Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role

A smartwatch-based CPR feedback device improves chest compression quality among health care professionals and lay rescuers

Background

Cardiopulmonary resuscitation (CPR) quality significantly impacts patient outcomes during cardiac arrests. With advancements in health care technology, smartwatch-based CPR feedback devices have emerged as potential tools to enhance CPR delivery.

Objective

This study evaluated a novel smartwatch-based CPR feedback device in enhancing chest compression quality among health care professionals and lay rescuers.

Methods

A single-center, open-label, randomized crossover study was conducted with 30 subjects categorized into 3 groups based on rescuer category. The Relay Response BLS smartwatch application was compared to a defibrillator-based feedback device (Zoll OneStep CPR Pads). Following an introduction to the technology, subjects performed chest compressions in 3 modules: baseline unaided, aided by the smartwatch-based feedback device, and aided by the defibrillator-based feedback device. Outcome measures included effectiveness, learnability, and usability.

Results

Across all groups, the smartwatch-based device significantly improved mean compression depth effectiveness (68.4% vs 29.7%; P < .05) and mean rate effectiveness (87.5% vs 30.1%; P < .05), compared to unaided compressions. Compression variability was significantly reduced with the smartwatch-based device (coefficient of variation: 14.9% vs 26.6%), indicating more consistent performance. Fifteen of 20 professional rescuers reached effective compressions using the smartwatch-based device in an average 2.6 seconds. A usability questionnaire revealed strong preference for the smartwatch-based device over the defibrillator-based device.

Conclusion

The smartwatch-based device enhances the quality of CPR delivery by keeping compressions within recommended ranges and reducing performance variability. Its user-friendliness and rapid learnability suggest potential for widespread adoption in both professional and lay rescuer scenarios, contributing positively to CPR training and real-life emergency responses.

Bilingual resuscitation training does not affect adherence to resuscitation guidelines but reduces leadership skills and overall team performance. An observational study with cross-border German-Polish training

Aim of study

This study aims to investigate feasibility and quality of a bilingual cardiopulmonary resuscitation training with interprofessional emergency teams from Germany and Poland.

Methods

As part of a cross-border European Territorial Cooperation (Interreg-VA) funded project a combined communication and simulation training was organised. Teams of German and Polish emergency medicine personnel jointly practised resuscitation. The course was held in both languages with consecutive translation.Quality of chest compression was assessed using a simulator with feedback application. Learning objectives (quality of cardiopulmonary resuscitation, adherence to guidelines, closed loop communication), and team performance were assessed by an external observer. Coopeŕs Team Emergency Assessment Measure questionnaire was used.

Results

Twenty-one scenarios with 17 participants were analysed. In all scenarios, defibrillation and medication were delivered with correct dosage and at the right time. Mean fraction of correct hand position was 85.7% ± 25.7 [95%-CI 74.0; 97.4], mean fraction of compression depth 75.1% ± 21.0 [95%-CI 65.6; 84.7], compression rate 117.7 min-1 ± 7.1 [95%-CI 114.4; 120.9], and chest compression fraction 83.3% ± 3.8 [95%-CI 81.6; 85.0].Quality of cardiopulmonary resuscitation was rated as "fair" to "good", adherence to guidelines as "good", and closed loop communication as "fair". Bilingual teams demonstrated good situational awareness, but lack of leadership and suboptimal overall team performance.

Conclusion

Bilingual and interprofessional cross-border resuscitation training in German and Polish tandem teams is feasible. It does not affect quality of technical skills such as high-quality chest compression but does affect performance of non-technical skills (e.g. closed loop communication and leadership).

Pediatric Cardiac Arrest and Resuscitation

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

Pediatric Chest Compression Improvement Via Augmented Reality Cardiopulmonary Resuscitation Feedback in Community General Emergency Departments: A Mixed-Methods Simulation-Based Pilot Study

BACKGROUND

Yearly, more than 20,000 children experience a cardiac arrest. High-quality pediatric cardiopulmonary resuscitation (CPR) is generally challenging for community hospital teams, where pediatric cardiac arrest is infrequent. Current feedback systems are insufficient. Therefore, we developed an augmented reality (AR) CPR feedback system for use in many settings.

OBJECTIVE

We aimed to evaluate whether AR-CPR improves chest compression (CC) performance in non-pediatric-specialized community emergency departments (EDs).

METHODS

We performed an unblinded, randomized, crossover simulation-based study. A convenience sample of community ED nonpediatric nurses and technicians were included. Each participant performed three 2-min cycles of CC during a simulated pediatric cardiac arrest. Participants were randomized to use AR-CPR in one of three CC cycles. Afterward, participants participated in a qualitative interview to inquire about their experience with AR-CPR.

RESULTS

Of 36 participants, 18 were randomized to AR-CPR in cycle 2 (group A) and 18 were randomized to AR-CPR in cycle 3 (group B). When using AR-CPR, 87-90% (SD 12-13%) of all CCs were in goal range, analyzed as 1-min intervals, compared with 18-21% (SD 30-33%) without feedback (p < 0.001). Analysis of qualitative themes revealed that AR-CPR may be usable without a device orientation, be effective at cognitive offloading, and reduce anxiety around and enhance confidence in the CC delivered.

CONCLUSIONS

The novel CPR feedback system, AR-CPR, significantly changed the CC performance in community hospital non-pediatric-specialized general EDs from 18-21% to 87-90% of CC epochs at goal. This study offers preliminary evidence suggesting AR-CPR improves CC quality in community hospital settings.

Data-informed debriefing for cardiopulmonary arrest: A randomized controlled trial

Aim

To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest.

Methods

We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions.

Results

A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups.

Conclusion

When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.

Data-driven resuscitation training using pose estimation

BACKGROUND

Cardiopulmonary resuscitation (CPR) training improves CPR skills while heavily relying on feedback. The quality of feedback can vary between experts, indicating a need for data-driven feedback to support experts. The goal of this study was to investigate pose estimation, a motion detection technology, to assess individual and team CPR quality with the arm angle and chest-to-chest distance metrics.

METHODS

After mandatory basic life support training, 91 healthcare providers performed a simulated CPR scenario in teams. Their behaviour was simultaneously rated based on pose estimation and by experts. It was assessed if the arm was straight at the elbow, by calculating the mean arm angle, and how close the distance between the team members was during chest compressions, by calculating the chest-to-chest distance. Both pose estimation metrics were compared with the expert ratings.

