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A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest
G Model
ARTICLE IN PRESS
RESUS-7340; No. of Pages 2
Resuscitation xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest
When approaching out-of-hospital cardiac arrest, basic interventions such as adequate chest compressions and early defibrillation are key components of a successful resuscitation strategy; the more complex interventions of advanced life support – invasive airway management and intravenous medications – are also important, yet less so. Such statements, however, have not always represented expert opinion. In fact, the American Heart Association (AHA) published its first guideline for the management of out-ofhospital cardiac arrest (OCHA) in 1974 [1]. In this guideline, the AHA suggested that the greatest opportunity for survival involved the early application of complex, advanced life support (ALS) interventions, placing significant emphasis on defibrillation, invasive airway insertion, and intravenous access with administration of cardioactive medications; ironically, less importance was placed on cardiopulmonary resuscitation (CPR) [1]. As so often happens in science and its translation to clinical medicine, this early standard proved to be flawed; in fact, over the past four decades, both the European Resuscitation Council (ERC) and the AHA Guidelines, among other resuscitation councils, have shifted from a complex approach to a more basic resuscitation strategy [2,3]. A range of investigations have supported this transition to basic OHCA care. For instance, the Ontario Pre-hospital Advanced Life Support investigators explored the impact of ALS care on OHCA outcome, noting that basic interventions (emergency system activation, CPR, and early defibrillation) had a greater positive impact on survival than ALS maneuvers; in addition, a comparison of two resuscitation strategies (basic versus advanced) in this study yielded similar patient outcomes [4]. Another example includes a comparison of two differing OHCA resuscitation approaches, one in the United States and the other in the United Kingdom; in this comparison, it was noted that the strategy emphasizing basic interventions produced similar results to the ALS-based system [5]. Other publications, based upon various strategies from around the world, have demonstrated the importance of the basic interventions in cardiac arrest management while also showing that advanced life support has a limited, less robust, positive impact on survival. And, of course, one recommendation has not changed over the past four decades − that the likelihood of meaningful survival is associated with rapid delivery of life-saving therapies [1–3].
DOI of original article: http://dx.doi.org/10.1016/j.resuscitation.2017.09.006.
The basic interventions of significance in OHCA include early recognition of the event, immediate activation of the emergency response system, effective CPR, and prompt defibrillation. . .earlier in cardiac arrest rather than later. While trained healthcare providers are the preferred responders for OHCA [6,7], most often untrained, lay personnel are the only available rescuers, particularly in the first few, vital minutes of out-of-hospital cardiac arrest. In fact, the vast majority of OHCA events are initially attended to by lay rescuers in its early stages. Lay provider recognition of OHCA, coupled with early effective CPR and defibrillation using public access automatic external defibrillators, has been shown to significantly increase resuscitation rates and ultimate outcomes [8–11]. Considering the extreme time-sensitivity with regards to prompt therapy and its relation to more optimal outcome, lay provider interventions must be explored in detail. In this edition of Resuscitation, Gyllenborg et al. [12] do just that. With datadriven observations regarding the quality of resuscitation by lay providers, we can construct appropriate educational, organizational, and response systems, optimizing treatments provided by these untrained rescuers. This study [12] is quite important in that limited data exists regarding the quality of CPR, namely chest compressions (rate, depth, and pause periods), performed by lay providers in OHCA. Gyllenborg et al. [12] have contributed to this small yet important database of lay provider resuscitation skills and abilities; in their report, they describe the results of an observational study of bystander