Elsevier

Resuscitation

Volume 80, Issue 11, November 2009, Pages 1259-1263
Resuscitation

Clinical paper
Quantitative analysis of chest compression interruptions during in-hospital resuscitation of older children and adolescents

https://doi.org/10.1016/j.resuscitation.2009.08.009Get rights and content

Abstract

Aim

To quantitatively describe pauses in chest compression (CC) delivery during resuscitation from in-hospital pediatric and adolescent cardiac arrest. We hypothesized that CPR error will be more likely after a chest compression provider change compared to other causes for pauses.

Methods

CPR recording/feedback defibrillators were used to evaluate CPR quality for victims ≥8 years who received CPR in the PICU/ED. Audiovisual feedback was supplied in accordance with AHA targets. Etiology of CC pauses identified by post-event debriefing/reviews of stored CPR quality data.

Results

Analysis yielded 205 pauses during 304.8 min of CPR from 20 consecutive cardiac arrests. Etiologies were: 57.1% for provider switch; 23.9% for pulse/rhythm analysis; 4.4% for defibrillation; and 14.6% “other.” Provider switch accounted for 41.2% of no-flow duration. Compared to other causes, CPR epochs following pauses due to provider switch were more likely to have measurable residual leaning (OR: 5.52; CI95: 2.94, 10.32; p < 0.001) and were shallower (43 ± 8 vs. 46 ± 7 mm; mean difference: −2.42 mm; CI95: −4.71, −0.13; p = 0.04). Individuals performing continuous CPR  120 s as compared to those switching earlier performed deeper chest compressions (42 ± 6 vs. 38 ± 7 mm; mean difference: 4.44 mm; CI95: 2.39, 6.49; p < 0.001) and were more compliant with guideline depth recommendations (OR: 5.11; CI95: 1.67, 15.66; p = 0.004).

Conclusions

Provider switches account for a significant portion of no-flow time. Measurable residual leaning is more likely after provider switch. Feedback systems may allow some providers to continue high quality CPR past the recommended switch time of 2 min during in-hospital resuscitation attempts.

Introduction

In an attempt to improve the quality of cardiopulmonary resuscitation (CPR) delivered during cardiac arrest, quantitative CPR monitoring systems have been developed and deployed during adolescent and adult resuscitation.1, 2, 3, 4, 5 These quality CPR or Q-CPR devices record objective data on CPR quality and provide real-time automated audiovisual corrective feedback to the rescuer through interface with defibrillator systems.6 CPR quality and short term outcomes have been improved during both simulated and actual cardiac arrests with this technology.2, 3

Current CPR guidelines recommend provider switches approximately every 2 min7, 8 to limit the decrement in CPR quality over time that is observed with rescuer fatigue.9, 10, 11, 12 However, as provider switches interrupt chest compression delivery (more pauses), this practice is likely at odds with the competing recommendation to limit the no-flow time during resuscitation (i.e., the time without spontaneous circulation or chest compression delivery). As the limitation of no-flow time is of particular importance in improving outcomes from cardiac arrest,13 these recommendations merit further in-depth quantitative examination.

Utilizing Q-CPR technology, the objective of this study is to quantitatively describe the pauses in chest compression (CC) delivery that occur during the resuscitation from in-hospital pediatric and adolescent cardiac arrest. We hypothesized that substandard CPR quality will be more likely to occur immediately after a change in chest compression provider compared to other causes for pauses in chest compression delivery.

Section snippets

Protocol/consent

This investigation is a prospective observational study with the primary objective being to quantitatively evaluate the pauses in chest compression delivery that occur during the resuscitation from pediatric and adolescent cardiac arrest. The study protocol including consent procedures was approved by the Institutional Review Board at The Children's Hospital of Philadelphia. Data collection procedures were completed in compliance with the guidelines of the Health Insurance Portability and

Description of chest compression pauses

The analysis yielded 205 pauses (median number per arrest: n = 9, IQR 6–14; total no-flow time: 2037.9 s; no-flow fraction: 11.1%; median pause duration: 4.4 s, IQR 2.5–10.6 s) identified during 304.8 min of CPR from 20 consecutive cardiac arrests (median resuscitation duration: 11.8 min, IQR 8.0–19.8 min). The cause for the chest compression pauses were as follows: 57.1% (117/205) for chest compression provider switch (median duration: 3.4 s; IQR 2.0–6.3 s); 23.9% (49/205) for pulse/rhythm analysis

Discussion

This study represents the first in-depth analysis of chest compression pauses during in-hospital pediatric and adolescent resuscitation, and the CPR error attributed to chest compression provider switches. These data establish that the majority of pauses are for provider switch and that these interruptions account for almost half of the total no-flow time. Measurable residual force (incomplete release) was more likely immediately after chest compression provider switch compared to other causes

Conclusions

This prospective observational study establishes that the majority of pauses during the resuscitation from pediatric and adolescent in-hospital cardiac arrests are for provider switch and that these interruptions account for almost half of the total no-flow time. Moreover, the period immediately after chest compression provider switch was a high-risk time for poor quality CPR. With CPR feedback systems deployed, many providers were able to continue high quality CPR for longer than 2 min;

Conflict of interest

The authors acknowledge the following potential conflicts of interest. Vinay Nadkarni, Dana Niles, Matt Maltese, Kristy Arbogast, Aaron Donoghue, and Robert Sutton receive unrestricted research grant support from the Laerdal Foundation for Acute Care Medicine.

Acknowledgements

This study was supported by a Laerdal Medical Foundation Center of Excellence Grant and the Endowed Chair of Pediatric Critical Care Medicine at the Children's Hospital of Philadelphia. We would like to thank all members of the Pediatric Intensive Care Unit and Emergency Department multidisciplinary team at CHOP, Stephanie Tuttle and Terrilynn Honesty for administrative assistance, and Helge Myklebust for manuscript review.

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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.2009.08.009.

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