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In-hospital chest compressions—The patient on a bed
Resuscitation 83 (2012) 795–796
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
In-hospital chest compressions—The patient on a bed
Basic life support (BLS) guidelines have, in the main, been designed to be easily taught to and remembered by lay members of the public as well as being suitable for healthcare professionals. To this end, simplification has been in the forefront of the minds of those responsible for previous and current guidelines. But has the need for simplification resulted in less-than-ideal CPR when performed by healthcare professionals? It has been clearly shown that the performance of CPR in hospital is not perfect.1 The introduction in recent years of ‘seamless’ basic and advanced guidelines for in-hospital resuscitation has allowed a more flexible approach to BLS,2 and has raised the question of what is the optimum way to perform CPR, particularly chest compression. Most in-hospital CPR is performed with the patient lying in bed on a mattress. This often results in chest compressions which are too shallow.3 Feedback devices should help, but the presence of a mattress renders most of these inaccurate, and adding a bed board is of limited value.4 One possible solution might be to use dual accelerometer devices. This has been shown (on a manikin) to produce more accurate feedback,5 but such technology is not yet fully developed and available. Based on mathematical modelling, it has been suggested that adequate compression could be better taught by reference to the force required, rather than the distance moved.6 Since all guidelines to date have referred to depth of compression, this would be a change of considerable proportion. A more pragmatic solution to the problem might be to train operators to increase their target compression depth by 1.5 cm when resuscitating a patient on a mattress.7 But bed surface is not the only consideration. The height of the operator in relation to the position of the patient has been shown to have a considerable influence on the quality of CPR. Shorter operators are unable to produce as great a compression depth as taller operators.8 Hospital beds can be adjusted, but even at their lowest the patient is still typically about 60 cm off the floor. One answer to this problem could be for the operator to stand on a stool by the side of the bed. Edelson and her colleagues have put this solution to the test in a cross-over, manikin simulation, and their report is in this issue of the journal.9 They found that the use of a step-stool increased the average chest compression depth by a rather modest 4 mm, but at the cost of an 18% increase in incomplete chest recoil. For shorter operators, the advantages did seem to outweigh the disadvantages. One problem, however, was that the study was carried out using the 2005 guideline of 4–5 cm compression depth, and many participants failed to reach even this, let alone the current (2010) recommendation of at least 5 cm depth. Perhaps more significant is that each operator was tested with the 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2012.03.019
manikin placed at a set height above the ground (63.5 cm) and used a step-stool of fixed height (23 cm). Although the participants were divided into three height bands, this does not answer the question, what is the ideal position for an individual operator? Three studies, each manikin simulations, have related quality of CPR more precisely to the position of the manikin relative to the height of the operator.10–12 All three concluded that the manikin should be at about the level of the operator’s knees, preferably with the operator kneeling rather than standing in order to reduce fatigue to a minimum.11 There may be circumstances when it is practical and safe to move a patient onto the floor, but this is not an ideal solution. An operator could kneel on the patient’s bed,13 perhaps using either the ‘over-the-head’ or ‘straddle’ technique14 rather than kneeling at the patient’s side, but this still raises health and safety issues. So what is the solution? It certainly seems that individuals performing CPR on a patient on a hospital bed should attempt to ensure that the patient’s back is at the level of their knees. Step stools, preferably with height adjustment, should be provided as part of a ward’s emergency equipment. The bed should then be adjusted for the individual operator, always ensuring that CPR is not interrupted. Once at the right level, operators should ensure that chest compressions are at the full depth of at least 5 cm, increasing this to at least 6.5 cm if the patient is lying on a mattress. There should then be complete release of pressure between compressions. Conflicts of interest None. References 1. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305–10. 2. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39–86. 3. Koster RW, Sayre MR, Botha M, et al. 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 5: adult basic life support. Resuscitation 2010;81S:e48–70. 4. Perkins GD, Kocierz L, Smith CL, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation 2008;80:79–82. 5. Nishisaki A, Nysaether J, Sutton R, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation 2009;80:540–5. 6. Boe JM, Babbs CF. Mechanisms of cardiopulmonary resuscitation performed with the patient on a soft bed vs a hard surface. Acad Emerg Med 1999;6:754–7. 7. Monsieurs KG. Chest compression on mattresses: time to achieve sufficient depth. Resuscitation 2009;80:503–4.
796
Editorial / Resuscitation 83 (2012) 795–796
8. Larsen PD, Perrin K, Galletly DC. Patterns of external chest compression. Resuscitation 2002;53:281–7. 9. Edelson DP, Call SL, Yuen TC, Vanden Hoek TL. The impact of a step-stool on cardiopulmonary resuscitation: a mannequin study. Resuscitation 2012;83: 874–8. 10. Cho J, Oh JH, Park YS, Park IC, Chung SP. Effects of bed height on the performance of chest compressions. Emerg Med J 2009;26:807–10. 11. Foo N-P, Chang J-H, Lin H-J, Guo H-R. Rescuer fatigue and cardiopulmonary resuscitation positions: a randomized controlled crossover trial. Resuscitation 2010;81:579–84. 12. Lewinsohn A, Sherren PB, Wijayatilake DS. The effects of bed height and time on the quality of chest compressions delivered during cardiopulmonary resuscitation: a randomized crossover simulation study. Emerg Med J 2011, doi:10.1136/emermed-2011-200416.
13. Sherren PB, Lewinsohn A, Wijayatilake DS. Effects of bed height on the performance of chest compressions: clinical application of results. Emerg Med J 2011;28:171. 14. Handley AJ, Handley JA. Performing chest compressions in a confined space. Resuscitation 2004;61:55–61.
