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A comparative study of the 1992 and 1997 recovery positions for use in the UK
Resuscitation 39 (1998) 153 – 160
A comparative study of the 1992 and 1997 recovery positions for use in the UK S. Turner a,*, I. Turner b, D. Chapman c, P. Howard d, P. Champion e, J. Hatfield d, A. James f, S. Marshall f, S. Barber g a
Stoke Mande6ille Hospital, Aylesbury, Buckinghamshire, UK b Papworth Hospital, Cambridge, UK c Princess Margaret Hospital, Swindon, UK d John Radcliffe Hospital, Oxford, UK e Wycombe General Hospital, High Wycombe, UK f Radcliffe Infirmary, Oxford, UK g Nuffield Orthopaedic Hospital, Oxford, UK Received 10 September 1998; accepted 20 November 1998
Abstract In April 1997 the ILCOR Basic Life Support advisory statements were announced in conjunction with changes to the recovery position for use in the UK. This study compared the new and old positions by using a questionnaire to assess how well each position satisfied the ILCOR statements. The study was carried out over six different hospital trusts by eight resuscitation training officers. Each tutor alternately taught the 1992 or 1997 recommended positions. After the practical session each student completed a questionnaire on ease of learning and use of the position, as well as other factors such as spinal stability. They were also asked to score the position when they were placed in recovery by other students. Their competency was assessed using the ALS criteria. Over the duration of the study 687 forms were suitable for analysis. For every question there was a significant trend in favour of the 92 position, with students finding the technique easier to learn and use, simpler for positioning for CPR and with less spinal movement during rolling. Possible sources of bias such as previous training, tutor or staff grade made no statistical difference to the results. When performed competently the 1997 position appears to cause less brachial compression, but other problems with learning or use of the 97 position outweigh this advantage. The 1992 position currently provides the best compromise between ease of use, spinal stability and other factors, and better satisfies the ILCOR advisory statements. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: ILCOR; Questionnaire; Resuscitation training officers; Recovery position
1. Introduction Over the last century there have been many changes in what we now call the recovery position, developing from an initial idea of simply turning the patients’ head to one side. There have been numerous recommendations for the best methodology and positioning of the unconscious patient. However, all of these have the * Corresponding author. Tel.: +44-1296-315000.
same aims: To ensure that an unconscious casualty who is breathing spontaneously, can maintain an open airway, maximise their ventilation and avoid aspiration. In the 1992 recommendations by the European Resuscitation Council (ERC) a new recovery position was introduced [1]. This involved placing one arm in a right angled position, which the casualty then rolled onto (Fig. 1). This method was generally well received but there were some anecdotal reports suggesting that there was poor perfusion to the lower arm. This was due to
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S. Turner et al. / Resuscitation 39 (1998) 153–160
compression of the brachial artery, with the potential for neurological or vascular injury. This was studied by Fulstow and Smith [2] and also Rathgeber et al. [3]. Their results confirmed that there was a limitation of blood flow to the lower arm when the casualty was placed in the 1992 recovery position. The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992, with their work providing consistent international guidelines on the various areas of resuscitation. The Basic Life Support working group found many variations in the recovery position, each with it’s own advocates. The group concluded that it was unable to recommend one specific position, but instead agreed on six principles that should be followed when managing the unconscious victim. These are: 1. The victim should be in as near true lateral position as possible with the head dependent to allow free drainage of fluid. 2. The position should be stable. 3. Any pressure on the chest that impairs breathing should be avoided. 4. It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spine injury. 5. Good observation of and access to the airway should be possible. 6. The position itself should not give rise to any injury to the victim. In April 1997 the Resuscitation Guidelines for the use in the UK were announced in conjunction with the ILCOR advisory statements [4 – 6]. The recommendations were adopted by the Resuscitation Council UK and included a new recovery position which was to be trialed for 1 year. This recovery position took into consideration the potential harm to the victims arm and modified the technique by placing the hand nearest to the rescuer well under the victims buttock. By then positioning the furthest knee and arm in a similar manner to that of the 1992 position, the patient is then rolled over, adjusting the limbs to ensure a stable position (Fig. 2). After the initial announcement there was much discussion about the new position. Despite its’ advocates, many
Fig. 1. The ERC 1992 recovery position.
Fig. 2. The modified recovery position for trial in the UK (the 1997 position).
were concerned with the potential injury to the casualty when rolling over the lower arm, and also twisting of the spine during the roll. It was also felt that the 97 position was complex and therefore possibly more difficult to learn and use. Some claimed that they were aware of injury to the shoulder when using a similar technique in earlier versions of the recovery position (pre 1992), although none were reported or researched fully at the time. There were also doubts expressed by many resuscitation trainers that this position would satisfy the advisory statements laid down by ILCOR. In view of these concerns it was felt that there should be a comparison of the techniques. The aim of this study was therefore to compare both the 92 position and the new modified technique with each other, and also to assess how well each fitted the ILCOR statements.