RESULTS

The data-driven and expert-based ratings for the arm angle differed by 77.3%, and based on pose estimation, 13.2% of participants kept the arm straight. The chest-to-chest distance ratings by expert and by pose estimation differed by 20.7% and based on pose estimation 63.2% of participants were closer than 1 m to the team member performing compressions.

CONCLUSIONS

Pose estimation-based metrics assessed learners' arm angles in more detail and their chest-to-chest distance comparably to expert ratings. Pose estimation metrics can complement educators with additional objective detail and allow them to focus on other aspects of the simulated CPR training, increasing the training's success and the participants' CPR quality.

TRIAL REGISTRATION

Not applicable.

The influence of the simulation environment on teamwork and cognitive load in novice trauma professionals at the emergency department: Piloting a randomized controlled trial

INTRODUCTION

This pilot study aimed to test the feasibility of conducting a randomized controlled trial to examine how simulation environments (in situ versus laboratory) influence teamwork skills development and cognitive load among novice healthcare trauma professionals in the emergency department.

METHOD

Twenty-four novice trauma professionals (nurses, medical residents, respiratory therapists) were assigned to in situ or laboratory simulations. They participated in two 15-minute simulations separated by a 45-minute debriefing on teamwork. After each simulation, they completed validated teamwork and cognitive load questionnaires. All simulations were video recorded to assess teamwork performance by trained external observers. Feasibility measures (e.g., recruitment rate, randomization procedure and intervention implementation) were recorded. Mixed ANOVAs were used to calculate effect sizes.

RESULTS

Regarding feasibility, several difficulties were encountered, such as a low recruitment rate and the inability to perform randomization. Outcome results suggest that the simulation environment does not affect novice trauma professionals' teamwork performance and cognitive load (small effect sizes), but a large effect size was observed for perceived learning.

CONCLUSION

This study highlights several barriers to conducting a randomized study in the context of interprofessional simulation-based education in the emergency department. Suggestions are made to guide future research in the field.

The Use of the Borg Rating of Perceived Exertion Scale in Cardiopulmonary Resuscitation

BACKGROUND

A cardiopulmonary arrest is a critical event whose survival rate is related to the quality of resuscitation maneuvers combined with the use of technology. It is important to understand the perception of fatigue during this procedure, aiming to improve the effectiveness of compressions to increase the chances of survival.

OBJECTIVES

To apply the Borg rating of perceived exertion scale (Borg scale) to analyze the exertion perceived by nurses during cardiopulmonary resuscitation maneuvers using a feedback device.

METHODS

Experimental study with a randomized distribution of nurses in a teaching hospital. Perceived exertion during simulated cardiopulmonary resuscitation with/without a feedback device was assessed using the Borg scale. The statistical significance level of 5% was adopted.

RESULTS

69 nurses working in critical and non-critical adult care units were included. Perceived exertion and heart rate were lower in the intervention group (p<0.001), influenced by the feedback device, with no significant difference between critical and non-critical units.

CONCLUSIONS

The Borg scale proved to be adequate for the proposed objectives. The feedback device contributed to lower exertion and heart rate reduction during resuscitation maneuvers. The low cost and ease of application favor its use during training and real-time resuscitation attempts to assess performance using a feedback device to reduce exertion and perception of fatigue. It allows reflection on the intervening factors and resources that can influence the quality of resuscitation attempts and the chances of survival.

A Decade Later-Progress and Next Steps for Pediatric Simulation Research

SUMMARY STATEMENT

A decade ago, at the time of formation of the International Network for Pediatric Simulation-based Innovation, Research, and Education, the group embarked on a consensus building exercise. The goal was to forecast the facilitators and barriers to growth and maturity of science in the field of pediatric simulation-based research. This exercise produced 6 domains critical to progress in the field: (1) prioritization, (2) research methodology and outcomes, (3) academic collaboration, (4) integration/implementation/sustainability, (5) technology, and (6) resources/support/advocacy. This article reflects on and summarizes a decade of progress in the field of pediatric simulation research and suggests next steps in each domain as we look forward, including lessons learned by our collaborative grass roots network that can be used to accelerate research efforts in other domains within healthcare simulation science.

Initial implementation of the resuscitation quality improvement program in emergency department of a teaching hospital in China

Background

Cardiopulmonary resuscitation (CPR) skills may decay over time after conventional instructor-led BLS training. The Resuscitation Quality Improvement® (RQI®) program, unlike a conventional basic life support (BLS) course, is implemented through mastery learning and low-dose, high-frequency training strategies to improve CPR competence. We facilitated the RQI program to compare the performance of novices vs those with previous BLS training experience before RQI implementation and to obtain their confidence and attitude of the RQI program.

Methods

A single-center observational study was conducted from May 9, 2021 to June 25, 2021 in an emergency department of a tertiary hospital. The performance assessment data of both trainees with a previous training experience in conventional BLS course (BLS group) and the novice ones with no prior experience with any BLS training (Non-BLS group) was collected by RQI cart and other outcome variables were rated by online questionnaire. Outcome measurements included chest compression and ventilation in both adult-sized and infant-sized manikins.

Results

A total of 149 participants were enrolled. Among them, 103 participants were in BLS group and 46 participants in Non-BLS group. Post RQI training, all the trainees achieved a passing score of 75 or more, and obtained an improvement in CPR performance. The number of attempts to pass RQI for compression and ventilation practice was lower in the BLS group in both adult and infant training sessions (P < 0.05). Although the BLS group had a poor baseline, it had fewer trials and the same learning outcomes, and the BLS group had better self-confidence. Trainees were well adapted to the innovative training modality, and satisfaction among all of the participants was high. Only the respondents for non-instructor led training, the satisfaction was low in both groups (72.8% in BLS group vs 65.2% in No-BLS group, strongly agreed).

Conclusion

Among novices, RQI can provide excellent CPR core skills performance. But for those who had previous BLS training experience, it was able to enhance the efficiency of the skills training with less time consumption. Most trainees obtained good confidence and satisfaction with RQI program, which might be an option for the broad prevalence of BLS training in China.

Manual and Mechanical Induced Peri-Resuscitation Injuries-Post-Mortem and Clinical Findings

(1) Background: Injuries related to resuscitation are not usually systematically recorded and documented. By evaluating this data, conclusions could be drawn about the quality of the resuscitation, with the aim of improving patient care and safety. (2) Methods: We are planning to conduct a multicentric, retrospective 3-phased study consisting of (1) a worldwide literature review (scoping review), (2) an analysis of anatomical pathological findings from local institutions in North Rhine-Westphalia, Germany to assess the transferability of the review data to the German healthcare system, and (3) depending on the results, possibly establishing potential prospective indicators for resuscitation-related injuries as part of quality assurance measures. (3) Conclusions: From the comparison of literature and local data, the picture of resuscitation-related injuries will be focused on and quality indicators will be derived.