CPR quality in 136 cases of OHCA in the Capital Region of Denmark over a four-year period (2012–2016). The quality of chest compressions was recorded by AED accelerometer data and was assessed by adherence to ERC 2010 and 2015 guidelines; the ERC guideline metrics used included rate of 100–120 min−1 , compression depth of 5–6 cm, and minimization of compression pauses (≥60/minute or chest compression fraction ≥60%). The authors reported the following characteristics of CPR performed by the lay rescuers, including median compression rate 100–120 min-1 (42%), compression depth 5–6 cm (26%), compression fraction ≥60% (51%) and compressions delivered per minute greater than 60/min (54%). Regarding pauses in chest compressions and the performance of defibrillation, the median peri-shock pause was 27 s and the pre-shock pause was 19 s. They noted that bystander CPR was largely compliant with guidelines in regards to compression rate; lay rescuers in this study, however, fell short in regards to appropriate compression depth. The authors also
https://doi.org/10.1016/j.resuscitation.2017.10.008 0300-9572/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Brady WJ, et al. A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.008
G Model RESUS-7340; No. of Pages 2
ARTICLE IN PRESS Editorial / Resuscitation xxx (2017) xxx–xxx
2
note two additional areas of potential improvement, including an increase in chest compression fraction (median of 60% with 54% obtaining >60/min) and a reduction of peri-defibrillatory shock pause length (median 27 s). Importantly, in a minute-to-minute analysis, no evidence of deterioration in CPR quality was found over the period of resuscitation. This article provides important insight into the quality and timing of chest compressions, thus allowing for targeted instruction and the development of other educational and clinical improvement projects aimed at this key period of OHCA management. Previous studies of bystander cardiopulmonary resuscitation have been unable to measure and assess compliance with current expert guidelines for compression depth and other important metrics [13–15]. Future education efforts in layperson CPR training likely will benefit from renewed focus on this point. In addition, as the authors mention, attention to interruptions in chest compression, the pauses, is also important; any educational intervention which reduces the pauses, and thus increases the chest compression fraction, will likely increase survival. Prolonged peri-shock pause is associated with a concomitant increase in mortality, and this may also be a target of future interventions including efforts in reducing the duration of pre-set “prompted” pauses inherent to vocalized AED instructions [16]. We know that early therapy provides the best opportunity for meaningful survival in the OHCA patient. In most instances of OHCA, the lay provider will be the initial rescuer. Empowering and educating the lay provider to intervene is vital; the interventions need not be complex nor advanced. In fact, basic interventions, such as high quality chest compressions and early defibrillation, have significant, positive impact on survival and neurologic status. Educational and training programs, aimed at the lay provider, are needed. Education and instruction, however brief, is beneficial; instruction not only increases the likelihood of a lay rescuer performing CPR but also improves lay provider CPR skills [17]. Furthermore, insight into the lay providers’ abilities is also needed. Gyllenborg et al. [12] have provided such insight into the lay providers’ chest compression performance. This information, as well as results from similar future investigations, can be applied to lay provider education programs; and, more importantly, this information can also translate into improved lay provider resuscitation skills and abilities. . .and increased rates of meaningful survival for victims of out-of-hospital cardiac arrest. Conflict of interest statement Commentary to Gyllenborg et al. 2017: “Quality of bystander cardiopulmonary resuscitation during real-life out-of-hospital cardiac arrest” in Resuscitation – A Better Understanding of Lay Providers’ CPR Performance during Resuscitation of Out-ofHospital Cardiac Arrest by William J. Brady MD, George Glass MD, & Robert E. O’Connor MD. We, authors of the above manuscript, attest that we have no conflicts of interest in the creation, submission, and publication of this work.