Anthony J. Handley 40 Queens Road, Colchester, United Kingdom E-mail address: [email protected] 14 March 2012
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
In-hospital chest compressions—The patient on a bed
Basic life support (BLS) guidelines have, in the main, been designed to be easily taught to and remembered by lay members of the public as well as being suitable for healthcare professionals. To this end, simplification has been in the forefront of the minds of those responsible for previous and current guidelines. But has the need for simplification resulted in less-than-ideal CPR when performed by healthcare professionals? It has been clearly shown that the performance of CPR in hospital is not perfect.1 The introduction in recent years of ‘seamless’ basic and advanced guidelines for in-hospital resuscitation has allowed a more flexible approach to BLS,2 and has raised the question of what is the optimum way to perform CPR, particularly chest compression. Most in-hospital CPR is performed with the patient lying in bed on a mattress. This often results in chest compressions which are too shallow.3 Feedback devices should help, but the presence of a mattress renders most of these inaccurate, and adding a bed board is of limited value.4 One possible solution might be to use dual accelerometer devices. This has been shown (on a manikin) to produce more accurate feedback,5 but such technology is not yet fully developed and available. Based on mathematical modelling, it has been suggested that adequate compression could be better taught by reference to the force required, rather than the distance moved.6 Since all guidelines to date have referred to depth of compression, this would be a change of considerable proportion. A more pragmatic solution to the problem might be to train operators to increase their target compression depth by 1.5 cm when resuscitating a patient on a mattress.7 But bed surface is not the only consideration. The height of the operator in relation to the position of the patient has been shown to have a considerable influence on the quality of CPR. Shorter operators are unable to produce as great a compression depth as taller operators.8 Hospital beds can be adjusted, but even at their lowest the patient is still typically about 60 cm off the floor. One answer to this problem could be for the operator to stand on a stool by the side of the bed. Edelson and her colleagues have put this solution to the test in a cross-over, manikin simulation, and their report is in this issue of the journal.9 They found that the use of a step-stool increased the average chest compression depth by a rather modest 4 mm, but at the cost of an 18% increase in incomplete chest recoil. For shorter operators, the advantages did seem to outweigh the disadvantages. One problem, however, was that the study was carried out using the 2005 guideline of 4–5 cm compression depth, and many participants failed to reach even this, let alone the current (2010) recommendation of at least 5 cm depth. Perhaps more significant is that each operator was tested with the 0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2012.03.019
manikin placed at a set height above the ground (63.5 cm) and used a step-stool of fixed height (23 cm). Although the participants were divided into three height bands, this does not answer the question, what is the ideal position for an individual operator? Three studies, each manikin simulations, have related quality of CPR more precisely to the position of the manikin relative to the height of the operator.10–12 All three concluded that the manikin should be at about the level of the operator’s knees, preferably with the operator kneeling rather than standing in order to reduce fatigue to a minimum.11 There may be circumstances when it is practical and safe to move a patient onto the floor, but this is not an ideal solution. An operator could kneel on the patient’s bed,13 perhaps using either the ‘over-the-head’ or ‘straddle’ technique14 rather than kneeling at the patient’s side, but this still raises health and safety issues. So what is the solution? It certainly seems that individuals performing CPR on a patient on a hospital bed should attempt to ensure that the patient’s back is at the level of their knees. Step stools, preferably with height adjustment, should be provided as part of a ward’s emergency equipment. The bed should then be adjusted for the individual operator, always ensuring that CPR is not interrupted. Once at the right level, operators should ensure that chest compressions are at the full depth of at least 5 cm, increasing this to at least 6.5 cm if the patient is lying on a mattress. There should then be complete release of pressure between compressions. Conflicts of interest None. References 1. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305–10. 2. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39–86. 3. Koster RW, Sayre MR, Botha M, et al. 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 5: adult basic life support. Resuscitation 2010;81S:e48–70. 4. Perkins GD, Kocierz L, Smith CL, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation 2008;80:79–82. 5. Nishisaki A, Nysaether J, Sutton R, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation 2009;80:540–5. 6. Boe JM, Babbs CF. Mechanisms of cardiopulmonary resuscitation performed with the patient on a soft bed vs a hard surface. Acad Emerg Med 1999;6:754–7. 7. Monsieurs KG. Chest compression on mattresses: time to achieve sufficient depth. Resuscitation 2009;80:503–4.
796
Editorial / Resuscitation 83 (2012) 795–796
8. Larsen PD, Perrin K, Galletly DC. Patterns of external chest compression. Resuscitation 2002;53:281–7. 9. Edelson DP, Call SL, Yuen TC, Vanden Hoek TL. The impact of a step-stool on cardiopulmonary resuscitation: a mannequin study. Resuscitation 2012;83: 874–8. 10. Cho J, Oh JH, Park YS, Park IC, Chung SP. Effects of bed height on the performance of chest compressions. Emerg Med J 2009;26:807–10. 11. Foo N-P, Chang J-H, Lin H-J, Guo H-R. Rescuer fatigue and cardiopulmonary resuscitation positions: a randomized controlled crossover trial. Resuscitation 2010;81:579–84. 12. Lewinsohn A, Sherren PB, Wijayatilake DS. The effects of bed height and time on the quality of chest compressions delivered during cardiopulmonary resuscitation: a randomized crossover simulation study. Emerg Med J 2011, doi:10.1136/emermed-2011-200416.
13. Sherren PB, Lewinsohn A, Wijayatilake DS. Effects of bed height on the performance of chest compressions: clinical application of results. Emerg Med J 2011;28:171. 14. Handley AJ, Handley JA. Performing chest compressions in a confined space. Resuscitation 2004;61:55–61.
Anthony J. Handley 40 Queens Road, Colchester, United Kingdom E-mail address: [email protected] 14 March 2012