Rescuers' characteristics associated with the correct chest compression during cardiopulmonary resuscitation

AIM

To analyse the caregivers' physical, anthropometrical and educational characteristics associated with adequate chest compression and full chest recoil during cardiopulmonary resuscitation (CPR).

METHODS

An observational prospective research study was conducted. Emergency and critical care health professionals and students performed two minutes of chest compressions on a dummy. Depth and residual leaning after the compressions were assessed and their association with several variables (physical, anthropometrical, and educational) was analysed using logistic regression models.

RESULTS

Two hundred thirty-eight volunteers participated. Previous experience of the rescuer in less than six CPRs (OR = 3.03; 95% CI 1.2-7.63) was related to a higher probability of not achieving an adequate depth of compressions. Greater height (OR: .93; 95% CI .87-.99) and grip strength (OR: .94; 95% CI .89-.99) were associated with correct performance of chest compression. We did not find any characteristic related to chest recoil.

CONCLUSIONS

The caregiver's previous experience with CPR was the strongest factor associated with adequate performance of chest compressions. To a lesser extent, the professional's height and upper body muscle strength also have an influence. No factors associated with the adequacy of full chest recoil were identified.

Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review

SUMMARY STATEMENT

The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.

Debriefing for Simulation-Based Medical Education: A Survey From the International Network of Simulation-Based Pediatric Innovation, Research and Education

CONTEXT

Current debriefing approaches and faculty development strategies for simulation educators differ around the world. We aim to describe the status of current debriefing practice and faculty development for simulation educators in this study.

METHODS

We distributed a paper-based survey during 2 international conferences to obtain data from active International Network for Simulation-based Pediatric Innovation, Research and Education members. The survey was tested to ensure content validity and consisted of the following 3 constructs: demographic characteristics, current debriefing practice, and issues related to faculty development.

RESULTS

One hundred nine of 114 participants (96%) completed the survey. Debriefing practice differs in terms of timing, duration, framework, and conversational framework. Most debriefings were less than 30 minutes (93/109, 85%), with many educators not using objective data during debriefing (47/109, 43%). Three- or 4-phase debriefing frameworks were used most commonly (66/109, 61%). Most participants have access to some faculty development opportunities (99/109, 91%). Barriers to faculty development are related to time and resource constraints (eg, freeing up facilitator's time: 75/109, 69%, competing priorities 64/109, 59%). Most participants indicated that their needs for debriefing to improve learning outcomes were met (95/109, 87%). The desired content for future faculty development opportunities varies between educators with different levels of expertise.

CONCLUSIONS

Approaches to debriefing among members of an international pediatric simulation network vary considerably. Although faculty development opportunities were available to most participants, future simulation programs should work on addressing barriers and optimizing faculty development plans to meet the needs of their educators.

Improving CPR Quality by Using a Real-Time Feedback Defibrillator During Pediatric Simulation Training

OBJECTIVE

The aim of this study was to assess the effectiveness of a defibrillator with real-time feedback during code team training to improve adherence to the American Heart Association (AHA) resuscitation guidelines.

METHODS

This is a retrospective cohort study designed to compare pediatric resident adherence to the AHA cardiopulmonary resuscitation guidelines before and after use of real-time feedback defibrillator during code team training simulation. After institution of a real-time feedback defibrillator, first-year resident's adherence to the AHA guidelines for chest compression rate (CCR), fraction, and depth during code team training from January 2017 to December 2018 was analyzed. It was then compared with results of a previously published study from our institution that analyzed the CCR and fraction from January 2015 to January 2016, before the implementation of a defibrillator with real-time feedback.

RESULTS

We compared 19 eligible session preintervention and 36 postintervention sessions. Chest compression rate and chest compression fraction (CCF) were assessed preintervention and postintervention. The depth of compression was only available postintervention. There was improvement in the proportion of code team training sessions with mean compression rate (74% preintervention vs 100% postintervention, P = 0.003) and mean CCF (79% vs 97%, P = 0.04) in adherence with the AHA guideline.

CONCLUSIONS

The use of real-time feedback defibrillators improved the adherence to the AHA cardiopulmonary resuscitation guidelines for CCF and CCR during pediatric resident simulation.

Code Team Training: Demonstrating Adherence to AHA Guidelines During Pediatric Code Blue Activations

OBJECTIVE

Pediatric code blue activations are infrequent events with a high mortality rate despite the best effort of code teams. The best method for training these code teams is debatable; however, it is clear that training is needed to assure adherence to American Heart Association (AHA) Resuscitation Guidelines and to prevent the decay that invariably occurs after Pediatric Advanced Life Support training. The objectives of this project were to train a multidisciplinary, multidepartmental code team and to measure this team's adherence to AHA guidelines during code simulation.

METHODS

Multidisciplinary code team training sessions were held using high-fidelity, in situ simulation. Sessions were held several times per month. Each session was filmed and reviewed for adherence to 5 AHA guidelines: chest compression rate, ventilation rate, chest compression fraction, use of a backboard, and use of a team leader. After the first study period, modifications were made to the code team including implementation of just-in-time training and alteration of the compression team.

RESULTS

Thirty-eight sessions were completed, with 31 eligible for video analysis. During the first study period, 1 session adhered to all AHA guidelines. During the second study period, after alteration of the code team and implementation of just-in-time training, no sessions adhered to all AHA guidelines; however, there was an improvement in percentage of sessions adhering to ventilation rate and chest compression rate and an improvement in median ventilation rate.

CONCLUSIONS

We present a method for training a large code team drawn from multiple hospital departments and a method of assessing code team performance. Despite subjective improvement in code team positioning, communication, and role completion and some improvement in ventilation rate and chest compression rate, we failed to consistently demonstrate improvement in adherence to all guidelines.

Teaching Infant Cardiopulmonary Resuscitation to Caregivers in the Emergency Department

OBJECTIVES

Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting.

METHODS

Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured.

RESULTS

Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings.

CONCLUSIONS

Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.

