medical records hospital district in question and analysed in an orderly manner using SPSS. Descriptive statistics are presented as mean (SD) and median [IQR].

RESULTS

We found that of the 349 patients, 144 (41%) received ROSC, 96 (28%) survived to the hospital and 51 (15%) survived for at least 30 days. CPR metrics data were available for 181 patients. CCIs were 3.0 versus 5.0 (p = .157) for the ones who did and those who did not survive at least 30 days. Correspondingly, following metrics were as follows: Mean compression depth was 5.1 (1.3) versus 5.6 (0.8) cm (p = .088), median 28 [18;40] versus 40 [26;54]% of the compressions were in target depth (p = .015) and median compression rate was 113 [109;119] versus 112 [108;120] min-1 (p = .757). The median no-flow fraction was 5.1 [2.8;7.1] versus 3.7 [2.5;5.5] s (p = .073). Ventricular fibrillation (OR 8.74, 95% CI 2.89-26.43, p < .001), public location (OR 3.163, 95% CI 1.03-9.69, p = .044) and compression rate of 100-110/min (OR 7.923, 95% CI 2.11-29.82, p = .002) were related to survival.

CONCLUSION

Patients who suffered out-of-hospital cardiac arrest in Southern Ostrobothnia received CPR that met the international CPR quality target values. The proportion of unintentional pauses during CPR was low and the 30-day survival rate exceeded the international average.

Do cardiopulmonary resuscitation real-time audiovisual feedback devices improve patient outcomes? A systematic review and meta-analysis

BACKGROUND

Cardiac arrest is a leading cause of mortality in America and has increased in the incidence of cases over the last several years. Cardiopulmonary resuscitation (CPR) increases survival outcomes in cases of cardiac arrest; however, healthcare workers often do not perform CPR within recommended guidelines. Real-time audiovisual feedback (RTAVF) devices improve the quality of CPR performed. This systematic review and meta-analysis aims to compare the effect of RTAVF-assisted CPR with conventional CPR and to evaluate whether the use of these devices improved outcomes in both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients.

AIM

To identify the effect of RTAVF-assisted CPR on patient outcomes and CPR quality with in- and OHCA.

METHODS

We searched PubMed, SCOPUS, the Cochrane Library, and EMBASE from inception to July 27, 2020, for studies comparing patient outcomes and/or CPR quality metrics between RTAVF-assisted CPR and conventional CPR in cases of IHCA or OHCA. The primary outcomes of interest were return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD), with secondary outcomes of chest compression rate and chest compression depth. The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale and Cochrane Collaboration's "risk of bias" tool. Data was analyzed using R statistical software 4.2.0. results were statistically significant if P < 0.05.

RESULTS

Thirteen studies (n = 17600) were included. Patients were on average 69 ± 17.5 years old, with 7022 (39.8%) female patients. Overall pooled ROSC in patients in this study was 37% (95% confidence interval = 23%-54%). RTAVF-assisted CPR significantly improved ROSC, both overall [risk ratio (RR) 1.17 (1.001-1.362); P = 0.048] and in cases of IHCA [RR 1.36 (1.06-1.80); P = 0.002]. There was no significant improvement in ROSC for OHCA (RR 1.04; 0.91-1.19; P = 0.47). No significant effect was seen in SHD [RR 1.04 (0.91-1.19); P = 0.47] or chest compression rate [standardized mean difference (SMD) -2.1; (-4.6-0.5)]; P = 0.09]. A significant improvement was seen in chest compression depth [SMD 1.6; (0.02-3.1); P = 0.047].

CONCLUSION

RTAVF-assisted CPR increases ROSC in cases of IHCA and chest compression depth but has no significant effect on ROSC in cases of OHCA, SHD, or chest compression rate.

