Using a smartphone application (PocketCPR) to determine CPR quality in a bystander CPR scenario - A manikin trial

Do laypersons need App-linked real-time feedback devices for effective resuscitation? - Results of a prospective, randomised simulation trial

Background

App-linked real-time feedback-devices for cardiopulmonary resuscitation (CPR) aim to improve laypersons' resuscitation quality. Resuscitation guidelines recommend these technologies in training settings. This is the first study comparing resuscitation quality of all App-linked feedback-devices currently on market.

Methods

A prospective randomised simulation study was performed. After standardised instructions, participants performed 2-minutes compression-only CPR on a manikin without feedback (baseline). Afterwards, participants performed 4 × 2 min CPR with four different feedback devices in randomised order (CorPatch® Trainer, CPRBAND AIO Training, SimCPR®ProTrainer, Relay Response™) (intervention). CPR metrics (chest compression depth (CD), chest compression rate (CR), percentage of correct CD/CR (%), correct hand position, correct chest recoil, and technical preparation-time) were assessed. Devices data were compared to the baseline group using Wilcoxon testing with IBM SPSS (primary outcome). Differences between devices were analysed with ANOVA testing (secondary outcome). Normally distributed data were described as mean ± standard deviation (SD) and non-normally distributed data as Median [Interquartile range (IQR). CPR self-confidence was measured by means of questionnaire before and after feedback devices' use. Comparison was performed by students t-test.

Results

Forty participants were involved. SimCPR®ProTrainer was the only device, which resulted in guideline-compliant chest compressions (Mean ± SD:5.37 ± 0.76) with improved chest compression depth (p < 0.001), and percentage of correct chest compression depth (p < 0.001) compared to unassisted CPR (baseline). CorPatch® Trainer as the only device with audio-visual recoil instructions resulted in improved chest recoil (Mean ± SD:72.25 ± 24.89) compared to baseline (Mean ± SD:49.00 ± 42.20; p < 0.01), while the other three devices resulted in significantly lower chest recoil rates (CPRBAND AIO Training: 37.03 ± 39.90; p < 0.01, SimCPR®ProTrainer: Mean ± SD:39.88 ± 36.50; p = 0.03, Relay Response™: Mean ± SD:36.88 ± 37.73; p = 0.02). CPR quality when using the different feedback devices differ in chest compression depth (p = 0.02), chest compression rate (p < 0.001), percentage of correct chest compression depth/rate (p = 0.03/p = 0.04), and technical preparation-time (p < 0.001). Feedback-devices' use increased participant's CPR self-confidence (p < 0.001).

Conclusion

Although, CPR feedback devices show improved CPR performance in layperson in some metrics, none of the tested CPR feedback devices supported layperson in overall adequate CPR performance. More and better technical functionality is necessary, to fully utilise the potential of CPR feedback devices and to prevent a worsening of CPR performance when layperson use this technology.

The effect of standalone audio-visual feedback devices on the quality of chest compressions during laypersons' cardiopulmonary resuscitation training: a systematic review and meta-analysis

AIMS

Individual studies that investigated the effect of standalone audio-visual feedback (AVF) devices during laypersons' cardiopulmonary resuscitation (CPR) training have yielded conflicting results. This review aimed to evaluate the effect of standalone AVF devices on the quality of chest compressions during laypersons' CPR training.

METHOD AND RESULT

Randomized controlled trials of simulation studies recruiting participants without actual patient CPR experience were included. The intervention evaluated was the quality of chest compressions with standalone AVF devices vs. without AVF devices. Databases, such as PubMed, Cochrane Central, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, and PsycINFO, were searched from January 2010 to January 2022. The risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis alongside a narrative synthesis was used for examining the effect of standalone AVF devices.Sixteen studies were selected for this systematic review. A meta-analysis revealed an increased compression depth of 2.22 mm [95% CI (Confidence Interval), 0.88-3.55, P = 0.001] when participants performed CPR using the feedback devices. Besides, AVF devices enabled laypersons to deliver compression rates closer to the recommended range of 100-120 per min. No improvement was noted in chest recoil and hand positioning when participants used standalone AVF devices.

