Elsevier

Resuscitation

Volume 110, January 2017, Pages 1-5
Resuscitation

Clinical paper
The impact of post-resuscitation feedback for paramedics on the quality of cardiopulmonary resuscitation

https://doi.org/10.1016/j.resuscitation.2016.08.034Get rights and content

Abstract

Purpose

The Guidelines place emphasis on high-quality cardiopulmonary resuscitation (CPR). This study aims to measure the impact of post-resuscitation feedback on the quality of CPR as performed by ambulance personnel.

Materials and methods

Two ambulances are dispatched for suspected cardiac arrest. The crew (driver and paramedic) of the first arriving ambulance is responsible for the quality of CPR. The crew of the second ambulance establishes an intravenous access and supports the first crew. All resuscitation attempts led by the ambulance crew of the study region were reviewed by two research paramedics and structured feedback was given based on defibrillator recording with impedance signal. A 12-months period before introduction of post-resuscitation feedback was compared with a 19-months period after introduction of feedback, excluding a six months run-in interval. Quality parameters were chest compression fraction (CCF), chest compression rate, longest peri-shock pause and longest non-shock pause.

Results

In the pre-feedback period 55 cases were analyzed and 69 cases in the feedback period. Median CCF improved significantly in the feedback period (79% vs 86%, p < 0.001). The mean chest compression rate was within the recommended range of 100–120/min in 87% of the cases in the pre-feedback period and in 90% of the cases in the feedback period (p = 0.65). The duration of longest non-shock pause decreased significantly (40 s vs 19 s, p < 0.001), the duration of the longest peri-shock pause did not change significantly (16 s vs 13 s, p = 0.27).

Conclusion

Post-resuscitation feedback improves the quality of resuscitation, significantly increasing CCF and decreasing the duration of longest non-shock pauses.

Introduction

The Guidelines of 2010 (and onward) emphasize the importance of high-quality cardiopulmonary resuscitation (CPR).1, 2 High quality CPR involves optimal compression depth and rate, avoiding leaning on the chest and minimizing interruptions of compressions for pre-shock rhythm analysis and charging, post-shock pauses and pauses for other measures such as intubation. Many pauses cannot be explained by mandated Advanced Life Support (ALS) activities but should be avoided as well.

Several studies of the quality of CPR as performed in hospitals and by emergency medical services (EMS), found that providers often did not perform CPR up to the standards for recommended rate, depth and minimizing pauses in chest compressions.3, 4, 5 A resuscitation attempt involves a complex set of actions and has to be carried out by multiple rescuers, often under suboptimal conditions. It is perhaps not surprising that providers not always perform CPR according to the standards because of these difficult conditions. Efforts to improve CPR performance by the use of real-time feedback of chest compression rate and depth have demonstrated improvements in CPR quality but did not yield improvements in clinical outcomes.6, 7, 8 Post-resuscitation feedback involves the evaluation of written run-reports, but also of the recorded tracings from the EMS defibrillator that offers objective data of crew performance.9, 10, 11, 12 Such post-resuscitation feedback is costly in terms of personnel involvement but could be justified as part of a program if it indeed results in quality improvement.

We studied the impact of post-resuscitation feedback on the quality of CPR performed by EMS personnel in the setting of a Dutch ambulance system.

Section snippets

Setting

The study took place in the southern region of Amsterdam. This area covers approximately 121 km2 and has a population of 157,443 people. The study group were ambulance crews (17 paramedics and 17 drivers) of a single operational unit, part of EMS Amsterdam and who attend most of out-of-hospital cardiac arrests (OHCA) occurring in this area.

EMS system in the study region

When the EMS dispatcher suspects an OHCA during an emergency call, the dispatcher sends out two ambulances from a single ALS tier and first responders (mostly

Results

During the study period, Amstelveen EMS attended 164 cases of OHCA as the first arriving ambulance crew. Due to a missing impedance signal, 16 cases could not be analyzed and 8 because of transmission failures. We also excluded 16 cases (1 pediatric OHCA, 6 patients who received an AED shock first, and ROSC before ambulance arrival and 9 resuscitation attempts were attended by external EMS personnel). We included 55 pre-feedback cases in the analysis and 69 cases in the feedback period (Fig. 1

Main findings

This study shows that after introduction of post-resuscitation feedback the quality of resuscitation improved: the CCF increased significantly from 79% to 86%, significantly more compressions from 81 to 93 were delivered in one minute and the duration of the longest non-shock pause decreased significantly from 40 s to 19 s. All these changes are associated with better outcome of resuscitation.16, 17, 18 In the pre-feedback and the feedback period the compression rate was already according to the

Limitations

Part of the explanation for these improvements could be a general change over time in this before–after study. During the pre-feedback period, which could be characterized as retrospective annotation, ambulance crews were not aware of the data analysis for the purpose of this study. In the years of the study (2011–2014) the 2010 ERC Guidelines on resuscitation were published with increasing focus on high quality CPR. Publications and conferences on high quality CPR could contribute to an

Conclusion

Post-resuscitation feedback improved the quality of resuscitation, especially increasing CCF and decreasing the duration of the longest non-shock pause.

Funding

RWK received funding for the ARREST data collection by an unconditional grant from Physio-Control Inc. (Redmond, WA, USA).

Conflict of interest statement

None.

Acknowledgements

We are greatly indebted to all participating ambulance crews of Amstelveen for their cooperation and efforts to improve OHCA accomplishments. The authors like to thank medical manager Pieternel van Exter and team manager Roelof Welvering for their encouragement and facilitation. We greatly appreciate the contributions of Loes Bekkers, Paulien Homma and Remy Stieglis to the data collection.

References (20)

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.08.034.

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