Association of Real-Time Feedback and Cardiopulmonary-Resuscitation Quality Delivered by Ambulance Personnel for Out-of-Hospital Cardiac Arrest

Background High-quality cardiopulmonary resuscitation (CPR) is associated with improved survival from out-of-hospital cardiac arrest and includes chest compression depth, chest compression rate, and chest compression fraction within international guideline recommendations. Previous studies have demonstrated divergent results of real-time feedback on CPR performance and patient outcomes. This study investigated the association between emergency medical service CPR quality and real-time CPR feedback for out-of-hospital cardiac arrest. Methods and Results This study collected out-of-hospital cardiac arrest data within the Capital Region of Denmark and compared CPR quality delivered by ambulance personnel. Data were collected in 2 consecutive phases from October 2018 to February 2020. Median chest compression depth was 6.0 cm (no feedback) and 5.9 cm (real-time feedback) (P=0.852). Corresponding proportion of guideline-compliant chest compressions for depth was 16.6% and 28.7%, respectively (P<0.001). Median chest compression rate per minute was 111 and 109 (P<0.001), respectively. Corresponding guideline adherence proportion for compression rate was 65.4% compared with 80.4% (P<0.001), respectively. Chest compression fraction was 78.9% compared with 81.9% (P<0.001), respectively. The combination of guideline-compliant chest compression depth and chest compression rate simultaneously was 8.5% (no feedback) versus 18.8% (feedback) (P<0.001). Improvements were not significant for return of spontaneous circulation (odds ratio [OR], 1.08 [95% CI, 0.84-1.39]), sustained return of spontaneous circulation (OR, 1.00 [95% CI, 0.77-1.31]), or survival to hospital discharge (OR, 0.91 [95% CI, 0.64-1.30]). Conclusions Real-time feedback was associated with improved guideline compliance for chest compression depth, rate, and fraction but not return of spontaneous circulation, sustained return of spontaneous circulation, or survival to hospital discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04152252.

The effect of audiovisual feedback of monitor/defibrillators on percentage of appropriate compression depth and rate during cardiopulmonary resuscitation

BACKGROUND

High quality cardiopulmonary resuscitation (CPR) is one of the key elements of the survival chain in cardiac arrest. Audiovisual feedback of chest compressions have been suggested to be beneficial by increasing the quality of CPR in the simulated cardiac arrests.

METHODS

A prospective before and after study was performed to investigate the effect of a real-time audiovisual feedback system on CPR quality during in-hospital cardiac arrest in intensive care units from November 2018 to February 2022. In the feedback period, CPR was performed with the aid of the real-time audiovisual feedback system. The primary outcome was the percentage of compressions with both adequate depth (5.0-6.0 cm) and rate (100-120/minute).

RESULTS

A total of 27,295 compressions in 30 cardiac arrests in the no-feedback period and 27,965 compressions in 30 arrests in the feedback period were analyzed. The percentage of compressions with both adequate depth and rate was 11.8% in the feedback period and 16.8% in the no-feedback period (P < 0.01). The percentage of compressions with adequate rate in the feedback period was lower than that in the no-feedback period (67.3% vs. 75.5%, P < 0.01). The percentage of beyond-target depth with the feedback was significantly higher than that without feedback (64.2% vs. 51.4%, P < 0.01).

CONCLUSION

Real-time audiovisual feedback system did not increase CPR quality and was associated with a higher percentage of compression depth deeper than the recommended 5.0-6.0 cm. It is essential to explore more effective ways of implementing feedback in real clinical settings to improve of the quality of CPR.

TRIAL REGISTRATION

NCT03902873 (study start: Nov. 2018, initial release April 2019, retrospectively registered).

Assessing student paramedics' measurements of fatigue and quality of cardiopulmonary resuscitation on a simulated cardiac arrest case

OBJECTIVE

The International Liaison Committee on Resuscitation (ILCOR) and the Australian Resuscitation Council (ARC) recommend that high-quality cardiopulmonary resuscitation (CPR) is the key to performance outcomes, emphasising compression and rotation through this process. The proposed study has a two-stage approach to evaluating cardiopulmonary resuscitations effectiveness by out-of-hospital practitioners. The first stage aimed to evaluate the influence of providing real-time biofeedback using the Q-CPR system on the provision of CPR by student paramedics. Secondly, the study quantified the effects of physical fatigue on maintaining quality cardiopulmonary resuscitation performed by paramedic students.