2. Methods Basic Life Support (BLS) training within the Oxford region is the responsibility of the resuscitation training officers (RTO’s) within each hospital. BLS training, which includes the recovery position, is mainly aimed at medical and nursing staff, but also extends to non-clinical personnel such as porters, secretaries or ancillary staff This study aimed to compare the two positions across a range of staff and hospitals in order to avoid any bias and to assess the applicability of the techniques in general rather than specialist use. There is no direct method for measuring how the recovery position is performed, as compared to the use of recording manikins for chest compression’s or ventilation during CPR. Plethysmography techniques have been used to measure blood flow in the arms in people placed in the recovery position, but this is not practical over large numbers of students and does not provide information on other factors such as ease of use or stability in the final position. For these reasons we decided to adopt a questionnaire which would ask for the students’ opinions of the technique that they had been taught. Considerable time
S. Turner et al. / Resuscitation 39 (1998) 153–160
went into the development of the questions and the layout of the form [7,8], in order that the questionnaire was quick and easy to use, asked valid questions and was reliable. The ILCOR statements provided an ideal starting point in the development of the questionnaire. All of the questions were designed to assess how well each technique met the ILCOR criteria and it was decided that two groups of questions were appropriate. Firstly the students were asked their opinion on how the technique met the criteria when they performed it on others. Secondly, the students were asked to rate the technique when it was performed on them. This was necessary because factors such as comfort, spinal move-
155
ment etc. could only be assessed accurately by someone acting as the casualty, whilst ease of use could only be assessed by performing the technique. Closed questions were chosen in order to standardise and simplify the collections and analysis of the results. The questions were carefully worded to be easy to understand and to avoid double questions or leading statements. The Likert scale was selected as the most appropriate method for recording the answers. This type of scale has been well validated and allows a range of response for each question rather than a simple yes/no answer [9]. The comfort of the arms and shoulders was asked about separately to avoid confusion. The questions finally adopted are shown below:
The following questions are for you to describe how easy the recovery position was to use or learn. Place a tick in the box beside each question that best describes your answer Bad Poor OK Good Excellent (1) Was it easy to roll someone onto their [] [] [] [] [] side (2) Was their back and neck kept [] [] [] [] [] straight with no twisting (3) Were they steady when left on [] [] [] [] [] their side (4) Was it easy to check breathing in [] [] [] [] [] recovery position (5) Was it quick to roll them over for [] [] [] [] [] resuscitation (6) Was the recovery position easy to [] [] [] [] [] learn The following questions are for you to describe how the recovery position felt when you were the patient. Place a tick in the box beside each question that best describes how you felt Bad Poor OK Good Excellent (7) The roll was smooth [] [] [] [] [] (8) The roll did not twist your back [] [] [] [] [] and neck (9) You could breathe easily in the [] [] [] [] [] final position (10) The position was comfortable for [] [] [] [] [] your arms (11) The position was comfortable for [] [] [] [] [] your shoulders (12) Your head was supported with [] [] [] [] [] your airway open (13) You did not move or roll when [] [] [] [] [] left on your own In order to investigate possible sources of bias, such as the sex of the students, previous training, staff grade or competency, a further set of questions were added to record this information. The competency grade was completed by the tutor and each student allocated a mark from 1 (poor) through to 3 (very good) depending on how well they performed the recovery position. This competency scoring system is the same as used on Advanced Life Support Courses. A final, open section
for comments from the student was also provided. The questionnaire was tested on a number of small pilot groups and underwent three revisions before the final layout and wording was defined. The reliability of the questionnaire was assessed by asking a group of ten students to repeat the form a few days later. No significant difference in the results was seen between the two occasions, suggesting that the form is reliable in use.
S. Turner et al. / Resuscitation 39 (1998) 153–160
156
Table 1 The demographic details of the students enrolled in the study No. with 92 position
No. with 97 position
Female Male Total
260 42 302
328 57 385
Doctor Nurse/ODA Technical staff Physio HCA Other staff
9 128 17 15 34 99
30 214 26 32 20 63
Never trained Trained once before Trained several times
63 91 148
50 93 242
All of the students who were undertaking BLS training within the hospital were eligible for the trial. At first, a cross-over study where students were taught both techniques for comparison was considered. However, limited time for training, and the need for students to be confident in the technique that they had been taught, meant that a cross-over study was not practical. We therefore decided to teach alternate groups of students with either the 92 or the 97 position. The results from the pilot studies suggested that approximately 700 students would be needed to provide an accurate statistical analysis, including confounding effects such as staff grade etc.
Each student was asked to place at least two people in the recovery position. They were also placed in the recovery position by a different person on two separate occasions. This was done to avoid students developing a bad impression if they were paired with a difficult casualty or rescuer. Each student was left in the recovery position for 1–2 min. The study was started on the 1st of August, 1997. This allowed all of the tutors 3–4 months to become familiar with teaching the new position before the start of the trial period and therefore reduced the chances of this being a possible source of bias. The students were all attending BLS sessions within the hospitals, either as routine training or part of more advanced courses. Each group was taught one of the two positions and asked to fill in a questionnaire at the end of the training session. Data collection was completed by the 31st of December, 1997.
3. Results Over the duration of the study 725 students completed the questionnaire, with 38 forms being rejected as incomplete. This left 687 forms for analysis. The demographic details of the study group are shown in Table 1. Because the 97 position had to be taught on specific courses (e.g. Advanced Life Support courses), more students were enrolled in the 97 group during the study than in the 92 group. The large number of students studied meant that this had no significant effect on the analysis however.
Fig. 3. The percentage of students responding good/excellent for either position for the first six questions. These questions correspond to the student using the technique on others.
S. Turner et al. / Resuscitation 39 (1998) 153–160
157
Fig. 4. The percentage of students responding good/excellent for either position for the last seven questions. These questions correspond to the student acting as a casualty.
