Clinical paperQuantitative analysis of chest compression interruptions during in-hospital resuscitation of older children and adolescents☆
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.
References (32)
- et al.
CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system
Resuscitation
(2007) - et al.
Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study
Resuscitation
(2006) - et al.
Improving CPR performance using an audible feedback system suitable for incorporation into an automated external defibrillator
Resuscitation
(2003) - et al.
Decay in quality of closed-chest compressions over time
Ann Emerg Med
(1995) - et al.
Quality of chest compressions during 10 min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model
Resuscitation
(2008) - et al.
The effect on quality of chest compressions and exhaustion of a compression—ventilation ratio of 30:2 versus 15:2 during cardiopulmonary resuscitation—a randomized trial
Resuscitation
(2007) - et al.
Influence of chest compression rate guidance on the quality of cardiopulmonary resuscitation performed on manikins
Resuscitation
(2009) - et al.
Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest
Resuscitation
(2006) - et al.
Quality and efficiency of bystander CPR Belgian Cerebral Resuscitation Study Group
Resuscitation
(1993) - et al.
Skill mastery in cardiopulmonary resuscitation training classes
Am J Emerg Med
(1995)
Myocardial perfusion pressure: a predictor of 24-hour survival during prolonged cardiac arrest in dogs
Resuscitation
Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest
JAMA
Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents
Pediatrics
Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest
JAMA
The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support
Pediatrics
2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support
Pediatrics
Cited by (83)
Assessment of chest compression interruptions during advanced cardiac life support
2021, ResuscitationCitation Excerpt :A study by Sutton et al. found that even up to 41.2% of CPR no flow time was related to switching providers.24 However, using real-time CPR quality feedback systems during resuscitation, the authors found that a significant number of CPR providers was able to continue beyond the 2 min mark.24 As already stated in the ERC guidelines, the team leader should monitor the quality of CPR and alternate CPR providers only if the quality of CPR is poor.
A machine learning algorithm to improve patient-centric pediatric cardiopulmonary resuscitation
2020, Informatics in Medicine Unlocked
- ☆
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.