METHODS

Forty paramedic students completed cardiopulmonary resuscitation on an instrumented manikin with and without audio-visual biofeedback (Q-CPR within the Phillips MRx defibrillator) in a balanced cross-over fashion. To quantify the quality of cardiopulmonary resuscitation concerning the percentage of applied compressions that meet the current ARC guidelines in terms of rate, depth, and recoil time, a manikin feedback system (SimMan 3 G; Laerdal, Norwegian) was used.

RESULTS

When using the Q-CPR prompt with bio-feedback, overall, the depth and fatigue levels increased significantly, highlighting a correlation between correct depth and increased fatigue.

CONCLUSIONS

Audio prompts improved compression depth; however, fatigue levels increased. The depth during manual compression compared to the Q-CPR prompt was not statistically significant.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Comparison of real-time feedback and debriefing by video recording on basic life support skill in nursing students

BACKGROUND

Cardiopulmonary resuscitation skill have a direct impact on its success rate. Choosing the right method to acquire this skill can lead to effective performance. This investigation was conducted to compare the effect of Real-time feedback and debriefing by video recording on basic life support skill in nursing students.

METHODS

This quasi-experimental study was performed on 67 first year nursing students. First, a theoretical basic life support (BLS) training session was held for the all participants, at the end of session the pre-test was taken. Students were randomly assigned to two groups. A 4-hour practical BLS training session was conducted in the real - time feedback group as well as the debriefing by video recording group, and at the end of the training, a post-test was taken from each group. Each group received a post-test. Data were analyzed using SPSS 25 software.

RESULTS

Results showed a significant difference between mean (SD) of debriefing by video recording group in pre-test and post-test (p < 0.001) and in the real-time feedback group there was a significant difference between mean (SD) in pre-test and post-test (p < 0.001), respectively. In addition, there was no significant difference between the mean score of basic life support skill in real-time feedback and debriefing by video recording.

CONCLUSIONS

Both real-time feedback and debriefing by video recording were effective on basic life support skill.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

The impact of cognitive aids on resuscitation performance in in-hospital cardiac arrest scenarios: a systematic review and meta-analysis

Different cognitive aids have been recently developed to support the management of cardiac arrest, however, their effectiveness remains barely investigated. We aimed to assess whether clinicians using any cognitive aids compared to no or alternative cognitive aids for in-hospital cardiac arrest (IHCA) scenarios achieve improved resuscitation performance. PubMed, EMBASE, the Cochrane Library, CINAHL and ClinicalTrials.gov were systematically searched to identify studies comparing the management of adult/paediatric IHCA simulated scenarios by health professionals using different or no cognitive aids. Our primary outcomes were adherence to guideline recommendations (overall team performance) and time to critical resuscitation actions. Random-effects model meta-analyses were performed. Of the 4.830 screened studies, 16 (14 adult, 2 paediatric) met inclusion criteria. Meta-analyses of eight eligible adult studies indicated that the use of electronic/paper-based cognitive aids, in comparison with no aid, was significantly associated with better overall resuscitation performance [standard mean difference (SMD) 1.16; 95% confidence interval (CI) 0.64; 1.69; I² = 79%]. Meta-analyses of the two paediatric studies, showed non-significant improvement of critical actions for resuscitation (adherence to guideline recommended sequence of actions, time to defibrillation, rate of errors in defibrillation, time to start chest compressions), except for significant shorter time to amiodarone administration (SMD - 0.78; 95% CI - 1.39; - 0.18; I² = 0). To conclude, the use of cognitive aids appears to have benefits in improving the management of simulated adult IHCA scenarios, with potential positive impact on clinical practice. Further paediatric studies are necessary to better assess the impact of cognitive aids on the management of IHCA scenarios.

Effect of real-time feedback on patient's outcomes and survival after cardiac arrest: A systematic review and meta-analysis

PURPOSE

This study investigated the effect of real-time feedback on the restoration of spontaneous circulation, survival to hospital discharge, and favorable functional outcomes after hospital discharge.