Time out! Pauses during advanced life support in high-fidelity simulation: A cross-sectional study

BACKGROUND

Prolonged preshock pauses are associated with negative effects on patient outcomes and survival. A greater understanding of these pauses may help to improve the quality of advanced life support (ALS) and clinical outcomes.

OBJECTIVE

The objective of this study was to identify the pauses that occur during ALS situations in high-fidelity simulation scenarios and the frequency and duration of these pauses.

METHODS

One hundred forty-two nursing students participated in this cross-sectional study, involving high-fidelity simulation scenario of cardiorespiratory arrest in a simulated hospital room. Pauses were assessed using an observation checklist.

RESULTS

Students performed the scenario in an average time of 8.32 (standard deviation = 1.13) minutes. Pauses between chest compressions were longer than recommended (mean = 0.36, standard deviation = 1.14). A strong positive correlation was found between the identification of the arrhythmia and the initiation of countershock (rs = 0.613, p < 0.001).

CONCLUSIONS

Nursing students generally performed ALS within the time limits recommended by resuscitation guidelines. Early identification of shockable rhythms may lead to early nurse-initiated defibrillation. Strategies to speed up the identification of arrhythmias should be put in place to minimise preshock pauses and improve ALS outcomes.

Impact of video quality when evaluating video-assisted cardiopulmonary resuscitation: a randomized, controlled simulation trial

BACKGROUND

Although not routinely established during cardiopulmonary resuscitation (CPR), video-assisted CPR has been described as beneficial in the communication with emergency medical service (EMS) authorities in out-of-hospital cardiac arrest scenarios. Since the influence of video quality has not been investigated systematically and due to variation of quality of a live-stream video during video-assisted CPR, we investigated the influence of different video quality levels during the evaluation of CPR performance in video sequences.

METHODS

Seven video sequences of CPR performance were recorded in high quality and artificially reduced to medium and low quality afterwards. Video sequences showed either correct CPR performance or one of six typical errors: too low and too high compression rate, superficial and increased compression depth, wrong hand position and incomplete release. Video sequences were randomly assigned to the different quality levels. During the randomised and double-blinded evaluation process, 46 paramedics and 47 emergency physicians evaluated seven video sequences of CPR performance in different quality levels (high, medium and low resolution).

RESULTS

Of 650 video sequences, CPR performance was evaluable in 98.2%. CPR performance was correctly evaluated in 71.5% at low quality, in 76.8% at medium quality, and in 77.3% at high quality level, showing no significant differences depending on video quality (p = 0.306). In the subgroup analysis, correct classification of increased compression depth showed significant differences depending on video quality (p = 0.006). Further, there were significant differences in correct CPR classification depending on the presented error (p < 0.001). Allegedly errors, that were not shown in the video sequence, were classified in 28.3%, insignificantly depending on video quality. Correct evaluation did not show significant interprofessional differences (p = 0.468).

CONCLUSION

Video quality has no significant impact on the evaluation of CPR in a video sequence. Even low video quality leads to an acceptable rate of correct evaluation of CPR performance. There is a significant difference in evaluation of CPR performance depending on the presented error in a video sequence.

TRIAL REGISTRATION

German Clinical Trial Register (Registration number DRKS00015297 ) Registered on 2018-08-21.

Rescuers' characteristics associated with the correct chest compression during cardiopulmonary resuscitation

AIM

To analyse the caregivers' physical, anthropometrical and educational characteristics associated with adequate chest compression and full chest recoil during cardiopulmonary resuscitation (CPR).

METHODS

An observational prospective research study was conducted. Emergency and critical care health professionals and students performed two minutes of chest compressions on a dummy. Depth and residual leaning after the compressions were assessed and their association with several variables (physical, anthropometrical, and educational) was analysed using logistic regression models.

RESULTS

Two hundred thirty-eight volunteers participated. Previous experience of the rescuer in less than six CPRs (OR: 3.03; CI 95%: 1.2-7.63) was related to a higher probability of not achieving an adequate depth of compressions. Greater height (OR: .93; 95% CI: .87-.99) and grip strength (OR: .94; 95% CI: .89-.99) were associated with correct performance of chest compression. We did not find any characteristic related to chest recoil.

CONCLUSIONS

The caregiver's previous experience with CPR was the strongest factor associated with adequate performance of chest compressions. To a lesser extent, the professional's height and upper body muscle strength also have an influence. No factors associated with the adequacy of full chest recoil were identified.

Prediction of cerebral perfusion pressure during CPR using electroencephalogram in a swine model of ventricular fibrillation

BACKGROUND

Measuring the quality of cardiopulmonary resuscitation (CPR) is important for improving outcomes in cardiac arrest. Cerebral perfusion pressure (CePP) could represent cerebral circulation during CPR, but it is difficult to measure non-invasively. In this study, we developed the electroencephalogram (EEG) based brain index (EBRI) derived from EEG signals by machine learning techniques, which could estimate CePP accurately in a porcine cardiac arrest model.

METHODS

We conducted a randomised crossover study using nine female pigs. After 1 min of untreated ventricular fibrillation, we performed CPR with 12 different 2-min tilting angle sessions, including two different head-up tilt (HUT) angles (30°, 15°) twice, horizontal angle (0°) four times and two different head-down tilt (HDT) angles (-15°, -30°) twice with the random order. We collected EEG signals using a single channel EEG electrode in real-time during CPR. We derived the EBRI models to predict the CePP classified by the 5 or 10 groups using three different machine learning algorithms, including the support vector machine (SVM), k-nearest neighbour (KNN) and random forest classification (RFC) method. We assessed the accuracy, sensitivity and specificity of each model.

RESULTS

The accuracy of the EBRI model using an SVM algorithm in the 5-group CePP classification was 0.935 with a standard deviation (SD) from 0.923 to 0.946. The accuracy in the 10-group classification was 0.904 (SD: 0.896, 0.913). The accuracy of the EBRI using the KNN method in the 5-group classification was 0.927 (SD: 0.920, 0933) and in the 10-group was 0.894 (SD: 0.880, 0.907). The accuracy of the RFC algorithm was 0.947 (SD: 0.931, 0.963) in the 5-group classification and 0.920 (SD: 0.911, 0.929) in the 10-group classification.

CONCLUSION

We developed the EBRI model using non-invasive acquisition of EEG signals to predict CePP during CPR. The accuracy the EBRI model was 0.935, 0.927 and 0.947 for each machine learning algorithm, and the EBRI could be used as a surrogate indicator for measuring cerebral perfusion during CPR.