CONCLUSION

The quality of the included studies was variable, and different standalone AVF devices were used. Standalone AVF devices were instrumental in guiding laypersons to deliver deeper compressions without compromising the quality of compression rates. However, the devices did not improve the quality of chest recoil and placement of the hands.

REGISTRATION

PROSPERO: CRD42020205754.

Comparison of chest compression quality between the overlapping hands and interlocking hands techniques: A randomised cross-over trial

BACKGROUND

Performing quality chest compressions is fundamental to the management of cardiopulmonary arrest. The aim of this study was to compare the efficacy of two hand positions: overlapping versus interlocking for performing chest compressions during cardiopulmonary arrest.

METHODS

The HP2C (for Hands Position and Chest Compression) was a prospective, randomised, open-label, cross-over, single-centre study. Participants were recruited from the Emergency Medical Service (EMS) teams and the prehospital firefighter teams. They were randomised to start chest compressions either with overlapping or interlocking hands and then performed the other technique after a washout period. The judgement criteria were the overall chest compressions success score generated by software in accordance with ILCOR recommendations, the quality of compression, release, rate and subjective intensity measured with the Borg scale.

RESULTS

A total of 100 participants were included in the study. The mean age of the caregivers was 38 ± 9.3 years. The median CPR score was 79.5% IQR [48.5-94.0] in the overlapping hands group and 71% IQR [38.0-92.8] in the interlocking hands group (p-value = 0.37). There was no significant difference for the other criteria, especially no difference in term of intensity of effort. However, there was a trend towards better results with overlapping hands.

CONCLUSIONS

This study failed to demonstrate a difference in effectiveness between overlapping and interlocking hand chest compressions during cardiopulmonary resuscitation.

Effect of real-time feedback device compared to use or non-use of a checklist performance aid on post-training performance and retention of infant cardiopulmonary resuscitation: A randomized simulation-based trial

INTRODUCTION

This study aims to determine the best method for achieving optimal performance of pediatric cardiopulmonary resuscitation (CPR) during simulation-based training, whether with or without a performance aid.

METHODS

In this randomized controlled study, 46 participants performed simulated CPR in pairs on a Resusci Baby QCPR™ mannequin, repeated after four weeks. All participants performed the first simulation without performance aids. For the second simulation, they were randomly assigned to one of three groups with stratification based on status: throughout CPR, Group A (n = 16) was the control group and did not use a performance aid; Group B (n = 16) used the CPR checklist; Group C (n = 14) used real-time visualization of their CPR activity on a feedback device. Overall performance was assessed using the QCPR™.

RESULTS

All groups demonstrated improved performance on the second simulation (p < 0.01). Use of the feedback device resulted in better CPR performance than use of the CPR checklist (p = 0.02) or no performance aid (p = 0.04). Additionally, participants thought that the QCPR™ could effectively improve their technical competences.

CONCLUSIONS

Performance aid based on continuous feedback is helpful in the learning process. The use of the QCPR™, a real-time feedback device, improved the quality of resuscitation during infant CPR simulation-based training.

Monitoring cardiopulmonary resuscitation quality in emergency departments: a national survey in China on current knowledge, attitudes, and practices

Background

To investigate current knowledge, attitudes, and practices for CPR quality control among emergency physicians in Chinese tertiary hospitals.

Methods

Anonymous questionnaires were distributed to physicians in 75 tertiary hospitals in China between January and July 2018.