The number of students who answered each question in each category was analysed using the x2-squared test. Because relatively few answers were found in both the bad and poor categories, these were combined to give four possible answers to each question. Sufficient numbers of students in these four categories made a x2 analysis valid for every question. Similar results were seen for all of the first six questions, with a highly significant trend in favour of the 92 position (P B0.001 for all questions). The results for these questions are presented as a graph (Fig. 3) of the percentage of marks in the good/excellent categories for each question for the two positions. The results from the second set of questions, where the students were asked their opinions after acting as the casualty, were analysed in an identical manner (Fig. 4). Again there is a highly significant trend towards higher marking for the 92 recovery position (P B0.001 for all questions except question 12, where P =0.02). Table 2 The numbers of students in each competency category for the two positions Competency
92 position
97 position
Poor (1) Average (2) Good (3)
49 227 26
59 297 29
The degree of competency for each student was also assessed and compared between the two positions (Table 2). No significant difference was seen between the two positions. In order to simplify analysis of confounding factors a combined score was compiled by adding the marks for each question together. The questions were grouped either as those in which the student performed the test or those in which they were the casualty (Table 3). Comparison of the results showed higher scores for the 92 position compared to the 97 position (PB0.001, Mann-Whitney U test) in both cases. The combined scores for each question group were then used to investigate possible sources of bias within the study, such as previous training, tutor etc. Table 4 shows the median score for both recovery positions when the students are split to take account of the sex of the student, previous training or competency. The sex of the student had no significant effect on the response (Kruskal-Wallis ANOVA test), with male and female students scoring the two positions in an identical manner. The amount of previous training had a slight effect on scoring, as did the degree of competency. The more experienced, or more competent students were more critical of both techniques in terms of the scores allocated. The preference for the 92 position was maintained however. The students’ occupation did have some effect on the results, with statistically significant differences between
S. Turner et al. / Resuscitation 39 (1998) 153–160
158
Table 3 The combined scores for both groups of questions and both positions Question group
Median score-92 position
Median score-97 position
Significance of difference
Questions 1–6 Questions 7–13
26 29
20 24
PB0.001 PB0.001
groups (PB0.01). Doctors appeared to be more critical in general, scoring both positions slightly lower. However, the same underlying trend for the 92 position to score higher than the 97 position was seen in every group. The results for the different tutors also showed significant differences (P B 0.01), with the students of some of the tutors showing less of a difference between the two positions than the others (Table 5). However, there was still a significant difference, in favour of the 92 position, for all of the tutors. A minority of the forms had comments by the students on the recovery position they had learnt. As this was an open question, the responses obtained were quite varied and not amenable to simple analysis. For simplicity we recorded the number of occurrences of the major types of comment for each recovery position (Table 6). Students generally found the 92 position simpler and easier to learn, although there was some discomfort in the final position, mainly with compression of the lower arm. However, many of the students in the 97 group complained of significant discomfort or pain during the roll. A significant proportion of the 97 group also complained of arm pain in the final position, mainly due to inadequate release of the lower arm. There were insufficient numbers of comments to analyse the effects of previous training, occupation or other factors. Table 4 The combined scores when students were grouped according to sex, training or competency
4. Discussion The aim of this study was to assess and compare students’ attitudes to the two recovery position taught. The questionnaire format provided a quick and simple method of collecting data from a wide range of staff, with a large number of respondents (725) and a high response rate (95%). Comparison of the demographics of the student groups for both positions showed little difference for most characteristics, although there was a trend to fewer doctors and more ancillary staff in the 92 group. Analysis of each job category, staff grade or student sex ensured that bias effects due to different proportions in each group could be investigated and corrected for. This is discussed in more detail later. One of the main concerns with the 97 position when it was first taught was that it should be possible to turn the victim onto their back quickly and easily if resuscitation was needed. This is a straightforward, obvious and easy manoeuvre with the 92 position, with the rescuer gently pushing them back. Because it is simple it requires minimal teaching and does not rely on student retention in the event of a real situation. The 97 method involves a series of awkward movements which are not intuitively obvious, involving lifting the lower arm turning the head and then rolling the patient almost a complete turn towards the rescuer. This requires significant teaching input and practice so as to not injure the patient or the rescuer, with obvious implications for skill retention. It was also found to be particularly difficult in a larger patient, and was the subject of numerous comments on forms by the students. The other issue with returning the patient to their back is the amount of space that it requires. The 92
Factor
Median score-92 po- Median score-97 posisition tion
Female Male
25 26
20 19
Never trained before Trained once before Trained many times before
26
20
Table 5 The median combined scores (for questions 1–6) for different tutors and the two recovery positionsa
24
20
Tutor
Median score-92 position
Median score-97 position
26
20
Competency grade 1 Competency grade 2 Competency grade 3
25
21
26
20
1 2 3 4 5 6
27 25 25 26 25 25
20 22 19 22 17 22
27
20 a Two tutors were excluded as they had too few students to allow accurate statistical analysis.