Embracing informed learner self-assessment during debriefing: the art of plus-delta

The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners' capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.

[Education for resuscitation]

Diese Leitlinien des European Resuscitation Council basieren auf dem internationalen wissenschaftlichen Konsens 2020 zur kardiopulmonalen Reanimation mit Behandlungsempfehlungen (International Liaison Committee on Resuscitation 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations [ILCOR] 2020 CoSTR). Dieser Abschnitt bietet Bürgern und Angehörigen der Gesundheitsberufe Anleitungen zum Lehren und Lernen der Kenntnisse, der Fertigkeiten und der Einstellungen zur Reanimation mit dem Ziel, das Überleben von Patienten nach Kreislaufstillstand zu verbessern.

Use of backboards in cardiopulmonary resuscitation: a systematic review and meta-analysis

To achieve optimal chest compression depth, victims of cardiac arrest should be placed on a firm surface. Backboards are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. A systematic search was performed to include studies on humans and simulation manikins assessing CPR quality with or without backboards. The primary outcome of the meta-analysis was the difference in chest compression depth between these two conditions. Out of 557 records, 16 studies were included in the review and all were performed on manikins. The meta-analysis, performed on 15 articles, showed that the use of backboards during CPR increases chest compression depth by 1.46 mm in manikins. Despite statistically significant, this increase could have a limited clinical impact on CPR, due to the substantial heterogeneity of experimental conditions and the scarcity of other CPR quality indicators.

European Resuscitation Council Guidelines 2021: Education for resuscitation

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

A randomised trial of the effectiveness of instructor versus automated manikin feedback for training junior doctors in life support skills

INTRODUCTION

Australian Standards require that clinicians undergo regular training in skills required to respond to the acute deterioration of a patient. Training focuses on the ability to appropriately respond to cardiac arrest, including delivering cardiac compressions, ventilation and appropriate defibrillation. Providing such training comes at a significant cost to the organisation and impacts on clinician time in direct patient care. If effective, the use of an automated manikin could significantly reduce costs and provide consistent training experiences.

METHODS

Fifty-six resident medical officers were randomised to two groups to test two skills components of hospital life support training under two feedback conditions. The skills components were cardiac compressions and bag-valve-mask ventilation. The feedback conditions were automated feedback delivered by a simulation manikin and traditional feedback delivered by an instructor. All participants were exposed to both skills components and both feedback conditions in a counterbalanced block design. Participants completed surveys before and after training.

RESULTS

The results demonstrated significantly better performance in cardiac compressions under the automated manikin feedback condition compared with the instructor feedback condition. This difference was not observed in bag-valve-mask ventilation. The majority of participants found the automated manikin feedback more useful than the instructor feedback.

DISCUSSION

Automated manikin feedback was not inferior to instructor feedback for skill acquisition in cardiac compressions training. The automated feedback condition did not achieve the same level of significance in bag-valve-mask ventilation training. Results suggest training with automated feedback presents a cost-effective opportunity to lessen the training burden, whilst improving skill acquisition.

Cardiopulmonary resuscitation skill training and retention in teens (CPR START): A randomized control trial in high school students

Aim

High school students are currently the largest group of individuals in the US receiving CPR training every year. This study examines the effect of adding a real-time visual feedback device to a standard instructor-led CPR course on skill acquisition and retention in high school students.

Methods

All study participants underwent baseline CPR skill testing and received a standard instructor-led compression-only CPR course. We then randomized students to a ‘Feedback Group’, consisting of 2 min of CPR training using a real-time visual feedback device, or ‘Standard Group’ that continued to practice on the inflatable manikin. CPR skills for all students were tested afterwards using the feedback device and reported as a compression score (CS) derived from their chest compression depth, rate, hand position, and full chest recoil. We compared the CS at baseline, week-0 (immediately post-intervention), week-10, week-28, and week-52 between groups.

Results

A total of 220 students were included in the analyses (Feedback Group = 110, Standard Group = 110). Both groups showed similar CPR performance at baseline. At week-0, the Feedback Group had a significantly higher CS compared to the Standard Group (adjusted difference: 20% [95% CI: 11%–29%; p < 0.001]). This difference attenuated over time but remained significant at the week-10 and week-28 follow-up; however, by the week-52 follow-up, there was no significant difference between groups.

Conclusions

Using a real-time visual feedback device during CPR training significantly improves skill acquisition and retention in high school students and should be integrated into the high school CPR curriculum.

Cardiopulmonary Resuscitation Feedback: A Comparison of Device-Measured and Self-Assessed Chest Compression Quality

BACKGROUND

High-quality cardiopulmonary resuscitation is the foundation of cardiac arrest care. Guidelines specify chest compression depth, recoil, and rate, but providers often fail to achieve these targets. Furthermore, providers are largely unable assess the quality of their own or other peoples' chest compressions. Chest compression feedback devices can improve chest compression quality; their use is endorsed internationally, but they remain largely absent in clinical care. This article analyzes preclinical data collected during a quality improvement project. It describes provider demographics and perceptions about their chest compression quality and correlates them to measured chest compression quality, compares clinician perception of chest compressions to objective measures, and describes the effect of feedback on compression quality.

METHODS

Clinicians were recruited from 2 metropolitan emergency departments. A questionnaire was used to assess participants' levels of training and experience. A before-and-after assessment of chest compression quality was performed using a Laerdal CPRmeter 2 and a CPR mannequin. Pretest measures of chest compression quality were made by covering the device screen thereby blinding providers to feedback; repeat measures were then collected from the same participants but unblinded to feedback. Provider charecteristic were collected by survey. Correlations between blinded chest compression quality and provider charecteristics; the reliability of providers estimated compared to measured quality; and the effects of feedback on chest compression quality were assessed using Pearsons correlations, Cohens κ, and paired t testing.

RESULTS

84 participants were assessed. The mean years of certification were 11.74. Ninty-five percent of the providers self-assessed as more experienced than novice and 81% reported performing cardiopulmonary resuscitation at least occasionally. The frequency of performing chest compressions was correlated with self-assessed skill (r = 0.58, P < .001). However, self-assessed skill was only weakly correlated with chest compression quality (r = 0.29, P = .01) and not at all with the frequency of performing chest compressions or years of certification. There was no agreement between self-assessed and device-measured chest compression depth (κ = -0.10, P = 0.11), recoil (κ = -0.14, P = .03), or rate (κ = 0.06, P =.30). The overall quality of compressions improved by 16.9%; the percentage of chest compressions achieving target depth by 3.58%; recoil by 22.82%; and rate by 23.66% with feedback. A total of 97.6% of the staff rated chest compression feedback helpful.