References [1]. American Heart Association: Standards for cardiopulmonary resuscitation. (CPR) and emergency cardiac care (ECC). J Am Med Assoc 1974;227:S833–68. [2]. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life support, 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132(Suppl. 2):S444–64. [3]. Soar J, Nolan JP, Böttiger BW, et al. European resuscitation council guidelines for resuscitation 2015: section 3: adult advanced life support. Resuscitation 2015;95:100–47. [4]. Stiell IG, Wells GA, Field B, for the OPALS Study Group, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. New Engl J Med 2004;351:647–56. [5]. Mitchell RG, Brady W, Guly UM, Pirrallo RG, Robertson CE. Comparison of two emergency response systems and their effect on survival from out-of-hospital cardiac arrest. Resuscitation 1997;35:225–9. [6]. Park YM, Shin SD, Lee YJ, et al. Cardiopulmonary resuscitation by trained responders versus lay persons and outcomes of out-of-hospital cardiac arrest: a community observational study. Resuscitation 2017;118:55–62. [7]. Nord A, Svensson L, Karlsson T, et al. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation 2017;120:88–94. [8]. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression–only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. J Am Med Assoc 2010;304:1447–54. [9]. Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation 2007;116:2900–7. [10]. Berdowski J, Blom MT, Bardai A, et al. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation 2011;124:2225–32. [11]. Ringh M, Jonsson M, Nordberg P, et al. Survival after public access defibrillation in stockholm, Sweden–s striking success. Resuscitation 2015;91:1–7. [12]. Gyllenborg T, Granfeldt A, Lippert F, Riddervold IS, Folke F., Quality of Bystander Cardiopulmonary Resuscitation During Real Life Out-of-Hospital Cardiac Arrest. Resuscitation (publication pending). [13]. Nishi T, Takei Y, Kamikura T, et al. Improper bystander-performed basic life support in cardiac arrests managed with public automated external defibrillators. Am J Emerg Med 2015;33:43–9. [14]. Rea TD, Stickney RE, Doherty A, Lank P. Performance of chest compressions by laypersons during the Public Access Defibrillation Trial. Resuscitation 2010;81:293–6. [15]. Beesems SG, Wijmans L, Tijssen JGP, Koster RW. Duration of ventilations during cardiopulmonary resuscitation by lay rescuers and first responders, clinical perspective: relationship between delivering chest compressions and outcomes. Circulation 2013;127:1585–90. [16]. Cheskes S, Schmicker RH, Christenson J, et al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation 2011;124:58–66. [17]. Bobrow BJ, Vadeboncoeur TF, Spaite DW, Potts J, Denninghoff K, Chikani V, et al. The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes 2011;4:220–6.
William J. Brady ∗ George Glass Robert E. O’Connor Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, USA ∗ Corresponding author. E-mail address: [email protected] (W.J. Brady)
7 October 2017
Please cite this article in press as: Brady WJ, et al. A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.008
ARTICLE IN PRESS
RESUS-7340; No. of Pages 2
Resuscitation xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest
When approaching out-of-hospital cardiac arrest, basic interventions such as adequate chest compressions and early defibrillation are key components of a successful resuscitation strategy; the more complex interventions of advanced life support – invasive airway management and intravenous medications – are also important, yet less so. Such statements, however, have not always represented expert opinion. In fact, the American Heart Association (AHA) published its first guideline for the management of out-ofhospital cardiac arrest (OCHA) in 1974 [1]. In this guideline, the AHA suggested that the greatest opportunity for survival involved the early application of complex, advanced life support (ALS) interventions, placing significant emphasis on defibrillation, invasive airway insertion, and intravenous access with administration of cardioactive medications; ironically, less importance was placed on cardiopulmonary resuscitation (CPR) [1]. As so often happens in science and its translation to clinical medicine, this early standard proved to be flawed; in fact, over the past four decades, both the European Resuscitation Council (ERC) and the AHA Guidelines, among other resuscitation councils, have shifted from a complex approach to a more basic resuscitation strategy [2,3]. A range of investigations have supported this transition to basic OHCA care. For instance, the Ontario Pre-hospital Advanced Life Support investigators explored the impact of ALS care on OHCA outcome, noting that basic interventions (emergency system activation, CPR, and early defibrillation) had a greater positive impact on survival than ALS maneuvers; in addition, a comparison of two resuscitation strategies (basic versus advanced) in this study yielded similar patient outcomes [4]. Another example includes a comparison of two differing OHCA resuscitation approaches, one in the United States and the other in the United Kingdom; in this comparison, it was noted that the strategy emphasizing basic interventions produced similar results to the ALS-based system [5]. Other publications, based upon various strategies from around the world, have demonstrated the importance of the basic interventions in cardiac arrest management while also showing that advanced life support has a limited, less robust, positive impact on survival. And, of course, one recommendation has not changed over the past four decades − that the likelihood of meaningful survival is associated with rapid delivery of life-saving therapies [1–3].
DOI of original article: http://dx.doi.org/10.1016/j.resuscitation.2017.09.006.