METHODS

PubMed, ScienceDirect, and China National Knowledge Infrastructure databases were searched to screen the relevant studies up to June 2020. Fixed-effects or random-effects model were used to calculate the pooled estimates of relative ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

Ten relevant articles on 4281 cardiac arrest cases were identified. The pooled analyses indicated that real-time feedback did not improve restoration of spontaneous circulation (RR: 1.13, 95% CI: 0.92-1.37, and P = .24; I2 = 81%; P < .001), survival to hospital discharge (RR: 1.27, 95% CI: 0.90-1.79, and P = .18; I2 = 74%; P < .001), and favorable neurological outcomes after hospital discharge (RR: 1.09, 95% CI: 0.87-1.38; P = .45; I2 = 16%; P = .31). The predefined subgroup analysis showed that the sample size and arrest location may be the origin of heterogeneity. Begg's and Egger's tests showed no publication bias, and sensitivity analysis indicated that the results were stable.

CONCLUSION

The meta-analysis had shown that the implementation of real-time audiovisual feedback was not associated with improved restoration of spontaneous circulation, increased survival, and favorable functional outcomes after hospital discharge.

Impact of the Over-the-Head Position with a Supraglottic Airway Device on Chest Compression Depth and Rate: A Post Hoc Analysis of a Randomized Controlled Trial

There is considerable controversy regarding the optimal airway management strategy in the case of out-of-hospital cardiac arrest. Registry-based studies yield contradicting results and the actual impact of using supraglottic devices on survival and neurological outcomes remains unknown. In a recent simulation study, the use of an i-gel^® device was associated with significantly shallower chest compressions. It was hypothesized that these shallower compressions could be linked to the provision of chest compressions in an over-the-head position, to the cumbersome airway management apparatus, and to a shallower i-gel^® insertion depth in the manikin. To test this hypothesis, we carried out a post hoc analysis, which is described in this report. Briefly, no association was found between the over-the-head position and compression depth.

Effect of Early Supraglottic Airway Device Insertion on Chest Compression Fraction during Simulated Out-of-Hospital Cardiac Arrest: Randomised Controlled Trial

Early insertion of a supraglottic airway (SGA) device could improve chest compression fraction by allowing providers to perform continuous chest compressions or by shortening the interruptions needed to deliver ventilations. SGA devices do not require the same expertise as endotracheal intubation. This study aimed to determine whether the immediate insertion of an i-gel^® while providing continuous chest compressions with asynchronous ventilations could generate higher CCFs than the standard 30:2 approach using a face-mask in a simulation of out-of-hospital cardiac arrest. A multicentre, parallel, randomised, superiority, simulation study was carried out. The primary outcome was the difference in CCF during the first two minutes of resuscitation. Overall and per-cycle CCF quality of compressions and ventilations parameters were also compared. Among thirteen teams of two participants, the early insertion of an i-gel^® resulted in higher CCFs during the first two minutes (89.0% vs. 83.6%, p = 0.001). Overall and per-cycle CCF were consistently higher in the i-gel^® group, even after the 30:2 alternation had been resumed. In the i-gel^® group, ventilation parameters were enhanced, but compressions were significantly shallower (4.6 cm vs. 5.2 cm, p = 0.007). This latter issue must be addressed before clinical trials can be considered.

Basic life support and systems saving lives

PURPOSE OF REVIEW

To describe recent science in basic life support (BLS) after cardiac arrest and how evolving knowledge in resuscitation is changing current guidelines and practices.

RECENT FINDINGS

The core elements of BLS have remained mostly unchanged since 2005 when Cardiopulmonary Resuscitation recommendations were changed from 2 ventilations to 15 compressions and up to three stacked shocks for shockable rhythms, to 30 compressions to 2 ventilations and single shocks. Since 2010, basic life support has largely focused on the importance of providing high-quality CPR for professional and lay rescuers alike. The most recent resuscitation updates has seen an increased focus on the systems perspective. The 'Systems Saving Lives' concept emphasizes the interconnection between community and Emergency Medical Services (EMS). The main changes in current resuscitation practice are within three important basic life support domains: recognition of cardiac arrest, interaction between rescuers and EMS and improving resuscitation quality.