CONCLUSIONS

Our findings suggest that participants' demographics were not correlated with chest compression quality and that providers cannot reliably assess chest compression quality. The data also demonstrate that with minimal training, feedback can significantly improve chest compression quality.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Real-Time Audiovisual Feedback Training Improves Cardiopulmonary Resuscitation Performance: A Controlled Study

OBJECTIVE

The aim of the study was to quantitatively measure the effect of teaching cardiopulmonary resuscitation (CPR) using a real-time audiovisual feedback manikin system on first-year medical student's CPR performance.

METHODS

This is a prospective, manikin-based intervention study, including 2 consecutive classes of medical school students enlisted to a mandatory first aid course. One class (control group) was taught using manikin-based standard CPR education models. The second class (intervention group) was taught similarly, but with the addition of real-time CPR quality feedback provided by the manikins. Students' performance was assessed using a standardized Objective Structured Clinical Examination scenario, during which no real-time feedback was provided. Critical CPR parameters were measured including compression depth, chest recoil, ventilation volume, and "hands-off" time.

RESULTS

A total of 201 participants were included in the study, 106 in the control group and 95 in the intervention group. Baseline demographic characteristics and previous medical knowledge were similar for the 2 groups. A significant improvement was observed for all primary study outcomes in favor of the real-time feedback group for median (interquartile range) chest compression fraction [57 (52.75%-60%) vs. 49 (43%-55%), P < 0.001], compressions with adequate depth [66.5 (19.5%-95.25%) vs. 0 (0%-12%), P < 0.001], ventilations with adequate volume [68.5 (33%-89%) vs. 37 (0%-70%), P < 0.00], and a simulator-derived composite "total CPR score" [39 (24%-61.25%) vs. 13 (3.5%-22%), P < 0.001]. In multiple regression analysis, the real-time feedback group's performance was significantly better than the control group in all primary outcomes, adjusting for participant's characteristics of age, sex, and body mass index.

CONCLUSIONS

The use of audiovisual feedback techniques to teach CPR improves skill acquisition with significant improvement in crucial prognosis-improving parameters, as tested in a "no-feedback" test scenario.

Effect of a Cardiopulmonary Resuscitation Coach on Workload During Pediatric Cardiopulmonary Arrest: A Multicenter, Simulation-Based Study

OBJECTIVES

Optimal cardiopulmonary resuscitation can improve pediatric outcomes but rarely is cardiopulmonary resuscitation performed perfectly despite numerous iterations of Basic and Pediatric Advanced Life Support. Cardiac arrests resuscitation events are complex, often chaotic environments with significant mental and physical workload for team members, especially team leaders. Our primary objective was to determine the impact of a cardiopulmonary resuscitation coach on cardiopulmonary resuscitation provider workload during simulated pediatric cardiac arrest.

DESIGN

Multicenter observational study.

SETTING

Four pediatric simulation centers.

SUBJECTS

Team leaders, cardiopulmonary resuscitation coach, and team members during an 18-minute pediatric resuscitation scenario.

INTERVENTIONS

National Aeronautics and Space Administration-Task Load Index.

MEASUREMENTS AND MAIN RESULTS

Forty-one teams (205 participants) were recruited with one team (five participants) excluded from analysis due to protocol violation. Demographic data revealed no significant differences between the groups in regard to age, experience, distribution of training (nurse, physician, and respiratory therapist). For most workload subscales, there were no significant differences between groups. However, cardiopulmonary resuscitation providers had a higher physical workload (89.3 vs 77.9; mean difference, -11.4; 95% CI, -17.6 to -5.1; p = 0.001) and a lower mental demand (40.6 vs 55.0; mean difference, 14.5; 95% CI, 4.0-24.9; p = 0.007) with a coach (intervention) than without (control). Both the team leader and coach had similarly high mental demand in the intervention group (75.0 vs 73.9; mean difference, 0.10; 95% CI, -0.88 to 1.09; p = 0.827). When comparing the cardiopulmonary resuscitation quality of providers with high workload (average score > 60) and low to medium workload (average score < 60), we found no significant difference between the two groups in percentage of guideline compliant cardiopulmonary resuscitation (42.5% vs 52.7%; mean difference, -10.2; 95% CI, -23.1 to 2.7; p = 0.118).

CONCLUSIONS

The addition of a cardiopulmonary resuscitation coach increases physical workload and decreases mental workload of cardiopulmonary resuscitation providers. There was no change in team leader workload.

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine

OBJECTIVES

Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.

METHODS

The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.

RESULTS AND ANALYSIS

Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.

CONCLUSIONS/IMPLICATIONS FOR EDUCATORS

We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.

Improving the position of resuscitation team leader with simulation (IMPORTS); a pilot cross-sectional randomized intervention study

BACKGROUND

Leadership and teamwork are important contributory factors in determining cardiac resuscitation performance and clinical outcome. We aimed to determine whether fixed positioning of the resuscitation team leader (RTL) relative to the patient influences leadership qualities during cardiac resuscitation using simulation.

METHODS

A cross-sectional randomized intervention study over 12 months' duration was conducted in university hospital simulation lab. ACLS-certified medical doctors were assigned to run 2 standardized simulated resuscitation code as RTL from a head-end position (HEP) and leg-end position (LEP). They were evaluated on leadership qualities including situational attentiveness (SA), errors detection (ED), and decision making (DM) using a standardized validated resuscitation-code-checklist (RCC). Performance was assessed live by 2 independent raters and was simultaneously recorded. RTL self-perceived performance was compared to measured performance.

RESULTS

Thirty-four participants completed the study. Mean marks for SA were 3.74 (SD ± 0.96) at HEP and 3.54 (SD ± 0.92) at LEP, P = .48. Mean marks for ED were 2.43 (SD ± 1.24) at HEP and 2.21 (SD ± 1.14) at LEP, P = .40. Mean marks for DM were 4.53 (SD ± 0.98) at HEP and 4.47 (SD ± 0.73) at LEP, P = .70. The mean total marks were 10.69 (SD ± 1.82) versus 10.22 (SD ± 1.93) at HEP and LEP respectively, P = .29 which shows no significance difference in all parameters. Twenty-four participants (71%) preferred LEP for the following reasons, better visualization (75% of participants); more room for movement (12.5% of participants); and better communication (12.5% of participants). RTL's perceived performance did not correlate with actual performance CONCLUSION:: The physical position either HEP or LEP appears to have no influence on performance of RTL in simulated cardiac resuscitation. RTL should be aware of the advantages and limitations of each position.

