Elsevier

Resuscitation

Volume 113, April 2017, Pages 96-100
Resuscitation

Clinical paper
Does an individualized feedback mechanism improve quality of out-of-hospital CPR?

https://doi.org/10.1016/j.resuscitation.2017.02.004Get rights and content

Abstract

Background

Despite its prevalence, survival from out-of-hospital cardiac arrest remains low. High quality CPR has been associated with improved survival in cardiac arrest patients. In early 2014, a program was initiated to provide feedback on CPR quality to prehospital providers after every treated cardiac arrest.

Objective

To assess whether individualized CPR feedback was associated with improved CPR quality measures in the prehospital setting.

Methods

This before and after retrospective review included all treated adult out-of-hospital cardiac arrest in patients in an urban community. Data was compared prior to and after the initiation of the CPR feedback program. We compared the percent of encounters reaching the system defined benchmarks as well as the average values for compression fraction, compression rate, compression depth, and pre-shock pause in the before period compared to the after period.

Results

There were 159 encounters in the before period and 117 in the after. Compared to the before group, the after group had higher average compression rates (111.2/min vs 113.8/min; p = 0.042), increased compression depths (4.9 cm vs 5.6 cm; p < 0.001), and increased rates of benchmark achievement for compression depth greater than 5 cm (48.1% vs 72.6%; p < 0.001). No significant difference was noted in pre-shock pause (21.4 s vs 14.7 s; p = 0.068). Additionally, no difference was noted between groups for compression fraction, though goal achievement was high in both groups.

Conclusion

We found that individual CPR feedback is associated with marginally improved quality of CPR in the prehospital setting. Further investigation with larger samples is warranted to better quantify this effect.

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.

References (19)

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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.

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