S. Turner et al. / Resuscitation 39 (1998) 153–160 Table 6 The numbers of students who made particular comments on the free section of the forms Comment
No. with 92 po- No. with 97 position sition
Position was easy to use 24 Position was difficult to use 5 Position was easy to learn 16 Position was hard to learn 0 Pain/discomfort during turn 3 Pain/discomfort in final posi- 11 tion Difficulty in positioning for 0 CPR Problems maintaining airway 1 Twisting of spine during po1 sitioning Poor stability in final posi2 tion
10 56 5 9 48 29 33 2 9 5
position uses little space and is suitable for use if in a confined area. The 97 position requires almost a complete roll of the patient, which involves significant space. This has practical implications in treating unconscious casualties in confined areas. Another important factor was that the ILCOR statements state that the rescuer should be able to roll the casualty easily and safely onto their side with particular regard to the possibility of spinal injury. The results from this study indicate that with both positions there is perceived to be some degree of spinal movement, although this appears to be significantly worse with the 97 position. The 97 position involves rolling the casualty across their shoulder, and often across their lower arm if this is incorrectly placed. The 92 position appears to offer slightly more patient control during the roll, and the fact that the roll is onto the underside arm rather than over it, reduces the degree of spinal movement. It can be argued that the importance of turning an unconscious patient into the recovery position to maintain an open airway outweighs any possible complications caused by spinal movement. This movement can also be greatly reduced with more personnel being involved in the turn, i.e. the log-roll technique. However, the recovery position is taught and practised as a one person emergency procedure, and ideally it should be a method that reduces spinal movement to a minimum. The ILCOR statements also state that the position itself should not give rise to any injury to the victim. One of the reasons for modifying the 92 position was due to the evidence showing reduced circulation to this arm, suggesting that the patient was at risk. This study showed that the amount of discomfort felt by students when left in the 92 recovery position was significant and
159
was more prevalent than was expected. Prior to the study only an occasional student had commented on any discomfort. In comparison, there was a higher indication of discomfort in the results for the 97 position, with the shoulder being selected by most as the main problem. Many comments were made on the 97 forms suggesting that it was the roll itself that was particularly uncomfortable, but once in the final position this discomfort eased. Further problems were noted when students did not release the lower arm, with numbness and pain in this arm. This suggests that the 97 position may well be better in terms of arm compression, but only when performed correctly by skilled staff. There only needs to be a slightly wrong position for this to become a problem (usually incomplete release of the lower arm). This was not considered an important part of the assessment during the trial design and was therefore not investigated during the study. The 1, 2, 3 competency score only reflects major errors and arm compression due to minor errors is likely to be more significant than reported. The area of comfort is particularly difficult to assess as all of the students who were rolled into the recovery position were conscious and provide a different situation to a real, flaccid, unconscious casualty. However, students who find that being rolled into a recovery position that is painful are less likely to practice and are likely to be less motivated to use the technique. Significantly, in view of current anecdotal reports of injuries with the 97 position, no injuries to any student were reported during the study. With regard to the other ILCOR statements, both positions appear to offer a stable, lateral position, with maintenance and access to a clear airway, and with no cause of impairment to breathing. The results and student comments indicate that although both positions achieve this, there was a significant preference for the 92 position. The degree of stability with both positions was felt to be good however. A further important factor involves ease of learning and competency. There was a significant trend towards the 92 position being considered as easier to learn. However, assessment of the students’ practical ability showed no significant difference between the two positions during the teaching session. The three point competency scale is a relatively crude instrument for assessing skill levels, but the results do show that although students prefer the 92 position, they are capable of placing casualties in either position successfully. Further studies would certainly benefit from a better definition of skill level to clarify this. Another factor which was not investigated during this study was skill retention. Anecdotal information from the different hospitals has shown poorer retention of the 97 position when students attend for re-assessment. This is another area that would require further study.
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Possible sources of bias in the study, such as sex of the student, staff grade, previous training or tutor were investigated. Neither sex or previous training had any significant influence on preference. The latter was particularly surprising as the majority of students who had had previous training were trained with the 92 position, and would have been expected to prefer it through familiarity. Significant differences were seen between different groups of staff, with doctors, nurses and physiotherapists all being more critical in general of both techniques than non-clinical staff. However, the same, statistically significant trends in favour of the 92 position were seen in all groups. A similar situation was seen with different tutors. Each used their own teaching methods and there were differences in response between students in different hospitals. However, there was again a highly significant trend in favour of the 92 position in all cases for all questions as well as the combined scores. One interesting feature was that competency had no influence on student perception of the technique. Poor students were just as likely to mark either technique highly (or badly) as more competent or experienced students. This may reflect poor awareness by the students of their practical ability.
5. Conclusions This study was designed to compare the opinions of students being taught either the 92 or 97 recovery positions. Their answers to a series of questions based on the ILCOR advisory statements showed that there was a significant preference for the 92 position, which was felt to be easier to learn and use. It also appeared to offer better protection to the spine and to be faster in returning a casualty to a suitable position for CPR. Possible sources of bias such as staff grade, previous experience or tutor made no difference to these results. Despite a greater preference for the 92 position however, there was no significant difference in competency between the two groups at the end of their training. The 97 position was suggested in response to con-
cerns about restricted arm blood flow with the 92 position. The difficulties encountered with the 97 position imply that although it may be better for the arm when performed correctly, the other problems outweigh this advantage when taught to a wide range of hospital staff. The 92 position currently provides the best compromise between ease of use, spinal stability and other factors. Introduction of any modifications to this position should be tested in a general setting to ensure that as well as avoiding limb compression the technique also meets all of the other ILCOR advisory statements.
Acknowledgements Thanks go to Dr Alison Gammon and Dr Michael Ward for their help and support during the study. Thanks also go to Ron James for the excellent illustrations.
References [1] Basic Life Support Working Party of the European Resuscitation Council. Guidelines for basic life support. Resuscitation 1992;24:103 – 10. [2] Fulstow R, Smith GB. The new recovery position, a cautionary tale. Resuscitation 1993;26:89 – 91. [3] Rathgeber J, Panzer W, Gunther U, Scholz M, Hoeft A, Bahr J, Kettler D. Influence of different types of recovery positions on perfusion indices of the forearm. Resuscitation 1996;32:13–7. [4] Chamberlain DA, Cummins RO. Advisory statements of the International Liaison Committee on Resuscitation (ILCOR). Resuscitation 1997;34:99 – 100. [5] Handley AJ, Becker LB, Allen M, van Drenth A, Kramer EB, Montgomery WH. Single rescuer adult basic life support. Resuscitation 1997;34:101 – 8. [6] Resuscitation Council (UK). The 1997 Resuscitation guidelines for use in the United Kingdom. London: Resuscitation Council (UK), 1997:13. [7] Henerson ME, Morrison LL, Fitz-Gibbon CT. How to measure attitudes. California: Sage, 1987. [8] Burns N, Grove SK. The practice of nursing research. Philadelphia: WB Saunders, 1994. [9] Spector PE. Summated rating scale construction: an introduction. California: Sage, 1992.