Real-Time Cardiopulmonary Resuscitation Feedback and Targeted Training Improve Chest Compression Performance in a Cohort of International Healthcare Providers

BACKGROUND

Optimal cardiopulmonary resuscitation (CPR) performance is the foundation of successful cardiac arrest resuscitation. However, health care providers perform inadequate compressions. Better training techniques and real-time CPR feedback may improve compression performance.

OBJECTIVE

We sought to evaluate the impact of a targeted training program combined with real-time defibrillator CPR feedback on chest compression performance in an international cohort of health care providers.

METHODS

Physicians, nurses, respiratory therapists, and technicians from 6 hospitals in 5 countries (Taiwan, Singapore, China, Bahrain, and Kuwait) participated in a standardized resuscitation workshop. Chest compression was measured before and after didactics and activation of CPR feedback. Compressions were performed for 1 min on standard CPR manikins placed on a hospital bed and backboard and measured using ZOLL R Series defibrillators. The percentage of compressions meeting target values for depth and rate were compared before and after the workshop and activation of real-time CPR feedback. No depth maximum was defined to allow for mattress compression.

RESULTS

Chest compressions were more likely to meet targets for depth (71-95%, odds ratio [OR] 8.61 [95% confidence interval {CI} 4.42-16.77], p < 0.001), rate (41-81%, OR 6.4 [95% CI 4.2-9.8], p < 0.001), and both depth and rate (5-42%, OR 2.4 [95% CI 6.7-22.9], p < 0.001) after the workshop and activation of real-time CPR feedback.

CONCLUSIONS

A targeted training intervention combined with real-time CPR feedback improved chest compression performance among health care providers from various countries.

Just-in-Time Training for Intraosseous Needle Placement and Defibrillator Use in a Pediatric Emergency Department

OBJECTIVES

Just-in-time training (JITT) is a method of simulation-based training where the training occurs within the clinical environment in a concise manner. Just-in-time training has shown effects at the learner, patient, and system-wide levels. We evaluated a JITT curriculum for the procedures of intraosseous (IO) needle placement and defibrillator use in a pediatric emergency department (ED) by comparing the trainees' comfort level in performing those procedures independently (Kirkpatrick level 2a) and trainees' knowledge of the procedures/equipment (Kirkpatrick level 2b) before and after the JITT.

METHODS

The study enrolled all fourth year medical students and residents (family medicine and pediatrics) who rotated through a children's hospital ED. The JITT curriculum included group discussion on storage locations of procedure equipment in the ED and clinical indications/contraindications followed by hands-on procedure training. One of 2 attending physicians facilitated the 10- to 20-minute JITT in the ED during their shifts. Trainees completed an anonymous survey to delineate medical training level, previous procedure experiences, procedure-related knowledge, and comfort level to perform the procedures independently. Identical surveys were completed before and after the JITT. The data were analyzed using percentage for categorical variables. For comparisons between pre-JITT and post-JITT survey data, χ tests or Fisher exact tests were used.

RESULTS

There were 65 surveys included (34 pre-JITT and 31 post-JITT surveys). The comfort level to perform procedures independently increased from pre-JITT 0% to post-JITT 48% (P < 0.001) for IO needle placement and from pre-JITT 3% to post-JITT 32% (P = 0.0016) for defibrillator use. The procedure-related knowledge also increased by ##greater than or equal to 50% post-JITT (P < 0.0001).

CONCLUSIONS

Our JITT curriculum significantly increased the comfort level of the trainees to perform IO needle insertion and defibrillator use independently. Procedure-related knowledge also increased. By increasing their comfort to perform these procedures independently, we aim to increase the likelihood that trainees can be competent contributing members of an acute medical response team in these respective roles.

Healthcare Provider Perceptions of Cardiopulmonary Resuscitation Quality During Simulation Training

OBJECTIVES

To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices.

DESIGN

Prospective observational study.

SETTING

In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard.

SUBJECTS

Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest.

INTERVENTIONS

High-fidelity simulation of resuscitation with continuous audiovisual feedback.

MEASUREMENTS AND MAIN RESULTS

Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 ± 10 compressions per minute; chest compression depth 2.05 ± 0.6 in; chest compression fraction 74% ± 10%; chest compression in target 22% ± 21%; preshock pause 8.6 ± 7.2 seconds; and postshock pause 6.4 ± 8.9 seconds. When all healthcare providers were analyzed, the association coefficient (κ) for chest compression rate (κ = 0.078), chest compression depth (κ = 0.092), chest compression fraction (κ = 0.004), preshock pause (κ = 0.321), and postshock pause (κ = 0.40) was low, with no variable achieving moderate agreement (κ > 0.4).

CONCLUSIONS

Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Implementation of Chest Compression Feedback Technology to Improve the Quality of Cardiopulmonary Resuscitation in the Emergency Department: A Quality Initiative Test-of-change Study

Background

Cardiopulmonary resuscitation (CPR) metrics including compression rate and depth are associated with improved outcomes and the need for high-quality CPR is emphasized in both the American Heart Association (AHA) and Heart and Stroke Foundation of Canada (HSFC) guidelines. While these metrics can be utilized to assess the quality of CPR, they are infrequently measured in an objective fashion in the emergency department.

Objectives

As part of an Emergency Department (ED) Quality Improvement (QI) project, we sought to determine the impact of real-time audio-visual (AV) feedback during CPR amongst ED healthcare providers.

Methods

Participants performed two minutes of uninterrupted CPR without AV feedback, followed by two minutes of CPR with AV feedback after a two-minute rest period in a simulated CPR setting. CPR metrics were captured by the defibrillator and uploaded to review software for analysis of each event.

Results

The use of real-time AV feedback resulted in a significant improvement in the number of participants meeting AHA/HSFC recommended depth (38%, p = 0.0003) and rate (35%, p = 0.0002). Importantly, ‘compressions in target’, where participants met both rate and depth simultaneously, improved with AV feedback (19 vs 61%, p < 0.0001).

Conclusions

We found a significant improvement in compliance with CPR depth and rate targets as well as ‘compressions in target’ with the use of real-time AV feedback during simulation training. Future research is needed to ascertain whether these results would be replicated in other settings. Our findings do provide a robust argument for the implementation of real-time AV CPR feedback in Hamilton Emergency Departments.