SUMMARY

This review highlights the importance of strengthening both community and emergency medical services efforts to improve outcomes in cardiac arrest. Strategies that enhance the communication and collaboration between lay rescuers and professional resuscitation systems are important new avenues to pursue in developing systems that save more lives.

Understanding of Development Emergency Medical Services in Laos Emergency Medicine Residents

BACKGROUND: Rising death tolls from traffic accidents are quickly becoming an inescapable problem in almost all countries around the world. That being said, the World Health Organization has launched an ambitious campaign aimed at reducing the death rate from traffic accidents by 50% in the next 10 years. Development of emergency medical services (EMSs) was the tool to success the goals, especially in low- to middle-income countries including Laos. However, no studies regard perspective of training EMS in Laos emergency medicine residents. AIM: The aim of our work is to demonstrate the effect of EMS training for Laos emergency medicine residents to the development of the national policy in Lao’s EMS. METHODS: A cross-sectional study was conducted in two countries (Laos and Thailand) from January 2020. The project activities were establishment of a command-and-control center, development of EMS support system, and training for emergency care professionals. RESULTS: The eight Laos emergency medicine residents were enrolled between January and March 2020. After practicing as a dispatcher and emergency medical consultant in Thailand at Khon Kaen University, the participants from Laos found that all personnel gained experience and improved their knowledge of technology in EMS and organization management. This had a direct impact on improving confidence in their return to practice in Laos. CONCLUSIONS: The human resource development through international collaboration between Thailand and Laos is contributing the effective knowledge and expertise learning in Laos. Moreover, the result of this training may provide the most effective care system resulting in the much-needed drop in the mortality rate of traffic accidents in Laos.

PediAppRREST: effectiveness of an interactive cognitive support tablet app in reducing deviations from guidelines in the management of paediatric cardiac arrest: protocol for a simulation-based randomised controlled trial

INTRODUCTION

Paediatric cardiac arrest (PCA), despite its low incidence, has a high mortality. Its management is complex and deviations from guideline recommendations occur frequently. We developed a new interactive tablet app, named PediAppRREST, to support the management of PCA. The app received a good usability evaluation in a previous pilot trial. The aim of the study is to evaluate the effectiveness of the PediAppRREST app in reducing deviations from guideline recommendations in PCA management.

METHODS AND ANALYSIS

This is a multicentre, simulation-based, randomised controlled, three-parallel-arm study. Participants are residents in Paediatric, Emergency Medicine, and Anaesthesiology programmes in Italy. All 105 teams (315 participants) manage the same scenario of in-hospital PCA. Teams are randomised by the study statistician into one of three study arms for the management of the PCA scenario: (1) an intervention group using the PediAppRREST app or (2) a control group Paediatric Advanced Life Support (CtrlPALS+) using the PALS pocket reference card; or (3) a control group (CtrlPALS-) not allowed to use any PALS-related cognitive aid. The primary outcome of the study is the number of deviations (delays and errors) in PCA management from PALS guideline recommendations, according to a novel checklist, named c-DEV15plus. The c-DEV15plus scores will be compared between groups with a one-way analysis of variance model, followed by the Tukey-Kramer multiple comparisons adjustment procedure in case of statistical significance.

ETHICS AND DISSEMINATION

The Ethics Committee of the University Hospital of Padova, coordinating centre of the trial, deemed the project to be a negligible risk study and approved it through an expedited review process. The results of the study will be disseminated in peer-reviewed journals, and at national and international scientific conferences. Based on the study results, the PediAppRREST app will be further refined and will be available for download by institutions/healthcare professionals.

TRIAL REGISTRATION NUMBER

NCT04619498; Pre-results.

Effect of real-time and post-event feedback in out-of-hospital cardiac arrest attended by EMS - A systematic review and meta-analysis

OBJECTIVES

A systematic review to determine if cardiopulmonary resuscitation (CPR) guided by either real-time or post-event feedback could improve CPR quality or patient outcome compared to unguided CPR in out-of-hospital cardiac arrest (OHCA).

METHODS

Four databases were searched; PubMed, Embase, CINAHL, and Cochrane Library in August 2020 for post 2010 literature on OHCA in adults. Critical outcomes were chest compression depth, rate and fraction. Important outcomes were any return of spontaneous circulation, survival to hospital and survival to discharge.