The basic interventions of significance in OHCA include early recognition of the event, immediate activation of the emergency response system, effective CPR, and prompt defibrillation. . .earlier in cardiac arrest rather than later. While trained healthcare providers are the preferred responders for OHCA [6,7], most often untrained, lay personnel are the only available rescuers, particularly in the first few, vital minutes of out-of-hospital cardiac arrest. In fact, the vast majority of OHCA events are initially attended to by lay rescuers in its early stages. Lay provider recognition of OHCA, coupled with early effective CPR and defibrillation using public access automatic external defibrillators, has been shown to significantly increase resuscitation rates and ultimate outcomes [8–11]. Considering the extreme time-sensitivity with regards to prompt therapy and its relation to more optimal outcome, lay provider interventions must be explored in detail. In this edition of Resuscitation, Gyllenborg et al. [12] do just that. With datadriven observations regarding the quality of resuscitation by lay providers, we can construct appropriate educational, organizational, and response systems, optimizing treatments provided by these untrained rescuers. This study [12] is quite important in that limited data exists regarding the quality of CPR, namely chest compressions (rate, depth, and pause periods), performed by lay providers in OHCA. Gyllenborg et al. [12] have contributed to this small yet important database of lay provider resuscitation skills and abilities; in their report, they describe the results of an observational study of bystander CPR quality in 136 cases of OHCA in the Capital Region of Denmark over a four-year period (2012–2016). The quality of chest compressions was recorded by AED accelerometer data and was assessed by adherence to ERC 2010 and 2015 guidelines; the ERC guideline metrics used included rate of 100–120 min−1 , compression depth of 5–6 cm, and minimization of compression pauses (≥60/minute or chest compression fraction ≥60%). The authors reported the following characteristics of CPR performed by the lay rescuers, including median compression rate 100–120 min-1 (42%), compression depth 5–6 cm (26%), compression fraction ≥60% (51%) and compressions delivered per minute greater than 60/min (54%). Regarding pauses in chest compressions and the performance of defibrillation, the median peri-shock pause was 27 s and the pre-shock pause was 19 s. They noted that bystander CPR was largely compliant with guidelines in regards to compression rate; lay rescuers in this study, however, fell short in regards to appropriate compression depth. The authors also
https://doi.org/10.1016/j.resuscitation.2017.10.008 0300-9572/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Brady WJ, et al. A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.008
G Model RESUS-7340; No. of Pages 2
ARTICLE IN PRESS Editorial / Resuscitation xxx (2017) xxx–xxx
2
note two additional areas of potential improvement, including an increase in chest compression fraction (median of 60% with 54% obtaining >60/min) and a reduction of peri-defibrillatory shock pause length (median 27 s). Importantly, in a minute-to-minute analysis, no evidence of deterioration in CPR quality was found over the period of resuscitation. This article provides important insight into the quality and timing of chest compressions, thus allowing for targeted instruction and the development of other educational and clinical improvement projects aimed at this key period of OHCA management. Previous studies of bystander cardiopulmonary resuscitation have been unable to measure and assess compliance with current expert guidelines for compression depth and other important metrics [13–15]. Future education efforts in layperson CPR training likely will benefit from renewed focus on this point. In addition, as the authors mention, attention to interruptions in chest compression, the pauses, is also important; any educational intervention which reduces the pauses, and thus increases the chest compression fraction, will likely increase survival. Prolonged peri-shock pause is associated with a concomitant increase in mortality, and this may also be a target of future interventions including efforts in reducing the duration of pre-set “prompted” pauses inherent to vocalized AED instructions [16]. We know that early therapy provides the best opportunity for meaningful survival in the OHCA patient. In most instances of OHCA, the lay provider will be the initial rescuer. Empowering and educating the lay provider to intervene is vital; the interventions need not be complex nor advanced. In fact, basic interventions, such as high quality chest compressions and early defibrillation, have significant, positive impact on survival and neurologic status. Educational and training programs, aimed at the lay provider, are needed. Education and instruction, however brief, is beneficial; instruction not only increases the likelihood of a lay rescuer performing CPR but also improves lay provider CPR skills [17]. Furthermore, insight into the lay providers’ abilities is also needed. Gyllenborg et al. [12] have provided such insight into the lay providers’ chest compression performance. This information, as well as results from similar future investigations, can be applied to lay provider education programs; and, more importantly, this information can also translate into improved lay provider resuscitation skills and abilities. . .and increased rates of meaningful survival for victims of out-of-hospital cardiac arrest. Conflict of interest statement Commentary to Gyllenborg et al. 2017: “Quality of bystander cardiopulmonary resuscitation during real-life out-of-hospital cardiac arrest” in Resuscitation – A Better Understanding of Lay Providers’ CPR Performance during Resuscitation of Out-ofHospital Cardiac Arrest by William J. Brady MD, George Glass MD, & Robert E. O’Connor MD. We, authors of the above manuscript, attest that we have no conflicts of interest in the creation, submission, and publication of this work.