The impact of real-time chest compression feedback increases with application of the 2015 guidelines

BACKGROUND

Cardiac arrest survival depends upon chest compression quality. Real-time audiovisual feedback may improve compression guideline adherence, particularly with the more specific 2015 guidelines.

METHODS

Subjects included healthcare providers from multiple U.S. hospitals. Compression rate and depth were recorded using standard manikins and real-time audiovisual feedback defibrillators (ZOLL R Series). Subjects were enrolled before (n = 756) and after (n = 995) release of the 2015 guidelines, which define narrower compression targets. Subjects performed 2 min of continuous compressions before and after activation of feedback. The percentage of compressions meeting appropriate rate/depth targets was determined before and after release of the 2015 guidelines.

RESULTS

An increase in compression guideline adherence was observed with use of feedback before [68.7% to 96.3%, p < .001] and after [16.6% to 94.1%, p < .001] release of the 2015 guidelines. The proportion of subjects requiring feedback to achieve adherence was higher for the 2015 guidelines [28.6% vs. 78.5%, OR 9.12, 95% CI 7.33-11.35, p < .001].

CONCLUSIONS

The use of real-time audiovisual feedback increases adherence to chest compression guidelines, particularly with application of the narrower 2015 guidelines targets for compression depth and rate.

Feasibility of an augmented reality cardiopulmonary resuscitation training system for health care providers

AIM OF THE STUDY

Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users' view of the real environment to simulate interactive training scenarios. We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs).

METHODS

In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants' demographics, CC quality, and satisfaction with the training environment were reported using quantitative and qualitative analysis.

RESULTS

Between 10/2018-11/2018, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27-41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46-58), and percent with complete recoil (median 80%, IQR 12-100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training.

CONCLUSIONS

As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.

Effect of real-time visual feedback device 'Quality Cardiopulmonary Resuscitation (QCPR) Classroom' with a metronome sound on layperson CPR training in Japan: a cluster randomized control trial

OBJECTIVES

'Quality Cardiopulmonary Resuscitation (QCPR) Classroom' was recently introduced to provide higher-quality Cardiopulmonary Resuscitation (CPR) training. This study aimed to examine whether novel QCPR Classroom training can lead to higher chest-compression quality than standard CPR training.

DESIGN

A cluster randomised controlled trial was conducted to compare standard CPR training (control) and QCPR Classroom (intervention).

SETTING

Layperson CPR training in Japan.

PARTICIPANTS

Six hundred forty-two people aged over 15 years were recruited from among CPR trainees.

INTERVENTIONS

CPR performance data were registered without feedback on instrumented Little Anne prototypes for 1 min pretraining and post-training. A large classroom was used in which QCPR Classroom participants could see their CPR performance on a big screen at the front; the control group only received instructor's subjective feedback.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were compression depth (mm), rate (compressions per minute (cpm)), percentage of adequate depth (%) and recoil (%). Survey scores were a secondary outcome. The survey included participants' confidence regarding CPR parameters and ease of understanding instructor feedback.

RESULTS

In total, 259 and 238 people in the control and QCPR Classroom groups, respectively, were eligible for analysis. After training, the mean compression depth and rate were 56.1±9.8 mm and 119.2±7.3 cpm in the control group and 59.5±7.9 mm and 116.8±5.5 cpm in the QCPR Classroom group. The QCPR Classroom group showed significantly more adequate depth than the control group (p=0.001). There were 39.0% (95% CI 33.8 to 44.2; p<0.0001) and 20.0% improvements (95% CI 15.4 to 24.7; P<0.0001) in the QCPR Classroom and control groups, respectively. The difference in adequate recoil between pretraining and post-training was 2.7% (95% CI -1.7 to 7.1; pre 64.2±36.5% vs post 66.9%±34.6%; p=0.23) and 22.6% in the control and QCPR Classroom groups (95% CI 17.8 to 27.3; pre 64.8±37.5% vs post 87.4%±22.9%; p<0.0001), respectively.

CONCLUSIONS

QCPR Classroom helped students achieve high-quality CPR training, especially for proper compression depth and full recoil. For good educational achievement, a novel QCPR Classroom with a metronome sound is recommended.

Influence of Cardiopulmonary Resuscitation Coaching and Provider Role on Perception of Cardiopulmonary Resuscitation Quality During Simulated Pediatric Cardiac Arrest

OBJECTIVES

We aimed to describe the impact of a cardiopulmonary resuscitation coach on healthcare provider perception of cardiopulmonary resuscitation quality during simulated pediatric cardiac arrest.

DESIGN

Prospective, observational study.

SETTING

We conducted secondary analysis of data collected from a multicenter, randomized trial of providers who participated in a simulated pediatric cardiac arrest.

SUBJECTS

Two-hundred pediatric acute care providers.

INTERVENTIONS

Participants were randomized to having a cardiopulmonary resuscitation coach versus no cardiopulmonary resuscitation coach. Cardiopulmonary resuscitation coaches provided feedback on cardiopulmonary resuscitation performance and helped to coordinate key tasks. All teams used cardiopulmonary resuscitation feedback technology.

MEASUREMENTS AND MAIN RESULTS

Cardiopulmonary resuscitation quality was collected by the defibrillator, and perceived cardiopulmonary resuscitation quality was collected by surveying participants after the scenario. We calculated the difference between perceived and measured quality of cardiopulmonary resuscitation and defined accurate perception as no more than 10% deviation from measured quality of cardiopulmonary resuscitation. Teams with a cardiopulmonary resuscitation coach were more likely to accurately estimate chest compressions depth in comparison to teams without a cardiopulmonary resuscitation coach (odds ratio, 2.97; 95% CI, 1.61-5.46; p < 0.001). There was no significant difference detected in accurate perception of chest compressions rate between groups (odds ratio, 1.33; 95% CI, 0.77-2.32; p = 0.32). Among teams with a cardiopulmonary resuscitation coach, the cardiopulmonary resuscitation coach had the best chest compressions depth perception (80%) compared with the rest of the team (team leader 40%, airway 55%, cardiopulmonary resuscitation provider 30%) (p = 0.003). No differences were found in perception of chest compressions rate between roles (p = 0.86).

CONCLUSIONS

Healthcare providers improved their perception of cardiopulmonary resuscitation depth with a cardiopulmonary resuscitation coach present. The cardiopulmonary resuscitation coach had the best perception of chest compressions depth.