RESULTS

A total of 9464 studies were identified with 61 eligibility for full text screening. A total of eight studies was included in the meta-analysis. Five studies investigated real-time feedback and three investigated post-event feedback. Meta-analysis revealed that real-time feedback statistically improves compression depth and rate while post-event feedback improved depth and fraction. Feedback did not statistically improve patient outcome but an improvement in absolute numbers revealed a clinical effect of feedback. Heterogenity varied from "might not be important" to "considerable".

CONCLUSION

To significantly improve CPR quality real-time and post-event feedback should be combined. Neither real-time nor post event feedback could statistically be associated with patient outcome however, a clinical effect was detected. The conclusions reached were based on few studies of low to very low quality.

PROSPERO REGISTRATION

CRD42019133881.

Importance of Immediate Electronic-Based Feedback to Enhance Feedback for First-Time CPR Trainees

Sudden cardiac arrest is one of the leading causes of death globally. The recommended clinical management in out-of-hospital cardiac arrest cases is the immediate initiation of high-quality cardiopulmonary resuscitation (CPR). Training mannequins should be combined with technology that provides students with detailed immediate feedback on the quality of CPR performance. This study aimed to verify the impacts of the type of feedback (basic or detailed) the responders receive from the device while learning CPR and how it influences the quality of their performance and the motivation to improve their skills. The study was conducted at the Medical University of Lublin among 694 multi-professional health students during first aid classes on basic life support (BLS). The students first practiced on an adult mannequin with a basic control panel; afterward, the same mannequin was connected to a laptop, ensuring a detailed record of the performed activities through a projector. Next, the participants expressed their subjective opinion on how the feedback provided during the classes, basic vs. detailed, motivated them to improve the quality of their CPR performance. Additionally, during the classes, the instructor conducted an extended observation of students’ work and behavior. In the students’ opinion, the CPR training with detailed feedback devices provided motivation for learning and improving CPR proficiency than that with a basic control panel. Furthermore, the comments given from devices seemed to be more acceptable to the students, who did not see any bias in the device’s evaluation compared to that of the instructor. Detailed device feedback motivates student health practitioners to learn and improve the overall quality of CPR. The use of mannequins that provide detailed feedback during BLS courses can improve survival in out-of-hospital cardiac arrest.

Differences between manual CPR and corpuls cpr in regard to quality and outcome: study protocol of the comparing observational multi-center prospective registry study on resuscitation (COMPRESS)

Background

The effect of mechanical CPR is diversely described in the literature. Different mechanical CPR devices are available. The corpuls cpr is a new generation of piston-driven devices and was launched in 2015. The COMPRESS-trial analyzes quality of chest compression and CPR-related injuries in cases of mechanical CPR by the corpuls cpr and manual CPR.

Methods

This article describes the design and study protocol of the COMPRESS-trial. This observational multi-center study includes all patients who suffered an out-of-hospital cardiac arrest (OHCA) where CPR is attempted in four German emergency medical systems (EMS) between January 2020 and December 2022. EMS treatment, in-hospital-treatment and outcome are anonymously reported to the German Resuscitation Registry (GRR). This information is linked with data from the defibrillator, the feedback system and the mechanical CPR device for a complete dataset.

Primary endpoint is chest compression quality (complete release, compression rate, compression depth, chest compression fraction, CPR-related injuries). Secondary endpoint is survival (return of spontaneous circulation (ROSC), admission to hospital and survival to hospital discharge). The trial is sponsored by GS Elektromedizinische Geräte G. Stemple GmbH.

Discussion

This observational multi-center study will contribute to the evaluation of mechanical chest compression devices and to the efficacy and safety of the corpuls cpr.

Trial registration

DRKS, DRKS-ID DRKS00020819. Registered 31 July 2020.