References [1]. American Heart Association: Standards for cardiopulmonary resuscitation. (CPR) and emergency cardiac care (ECC). J Am Med Assoc 1974;227:S833–68. [2]. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life support, 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132(Suppl. 2):S444–64. [3]. Soar J, Nolan JP, Böttiger BW, et al. European resuscitation council guidelines for resuscitation 2015: section 3: adult advanced life support. Resuscitation 2015;95:100–47. [4]. Stiell IG, Wells GA, Field B, for the OPALS Study Group, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. New Engl J Med 2004;351:647–56. [5]. Mitchell RG, Brady W, Guly UM, Pirrallo RG, Robertson CE. Comparison of two emergency response systems and their effect on survival from out-of-hospital cardiac arrest. Resuscitation 1997;35:225–9. [6]. Park YM, Shin SD, Lee YJ, et al. Cardiopulmonary resuscitation by trained responders versus lay persons and outcomes of out-of-hospital cardiac arrest: a community observational study. Resuscitation 2017;118:55–62. [7]. Nord A, Svensson L, Karlsson T, et al. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation 2017;120:88–94. [8]. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression–only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. J Am Med Assoc 2010;304:1447–54. [9]. Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation 2007;116:2900–7. [10]. Berdowski J, Blom MT, Bardai A, et al. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation 2011;124:2225–32. [11]. Ringh M, Jonsson M, Nordberg P, et al. Survival after public access defibrillation in stockholm, Sweden–s striking success. Resuscitation 2015;91:1–7. [12]. Gyllenborg T, Granfeldt A, Lippert F, Riddervold IS, Folke F., Quality of Bystander Cardiopulmonary Resuscitation During Real Life Out-of-Hospital Cardiac Arrest. Resuscitation (publication pending). [13]. Nishi T, Takei Y, Kamikura T, et al. Improper bystander-performed basic life support in cardiac arrests managed with public automated external defibrillators. Am J Emerg Med 2015;33:43–9. [14]. Rea TD, Stickney RE, Doherty A, Lank P. Performance of chest compressions by laypersons during the Public Access Defibrillation Trial. Resuscitation 2010;81:293–6. [15]. Beesems SG, Wijmans L, Tijssen JGP, Koster RW. Duration of ventilations during cardiopulmonary resuscitation by lay rescuers and first responders, clinical perspective: relationship between delivering chest compressions and outcomes. Circulation 2013;127:1585–90. [16]. Cheskes S, Schmicker RH, Christenson J, et al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation 2011;124:58–66. [17]. Bobrow BJ, Vadeboncoeur TF, Spaite DW, Potts J, Denninghoff K, Chikani V, et al. The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes 2011;4:220–6.
William J. Brady ∗ George Glass Robert E. O’Connor Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, USA ∗ Corresponding author. E-mail address: [email protected] (W.J. Brady)
7 October 2017
Please cite this article in press as: Brady WJ, et al. A better understanding of lay providers’ CPR performance during resuscitation of out-of-hospital cardiac arrest. Resuscitation (2017), https://doi.org/10.1016/j.resuscitation.2017.10.008