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A comparative study of the 1992 and 1997 recovery positions for use in the UK S. Turner a,*, I. Turner b, D. Chapman c, P. Howard d, P. Champion e, J. Hatfield d, A. James f, S. Marshall f, S. Barber g a
Stoke Mande6ille Hospital, Aylesbury, Buckinghamshire, UK b Papworth Hospital, Cambridge, UK c Princess Margaret Hospital, Swindon, UK d John Radcliffe Hospital, Oxford, UK e Wycombe General Hospital, High Wycombe, UK f Radcliffe Infirmary, Oxford, UK g Nuffield Orthopaedic Hospital, Oxford, UK Received 10 September 1998; accepted 20 November 1998
Abstract In April 1997 the ILCOR Basic Life Support advisory statements were announced in conjunction with changes to the recovery position for use in the UK. This study compared the new and old positions by using a questionnaire to assess how well each position satisfied the ILCOR statements. The study was carried out over six different hospital trusts by eight resuscitation training officers. Each tutor alternately taught the 1992 or 1997 recommended positions. After the practical session each student completed a questionnaire on ease of learning and use of the position, as well as other factors such as spinal stability. They were also asked to score the position when they were placed in recovery by other students. Their competency was assessed using the ALS criteria. Over the duration of the study 687 forms were suitable for analysis. For every question there was a significant trend in favour of the 92 position, with students finding the technique easier to learn and use, simpler for positioning for CPR and with less spinal movement during rolling. Possible sources of bias such as previous training, tutor or staff grade made no statistical difference to the results. When performed competently the 1997 position appears to cause less brachial compression, but other problems with learning or use of the 97 position outweigh this advantage. The 1992 position currently provides the best compromise between ease of use, spinal stability and other factors, and better satisfies the ILCOR advisory statements. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: ILCOR; Questionnaire; Resuscitation training officers; Recovery position
1. Introduction Over the last century there have been many changes in what we now call the recovery position, developing from an initial idea of simply turning the patients’ head to one side. There have been numerous recommendations for the best methodology and positioning of the unconscious patient. However, all of these have the * Corresponding author. Tel.: +44-1296-315000.
same aims: To ensure that an unconscious casualty who is breathing spontaneously, can maintain an open airway, maximise their ventilation and avoid aspiration. In the 1992 recommendations by the European Resuscitation Council (ERC) a new recovery position was introduced [1]. This involved placing one arm in a right angled position, which the casualty then rolled onto (Fig. 1). This method was generally well received but there were some anecdotal reports suggesting that there was poor perfusion to the lower arm. This was due to
0300-9572/98/$ - see front matter © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 9 8 ) 0 0 1 4 4 - 0
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S. Turner et al. / Resuscitation 39 (1998) 153–160
compression of the brachial artery, with the potential for neurological or vascular injury. This was studied by Fulstow and Smith [2] and also Rathgeber et al. [3]. Their results confirmed that there was a limitation of blood flow to the lower arm when the casualty was placed in the 1992 recovery position. The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992, with their work providing consistent international guidelines on the various areas of resuscitation. The Basic Life Support working group found many variations in the recovery position, each with it’s own advocates. The group concluded that it was unable to recommend one specific position, but instead agreed on six principles that should be followed when managing the unconscious victim. These are: 1. The victim should be in as near true lateral position as possible with the head dependent to allow free drainage of fluid. 2. The position should be stable. 3. Any pressure on the chest that impairs breathing should be avoided. 4. It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spine injury. 5. Good observation of and access to the airway should be possible. 6. The position itself should not give rise to any injury to the victim. In April 1997 the Resuscitation Guidelines for the use in the UK were announced in conjunction with the ILCOR advisory statements [4 – 6]. The recommendations were adopted by the Resuscitation Council UK and included a new recovery position which was to be trialed for 1 year. This recovery position took into consideration the potential harm to the victims arm and modified the technique by placing the hand nearest to the rescuer well under the victims buttock. By then positioning the furthest knee and arm in a similar manner to that of the 1992 position, the patient is then rolled over, adjusting the limbs to ensure a stable position (Fig. 2). After the initial announcement there was much discussion about the new position. Despite its’ advocates, many
Fig. 1. The ERC 1992 recovery position.
Fig. 2. The modified recovery position for trial in the UK (the 1997 position).
were concerned with the potential injury to the casualty when rolling over the lower arm, and also twisting of the spine during the roll. It was also felt that the 97 position was complex and therefore possibly more difficult to learn and use. Some claimed that they were aware of injury to the shoulder when using a similar technique in earlier versions of the recovery position (pre 1992), although none were reported or researched fully at the time. There were also doubts expressed by many resuscitation trainers that this position would satisfy the advisory statements laid down by ILCOR. In view of these concerns it was felt that there should be a comparison of the techniques. The aim of this study was therefore to compare both the 92 position and the new modified technique with each other, and also to assess how well each fitted the ILCOR statements.
