Elsevier

Resuscitation

Volume 80, Issue 9, September 2009, Pages 981-984
Resuscitation

Clinical paper
Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: A prospective multicenter study

https://doi.org/10.1016/j.resuscitation.2009.06.002Get rights and content

Abstract

Background

Rescuer fatigue during cardiopulmonary resuscitation (CPR) is a likely contributor to variable CPR quality during clinical resuscitation efforts, yet investigations into fatigue and CPR quality degradation have only been performed in simulated environments, with widely conflicting results.

Objective

We sought to characterize CPR quality decay during actual in-hospital cardiac arrest, with regard to both chest compression (CC) rate and depth during the delivery of CCs by individual rescuers over time.

Methods

Using CPR recording technology to objectively quantify CCs and provide audiovisual feedback, we prospectively collected CPR performance data from arrest events in two hospitals. We identified continuous CPR “blocks” from individual rescuers, assessing CC rate and depth over time.

Results

135 blocks of continuous CPR were identified from 42 cardiac arrests at the two institutions. Median duration of continuous CPR blocks was 112 s (IQR 101–122). CC rate did not change significantly over single rescuer performance, with an initial mean rate of 105 ± 11/min, and a mean rate after 3 min of 106 ± 9/min (p = NS). However, CC depth decayed significantly between 90 s and 2 min, falling from a mean of 48.3 ± 9.6 mm to 46.0 ± 9.0 mm (p = 0.0006) and to 43.7 ± 7.4 mm by 3 min (p = 0.002).

Conclusions

During actual in-hospital CPR with audiovisual feedback, CC depth decay became evident after 90 s of CPR, but CC rate did not change. These data provide clinical evidence for rescuer fatigue during actual resuscitations and support current guideline recommendations to rotate rescuers during CC delivery.

Introduction

The provision of high quality chest compressions (CCs) is a crucial component of cardiopulmonary resuscitation (CPR) and the successful treatment of cardiac arrest. For example, recent work has demonstrated that return of spontaneous circulation (ROSC) from in-hospital cardiac arrest was associated with higher CC rates,1 a finding consistent with earlier out-of-hospital studies of CPR quality.2, 3, 4 Other investigations have revealed improved outcomes associated with greater CC depth.5, 6 Recently, the American Heart Association released a statement endorsing “hands only” CPR for bystanders comprised solely of CCs, which highlights the importance of this potentially life-saving skill.7 However, CCs are physically demanding and it has been generally assumed that rescuer fatigue can lead to degradation in compression quality.8, 9

Over the past several decades, a number of simulation studies have attempted to characterize rescuer fatigue during CPR with widely varying results.10, 11, 12, 13 One such investigation among hospital staff found that rescuers fatigue quickly and that CC depth degrades after only 1 min of CPR delivery.10 Another manikin study found CPR quality decay within 3 min of CPR.11 In stark contrast, a recent paramedic study found that CPR could be performed for as long as 10 min without falling below CPR guideline recommendations.12

Furthermore, all of these studies were conducted in simulated settings using CPR manikins. Therefore, these investigations may not accurately reflect CPR performance during actual cardiac arrests, during which factors such as rescuer stress, motivation and other parameters may directly impact CPR quality. In addition, chest compliance varies both within manikins and in comparison to people. However, no data exist to date on changes in resuscitation quality over time during actual CPR delivery.

Section snippets

Methods

Using recently developed CPR sensing technology incorporated into clinical monitor/defibrillators with real-time audiovisual feedback, we conducted a multicenter study of changes in CC quality among individual rescuers over time during actual in-hospital resuscitation efforts. This prospective collection of cardiac arrest data was approved by the Institutional Review Boards (IRBs) of the University of Pennsylvania and the University of Chicago. All data were appropriately collected in a manner

Results

A total of 135 uninterrupted blocks of CCs with duration >90 s were identified from the cohort of 42 arrest episodes. The combined baseline characteristics of patients are shown in Table 1. Resuscitation characteristics of cardiac arrest episodes and continuous blocks of CCs are summarized in Table 2, analyzed individually for each hospital to evaluate for differences in CPR performance between institutions. The median (IQR) arrest duration was very similar for both institutions (18.3 (8.4–23.7)

Discussion

We demonstrated a decrease in CC depth over time for a single rescuer starting at 90 s of CPR, without any change in CC rate, during actual in-hospital resuscitations in which real-time audiovisual feedback was provided. To our knowledge, this study represents the first to evaluate decay in CC quality (commonly associated with rescuer fatigue) during actual in-hospital cardiac arrest resuscitation efforts.

Our results stand in contrast to some of the previous studies on rescuer fatigue during

Conclusion

In this multicenter clinical investigation, we demonstrated a moderate but statistically significant decay in chest compression depth over 3 min of in-hospital CPR from a cohort of individual rescuers, starting after 90 s, under conditions of automated CPR audiovisual feedback. Further work will be required to determine the clinical significance of this decay. However, these data provide clinical evidence for rescuer fatigue during actual resuscitations and support the need to rotate rescuers

Conflict of interest

This study was funded by Philips Healthcare, which had no role in the design and conduct of the study or analysis of the findings. In addition to research funding, Drs. Edelson, Abella, and Becker have received honoraria and consulting fees from Philips Healthcare. Dr. Abella has additionally received consulting fees from Cardiac Science Corporation; Dr. Becker has received research funding from Laerdal Medical Corporation. Drs. Edelson and Abella have received research funding from the

Acknowledgements

The authors wish to thank the dedicated housestaff and nurses at the University of Pennsylvania and University of Chicago for their dedication to the care of cardiac arrest patients and their willingness to participate in our research efforts.

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    Citation Excerpt :

    Similarly, our study found that compressions that fell out of target depth were usually too shallow and compressions that fell out of target rate were largely due to being too fast. A recent study showed that chest compression depth began to decrease after 90–120 s of CPR, but compression rate does not decrease accordingly (28). A possible hypothesis for low CiT and high CCF is that higher CCF could be related to fewer rescuer switches, possibly leading to rescuer fatigue and resulting in lower-quality compressions (20).

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.06.002.

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