Development and Usability of a Novel Interactive Tablet App (PediAppRREST) to Support the Management of Pediatric Cardiac Arrest: Pilot High-Fidelity Simulation-Based Study

Background

Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Deviations from international management guidelines are frequent and associated with poorer outcomes. Different strategies/devices have been developed to improve the management of cardiac arrest, including cognitive aids. However, there is very limited experience on the usefulness of interactive cognitive aids in the format of an app in PCA. No app has so far been tested for its usability and effectiveness in guiding the management of PCA.

Objective

To develop a new audiovisual interactive app for tablets, named PediAppRREST, to support the management of PCA and to test its usability in a high-fidelity simulation-based setting.

Methods

A research team at the University of Padova (Italy) and human–machine interface designers, as well as app developers, from an Italian company (RE:Lab S.r.l.) developed the app between March and October 2019, by applying an iterative design approach (ie, design–prototyping–evaluation iterative loops). In October–November 2019, a single-center nonrandomized controlled simulation–based pilot study was conducted including 48 pediatric residents divided into teams of 3. The same nonshockable PCA scenario was managed by 11 teams with and 5 without the app. The app user’s experience and interaction patterns were documented through video recording of scenarios, debriefing sessions, and questionnaires. App usability was evaluated with the User Experience Questionnaire (UEQ) (scores range from –3 to +3 for each scale) and open-ended questions, whereas participants’ workload was measured using the NASA Raw-Task Load Index (NASA RTLX).

Results

Users’ difficulties in interacting with the app during the simulations were identified using a structured framework. The app usability, in terms of mean UEQ scores, was as follows: attractiveness 1.71 (SD 1.43), perspicuity 1.75 (SD 0.88), efficiency 1.93 (SD 0.93), dependability 1.57 (SD 1.10), stimulation 1.60 (SD 1.33), and novelty 2.21 (SD 0.74). Team leaders’ perceived workload was comparable (P=.57) between the 2 groups; median NASA RTLX score was 67.5 (interquartile range [IQR] 65.0-81.7) for the control group and 66.7 (IQR 54.2-76.7) for the intervention group. A preliminary evaluation of the effectiveness of the app in reducing deviations from guidelines showed that median time to epinephrine administration was significantly longer in the group that used the app compared with the control group (254 seconds versus 165 seconds; P=.015).

Conclusions

The PediAppRREST app received a good usability evaluation and did not appear to increase team leaders’ workload. Based on the feedback collected from the participants and the preliminary results of the evaluation of its effects on the management of the simulated scenario, the app has been further refined. The effectiveness of the new version of the app in reducing deviations from guidelines recommendations in the management of PCA and its impact on time to critical actions will be evaluated in an upcoming multicenter simulation-based randomized controlled trial.

Pulse rate as an alternative, real-time feedback indicator for chest compression rate: a porcine model of cardiac arrest

Feedback indicators can improve chest compression quality during cardiopulmonary resuscitation (CPR). However, the application of feedback indicators in the clinic practice is rare. Pulse oximetry has been widely used and reported to correlate spontaneous circulation restoration during CPR. However, it is unclear if pulse oximetry can monitor the quality of chest compression. We hypothesized that pulse rate monitored by pulse oximetry can be used as a feedback indicator of the chest compression rate during CPR in a porcine model of cardiac arrest. Seven domestic male pigs (30–35 kg) were utilized in this study. Eighteen intermittent chest compression periods of 2 min were performed on each animal. Chest compression and pulse oximetry plethysmographic waveforms were recorded simultaneously. Chest compression and pulse rates were calculated based on both waveforms. Compression interruption and synchronous pulse interruption times were also measured. Agreement was analyzed between pulse rates and synchronous chest compression rates, as well as between compression interruption times and synchronous pulse interruption times. A total of 126 compression periods of 2 min were performed on seven animals. Interclass correlation coefficients and Bland–Altman analysis revealed reliable agreement between pulse rates and synchronous chest compression rates. Similarly, compression interruption and synchronous pulse interruption times obtained also showed high agreement. Pulse rate can be used as an alternative indicator of chest compression rate during CPR in a porcine model of cardiac arrest. Pulse interruption time also can be used to reflect compression interruption time precisely in this model.

Correction: Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: A prospective cohort study

[This corrects the article DOI: 10.1371/journal.pone.0229431.].