2. Methods Basic Life Support (BLS) training within the Oxford region is the responsibility of the resuscitation training officers (RTO’s) within each hospital. BLS training, which includes the recovery position, is mainly aimed at medical and nursing staff, but also extends to non-clinical personnel such as porters, secretaries or ancillary staff This study aimed to compare the two positions across a range of staff and hospitals in order to avoid any bias and to assess the applicability of the techniques in general rather than specialist use. There is no direct method for measuring how the recovery position is performed, as compared to the use of recording manikins for chest compression’s or ventilation during CPR. Plethysmography techniques have been used to measure blood flow in the arms in people placed in the recovery position, but this is not practical over large numbers of students and does not provide information on other factors such as ease of use or stability in the final position. For these reasons we decided to adopt a questionnaire which would ask for the students’ opinions of the technique that they had been taught. Considerable time
S. Turner et al. / Resuscitation 39 (1998) 153–160
went into the development of the questions and the layout of the form [7,8], in order that the questionnaire was quick and easy to use, asked valid questions and was reliable. The ILCOR statements provided an ideal starting point in the development of the questionnaire. All of the questions were designed to assess how well each technique met the ILCOR criteria and it was decided that two groups of questions were appropriate. Firstly the students were asked their opinion on how the technique met the criteria when they performed it on others. Secondly, the students were asked to rate the technique when it was performed on them. This was necessary because factors such as comfort, spinal move-
155
ment etc. could only be assessed accurately by someone acting as the casualty, whilst ease of use could only be assessed by performing the technique. Closed questions were chosen in order to standardise and simplify the collections and analysis of the results. The questions were carefully worded to be easy to understand and to avoid double questions or leading statements. The Likert scale was selected as the most appropriate method for recording the answers. This type of scale has been well validated and allows a range of response for each question rather than a simple yes/no answer [9]. The comfort of the arms and shoulders was asked about separately to avoid confusion. The questions finally adopted are shown below:
The following questions are for you to describe how easy the recovery position was to use or learn. Place a tick in the box beside each question that best describes your answer Bad Poor OK Good Excellent (1) Was it easy to roll someone onto their [] [] [] [] [] side (2) Was their back and neck kept [] [] [] [] [] straight with no twisting (3) Were they steady when left on [] [] [] [] [] their side (4) Was it easy to check breathing in [] [] [] [] [] recovery position (5) Was it quick to roll them over for [] [] [] [] [] resuscitation (6) Was the recovery position easy to [] [] [] [] [] learn The following questions are for you to describe how the recovery position felt when you were the patient. Place a tick in the box beside each question that best describes how you felt Bad Poor OK Good Excellent (7) The roll was smooth [] [] [] [] [] (8) The roll did not twist your back [] [] [] [] [] and neck (9) You could breathe easily in the [] [] [] [] [] final position (10) The position was comfortable for [] [] [] [] [] your arms (11) The position was comfortable for [] [] [] [] [] your shoulders (12) Your head was supported with [] [] [] [] [] your airway open (13) You did not move or roll when [] [] [] [] [] left on your own In order to investigate possible sources of bias, such as the sex of the students, previous training, staff grade or competency, a further set of questions were added to record this information. The competency grade was completed by the tutor and each student allocated a mark from 1 (poor) through to 3 (very good) depending on how well they performed the recovery position. This competency scoring system is the same as used on Advanced Life Support Courses. A final, open section
for comments from the student was also provided. The questionnaire was tested on a number of small pilot groups and underwent three revisions before the final layout and wording was defined. The reliability of the questionnaire was assessed by asking a group of ten students to repeat the form a few days later. No significant difference in the results was seen between the two occasions, suggesting that the form is reliable in use.
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Table 1 The demographic details of the students enrolled in the study No. with 92 position
No. with 97 position
Female Male Total
260 42 302
328 57 385
Doctor Nurse/ODA Technical staff Physio HCA Other staff
9 128 17 15 34 99
30 214 26 32 20 63
Never trained Trained once before Trained several times
63 91 148
50 93 242
All of the students who were undertaking BLS training within the hospital were eligible for the trial. At first, a cross-over study where students were taught both techniques for comparison was considered. However, limited time for training, and the need for students to be confident in the technique that they had been taught, meant that a cross-over study was not practical. We therefore decided to teach alternate groups of students with either the 92 or the 97 position. The results from the pilot studies suggested that approximately 700 students would be needed to provide an accurate statistical analysis, including confounding effects such as staff grade etc.
Each student was asked to place at least two people in the recovery position. They were also placed in the recovery position by a different person on two separate occasions. This was done to avoid students developing a bad impression if they were paired with a difficult casualty or rescuer. Each student was left in the recovery position for 1–2 min. The study was started on the 1st of August, 1997. This allowed all of the tutors 3–4 months to become familiar with teaching the new position before the start of the trial period and therefore reduced the chances of this being a possible source of bias. The students were all attending BLS sessions within the hospitals, either as routine training or part of more advanced courses. Each group was taught one of the two positions and asked to fill in a questionnaire at the end of the training session. Data collection was completed by the 31st of December, 1997.
3. Results Over the duration of the study 725 students completed the questionnaire, with 38 forms being rejected as incomplete. This left 687 forms for analysis. The demographic details of the study group are shown in Table 1. Because the 97 position had to be taught on specific courses (e.g. Advanced Life Support courses), more students were enrolled in the 97 group during the study than in the 92 group. The large number of students studied meant that this had no significant effect on the analysis however.
Fig. 3. The percentage of students responding good/excellent for either position for the first six questions. These questions correspond to the student using the technique on others.
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Fig. 4. The percentage of students responding good/excellent for either position for the last seven questions. These questions correspond to the student acting as a casualty.
