Clinical paperDoes an individualized feedback mechanism improve quality of out-of-hospital CPR?☆
Introduction
Out-of-hospital cardiac arrest presents a major public health problem in the United States with over 400,000 cases per year.1 Despite its prevalence, survival from out-of-hospital cardiac arrest remains low with only 10.4% surviving to hospital discharge.1 Although many prehospital providers are trained on the key aspects of successful CPR including high quality compressions with minimal interruptions and short pre-shock pauses, poor quality CPR continues to be reported.2, 3, 4 It is now possible to conduct in-depth evaluation of EMS providers CPR performance on actual patients using either stand alone devices or devices integrated into the cardiac monitoring system, but the effect of providing this feedback on future performance is unknown.
Several modifiable factors related to quality of CPR have been shown to improve short-term and long-term outcomes in cardiac arrest. Among these, early defibrillation, greater compression fraction (percentage of time in which compressions are taking place during the resuscitation), optimal compression rate, sufficient compression depth, and shorter pre-shock pause have all been found to be associated with survival in cardiac arrest patients.3, 5, 6, 7 In out-of-hospital cardiac arrest patients in the shockable rhythms of ventricular fibrillation (VF) or ventricular tachycardia (VT), a compression fraction over 60% was associated with higher survival to time of discharge.5 In both in-hospital (IHCA) as well as out-of-hospital cardiac arrest (OHCA) in patients with VF, defibrillation was more likely to be successful in obtaining return of spontaneous circulation (ROSC) in cases with shorter pre-shock pauses and increased mean compression depth in the time period immediately preceding defibrillation.6 In fact, subsequent research found that in all OHCA patients, compression depth greater than 38 mm had improved rates of ROSC, one day survival, and survival to discharge.3 Furthermore, compression rates of 125 compressions per minute were associated with increased rates of ROSC in all rhythm OHCA patients as compared to lower compression rates.7 Each of these studies has demonstrated that high quality CPR is related to improved patient outcomes.
In late 2013 and early 2014, a program was initiated by Milwaukee County Emergency Medical Services (MCEMS) to provide feedback on CPR quality metrics to prehospital basic life support (BLS) and advanced life support (ALS) providers after every cardiac arrest they treated. This feedback was provided on a paper document (Fig. 1) that delineated evidence based goals for CPR quality metrics including compression fraction, compression rate, compressions depth, and pre-shock pause and compared their performance during a specific resuscitation to those goals. The goal of this study is to assess whether the provision of individual CPR feedback was associated with an increased percentage of patient encounters that met CPR quality metric goals or improved metric averages in the prehospital setting. We hypothesized that the percent of patient encounters that met preset goals for each of four CPR metrics would increase after implementation of the CPR feedback program.
Section snippets
Study design
A before and after retrospective review was conducted. This study was approved by the Institutional Review Board through the Medical College of Wisconsin.
Population and setting
This study was performed using data from a midsize metropolitan EMS system in the United States. Milwaukee, WI has a population of about 600,000 individuals spread over about 97 square miles. The EMS system is fire-based and includes both EMT (BLS) and paramedic (ALS) level providers. Care in the system is supplemented by several private
Results
During the before period there were 175 adult cardiac arrest patient encounters. Of these, 17 were excluded due to insufficient or corrupted data. In total, 158 patient encounters were evaluated in the before group from 103 ALS providers and 55 BLS providers with 116 individual patients, as several patients had separate encounters from BLS and then ALS providers. During the after period there were 137 adult cardiac arrest patient encounters with 20 excluded due to insufficient or corrupted
Discussion
In this study, we found marginal improvements in CPR quality after the initiation of individual CPR feedback for ALS and BLS providers. This suggests that giving providers direct feedback on each individual resuscitation may lead to improved CPR quality. Unfortunately, this study was not powered to determine if there were changes in survival, but based on prior research there is potential that survival rates would increase with improved CPR quality.3, 5, 6, 7
The most notable improvements were
Conclusion
We found that the provision of a CPR feedback form was associated with improvement in the quality of CPR in relation to compression rate and depth. Further investigation with larger samples is warranted to better quantify these findings. Nevertheless, our results suggest a value for CPR quality feedback provision to prehospital EMS providers.
Conflict of interest statement
None.
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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.2017.02.004.