The number of students who answered each question in each category was analysed using the x2-squared test. Because relatively few answers were found in both the bad and poor categories, these were combined to give four possible answers to each question. Sufficient numbers of students in these four categories made a x2 analysis valid for every question. Similar results were seen for all of the first six questions, with a highly significant trend in favour of the 92 position (P B0.001 for all questions). The results for these questions are presented as a graph (Fig. 3) of the percentage of marks in the good/excellent categories for each question for the two positions. The results from the second set of questions, where the students were asked their opinions after acting as the casualty, were analysed in an identical manner (Fig. 4). Again there is a highly significant trend towards higher marking for the 92 recovery position (P B0.001 for all questions except question 12, where P =0.02). Table 2 The numbers of students in each competency category for the two positions Competency
92 position
97 position
Poor (1) Average (2) Good (3)
49 227 26
59 297 29
The degree of competency for each student was also assessed and compared between the two positions (Table 2). No significant difference was seen between the two positions. In order to simplify analysis of confounding factors a combined score was compiled by adding the marks for each question together. The questions were grouped either as those in which the student performed the test or those in which they were the casualty (Table 3). Comparison of the results showed higher scores for the 92 position compared to the 97 position (PB0.001, Mann-Whitney U test) in both cases. The combined scores for each question group were then used to investigate possible sources of bias within the study, such as previous training, tutor etc. Table 4 shows the median score for both recovery positions when the students are split to take account of the sex of the student, previous training or competency. The sex of the student had no significant effect on the response (Kruskal-Wallis ANOVA test), with male and female students scoring the two positions in an identical manner. The amount of previous training had a slight effect on scoring, as did the degree of competency. The more experienced, or more competent students were more critical of both techniques in terms of the scores allocated. The preference for the 92 position was maintained however. The students’ occupation did have some effect on the results, with statistically significant differences between
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Table 3 The combined scores for both groups of questions and both positions Question group
Median score-92 position
Median score-97 position
Significance of difference
Questions 1–6 Questions 7–13
26 29
20 24
PB0.001 PB0.001
groups (PB0.01). Doctors appeared to be more critical in general, scoring both positions slightly lower. However, the same underlying trend for the 92 position to score higher than the 97 position was seen in every group. The results for the different tutors also showed significant differences (P B 0.01), with the students of some of the tutors showing less of a difference between the two positions than the others (Table 5). However, there was still a significant difference, in favour of the 92 position, for all of the tutors. A minority of the forms had comments by the students on the recovery position they had learnt. As this was an open question, the responses obtained were quite varied and not amenable to simple analysis. For simplicity we recorded the number of occurrences of the major types of comment for each recovery position (Table 6). Students generally found the 92 position simpler and easier to learn, although there was some discomfort in the final position, mainly with compression of the lower arm. However, many of the students in the 97 group complained of significant discomfort or pain during the roll. A significant proportion of the 97 group also complained of arm pain in the final position, mainly due to inadequate release of the lower arm. There were insufficient numbers of comments to analyse the effects of previous training, occupation or other factors. Table 4 The combined scores when students were grouped according to sex, training or competency
4. Discussion The aim of this study was to assess and compare students’ attitudes to the two recovery position taught. The questionnaire format provided a quick and simple method of collecting data from a wide range of staff, with a large number of respondents (725) and a high response rate (95%). Comparison of the demographics of the student groups for both positions showed little difference for most characteristics, although there was a trend to fewer doctors and more ancillary staff in the 92 group. Analysis of each job category, staff grade or student sex ensured that bias effects due to different proportions in each group could be investigated and corrected for. This is discussed in more detail later. One of the main concerns with the 97 position when it was first taught was that it should be possible to turn the victim onto their back quickly and easily if resuscitation was needed. This is a straightforward, obvious and easy manoeuvre with the 92 position, with the rescuer gently pushing them back. Because it is simple it requires minimal teaching and does not rely on student retention in the event of a real situation. The 97 method involves a series of awkward movements which are not intuitively obvious, involving lifting the lower arm turning the head and then rolling the patient almost a complete turn towards the rescuer. This requires significant teaching input and practice so as to not injure the patient or the rescuer, with obvious implications for skill retention. It was also found to be particularly difficult in a larger patient, and was the subject of numerous comments on forms by the students. The other issue with returning the patient to their back is the amount of space that it requires. The 92
Factor
Median score-92 po- Median score-97 posisition tion
Female Male
25 26
20 19
Never trained before Trained once before Trained many times before
26
20
Table 5 The median combined scores (for questions 1–6) for different tutors and the two recovery positionsa
24
20
Tutor
Median score-92 position
Median score-97 position
26
20
Competency grade 1 Competency grade 2 Competency grade 3
25
21
26
20
1 2 3 4 5 6
27 25 25 26 25 25
20 22 19 22 17 22
27
20 a Two tutors were excluded as they had too few students to allow accurate statistical analysis.
S. Turner et al. / Resuscitation 39 (1998) 153–160 Table 6 The numbers of students who made particular comments on the free section of the forms Comment
No. with 92 po- No. with 97 position sition
Position was easy to use 24 Position was difficult to use 5 Position was easy to learn 16 Position was hard to learn 0 Pain/discomfort during turn 3 Pain/discomfort in final posi- 11 tion Difficulty in positioning for 0 CPR Problems maintaining airway 1 Twisting of spine during po1 sitioning Poor stability in final posi2 tion
10 56 5 9 48 29 33 2 9 5
position uses little space and is suitable for use if in a confined area. The 97 position requires almost a complete roll of the patient, which involves significant space. This has practical implications in treating unconscious casualties in confined areas. Another important factor was that the ILCOR statements state that the rescuer should be able to roll the casualty easily and safely onto their side with particular regard to the possibility of spinal injury. The results from this study indicate that with both positions there is perceived to be some degree of spinal movement, although this appears to be significantly worse with the 97 position. The 97 position involves rolling the casualty across their shoulder, and often across their lower arm if this is incorrectly placed. The 92 position appears to offer slightly more patient control during the roll, and the fact that the roll is onto the underside arm rather than over it, reduces the degree of spinal movement. It can be argued that the importance of turning an unconscious patient into the recovery position to maintain an open airway outweighs any possible complications caused by spinal movement. This movement can also be greatly reduced with more personnel being involved in the turn, i.e. the log-roll technique. However, the recovery position is taught and practised as a one person emergency procedure, and ideally it should be a method that reduces spinal movement to a minimum. The ILCOR statements also state that the position itself should not give rise to any injury to the victim. One of the reasons for modifying the 92 position was due to the evidence showing reduced circulation to this arm, suggesting that the patient was at risk. This study showed that the amount of discomfort felt by students when left in the 92 recovery position was significant and
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was more prevalent than was expected. Prior to the study only an occasional student had commented on any discomfort. In comparison, there was a higher indication of discomfort in the results for the 97 position, with the shoulder being selected by most as the main problem. Many comments were made on the 97 forms suggesting that it was the roll itself that was particularly uncomfortable, but once in the final position this discomfort eased. Further problems were noted when students did not release the lower arm, with numbness and pain in this arm. This suggests that the 97 position may well be better in terms of arm compression, but only when performed correctly by skilled staff. There only needs to be a slightly wrong position for this to become a problem (usually incomplete release of the lower arm). This was not considered an important part of the assessment during the trial design and was therefore not investigated during the study. The 1, 2, 3 competency score only reflects major errors and arm compression due to minor errors is likely to be more significant than reported. The area of comfort is particularly difficult to assess as all of the students who were rolled into the recovery position were conscious and provide a different situation to a real, flaccid, unconscious casualty. However, students who find that being rolled into a recovery position that is painful are less likely to practice and are likely to be less motivated to use the technique. Significantly, in view of current anecdotal reports of injuries with the 97 position, no injuries to any student were reported during the study. With regard to the other ILCOR statements, both positions appear to offer a stable, lateral position, with maintenance and access to a clear airway, and with no cause of impairment to breathing. The results and student comments indicate that although both positions achieve this, there was a significant preference for the 92 position. The degree of stability with both positions was felt to be good however. A further important factor involves ease of learning and competency. There was a significant trend towards the 92 position being considered as easier to learn. However, assessment of the students’ practical ability showed no significant difference between the two positions during the teaching session. The three point competency scale is a relatively crude instrument for assessing skill levels, but the results do show that although students prefer the 92 position, they are capable of placing casualties in either position successfully. Further studies would certainly benefit from a better definition of skill level to clarify this. Another factor which was not investigated during this study was skill retention. Anecdotal information from the different hospitals has shown poorer retention of the 97 position when students attend for re-assessment. This is another area that would require further study.
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Possible sources of bias in the study, such as sex of the student, staff grade, previous training or tutor were investigated. Neither sex or previous training had any significant influence on preference. The latter was particularly surprising as the majority of students who had had previous training were trained with the 92 position, and would have been expected to prefer it through familiarity. Significant differences were seen between different groups of staff, with doctors, nurses and physiotherapists all being more critical in general of both techniques than non-clinical staff. However, the same, statistically significant trends in favour of the 92 position were seen in all groups. A similar situation was seen with different tutors. Each used their own teaching methods and there were differences in response between students in different hospitals. However, there was again a highly significant trend in favour of the 92 position in all cases for all questions as well as the combined scores. One interesting feature was that competency had no influence on student perception of the technique. Poor students were just as likely to mark either technique highly (or badly) as more competent or experienced students. This may reflect poor awareness by the students of their practical ability.
5. Conclusions This study was designed to compare the opinions of students being taught either the 92 or 97 recovery positions. Their answers to a series of questions based on the ILCOR advisory statements showed that there was a significant preference for the 92 position, which was felt to be easier to learn and use. It also appeared to offer better protection to the spine and to be faster in returning a casualty to a suitable position for CPR. Possible sources of bias such as staff grade, previous experience or tutor made no difference to these results. Despite a greater preference for the 92 position however, there was no significant difference in competency between the two groups at the end of their training. The 97 position was suggested in response to con-
cerns about restricted arm blood flow with the 92 position. The difficulties encountered with the 97 position imply that although it may be better for the arm when performed correctly, the other problems outweigh this advantage when taught to a wide range of hospital staff. The 92 position currently provides the best compromise between ease of use, spinal stability and other factors. Introduction of any modifications to this position should be tested in a general setting to ensure that as well as avoiding limb compression the technique also meets all of the other ILCOR advisory statements.
Acknowledgements Thanks go to Dr Alison Gammon and Dr Michael Ward for their help and support during the study. Thanks also go to Ron James for the excellent illustrations.
References [1] Basic Life Support Working Party of the European Resuscitation Council. Guidelines for basic life support. Resuscitation 1992;24:103 – 10. [2] Fulstow R, Smith GB. The new recovery position, a cautionary tale. Resuscitation 1993;26:89 – 91. [3] Rathgeber J, Panzer W, Gunther U, Scholz M, Hoeft A, Bahr J, Kettler D. Influence of different types of recovery positions on perfusion indices of the forearm. Resuscitation 1996;32:13–7. [4] Chamberlain DA, Cummins RO. Advisory statements of the International Liaison Committee on Resuscitation (ILCOR). Resuscitation 1997;34:99 – 100. [5] Handley AJ, Becker LB, Allen M, van Drenth A, Kramer EB, Montgomery WH. Single rescuer adult basic life support. Resuscitation 1997;34:101 – 8. [6] Resuscitation Council (UK). The 1997 Resuscitation guidelines for use in the United Kingdom. London: Resuscitation Council (UK), 1997:13. [7] Henerson ME, Morrison LL, Fitz-Gibbon CT. How to measure attitudes. California: Sage, 1987. [8] Burns N, Grove SK. The practice of nursing research. Philadelphia: WB Saunders, 1994. [9] Spector PE. Summated rating scale construction: an introduction. California: Sage, 1992.
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