Results

A total of 1405 respondents answered the survey without obvious logical errors. Only 54.4% respondents knew all criteria of high-quality CPR. A total of 91.0% of respondents considered CPR quality monitoring should be used, 72.4% knew the objective method for monitoring, and 63.2% always/often monitored CPR quality during actual resuscitation. The main problems during CPR were related to chest compression: low quality due to fatigue (67.3%), inappropriate depth (57.3%) and rate (54.1%). The use of recommended monitoring methods was reported as follows, ETCO₂ was 42.7%, audio-visual feedback devices was 10.1%, coronary perfusion pressure was 17.9%, and invasive arterial pressure was 31.1%. A total of 96.3% of respondents considered it necessary to participate in regular CPR retraining, but 21.4% did not receive any retraining. The ideal retraining interval was considered to be 3 to 6 months, but the actual interval was 6 to 12 months. Only 49.7% of respondents reported that feedback devices were always/often used in CPR training.

Conclusion

Chinese emergency physicians were very concerned about CPR quality, but they did not fully understand the high-quality criteria and their impact on prognosis. CPR quality monitoring was not a routine procedure during actual resuscitation. The methods recommended in guidelines were rarely used in practice. Many physicians had not received retraining or received retraining at long intervals. Feedback devices were not commonly used in CPR training.

Responding to Cardiac Arrest in the Community in the Digital Age

Sudden cardiac arrest (SCA) is a common event, affecting almost 400,000 individuals annually in North America. Initiation of cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED) are critical for survival, yet many bystanders are reluctant to intervene. Digital technologies, including mobile devices, social media and crowdsourcing may help play a role to improve survival from SCA. In this article we review the current digital tools and strategies available to increase rates of bystander recognition of SCA, prompt immediate activation of Emergency Medical Services (EMS), initiate high quality CPR and to locate, retrieve and operate AEDs. Smartphones can help to both educate and connect bystanders with EMS dispatchers, through text messaging or video-calling, to encourage the initiation of CPR and retrieval of the closest AED. Wearable devices and household smartspeakers could play a future role in continuous vital signs monitoring in individuals at-risk of lethal arrhythmias and send an alert to either chosen contacts or EMS. Machine learning algorithms and mathematical modeling may aid EMS dispatchers with better recognition of SCA as well as policymakers with where to best place AEDs for optimal accessibility. There are challenges with the use of digital tech, including the need for government regulation and issues with data ownership, accessibility and interoperability. Future research will include smart cities, e-linkages, new technologies and using social media for mass education. Together or in combination, these emerging digital technologies may represent the next leap forward in SCA survival.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Smartphone apps to support laypersons in bystander CPR are of ambivalent benefit: a controlled trial using medical simulation

Background

Bystander-initiated resuscitation is essential for surviving out-of-hospital cardiac arrest. Smartphone apps can provide real-time guidance for medical laypersons in these situations. Are these apps a beneficial addition to traditional resuscitation training?

Methods

In this controlled trial, we assessed the impact of app use on the quality of resuscitation (hands-off time, assessment of the patient’s condition, quality of chest compression, body and arm positioning). Pupils who have previously undergone a standardised resuscitation training, encountered a simulated cardiac arrest either (i) without an app (control group); (ii) with facultative app usage; or (iii) with mandatory app usage. Measurements were compared using generalised linear regression.

Results

200 pupils attended this study with 74 pupils in control group, 65 in facultative group and 61 in mandatory group. Participants who had to use the app significantly delayed the check for breathing, call for help, and first compression, leading to longer total hands-off time. Hands-off time during chest compression did not differ significantly. The percentage of correct compression rate and correct compression depth was significantly higher when app use was mandatory. Assessment of the patient’s condition, and body and arm positioning did not differ.

Conclusions

Smartphone apps offering real-time guidance in resuscitation can improve the quality of chest compression but may also delay the start of resuscitation. Provided that the app gives easy-to-implement, guideline-compliant instructions and that the user is familiar with its operation, we recommend smartphone-guidance as an additional tool to hands-on CPR-training to increase the prevalence and quality of bystander-initiated CPR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00893-3.

Effect of a real-time feedback smartphone application (TCPRLink) on the quality of telephone-assisted CPR performed by trained laypeople in China: a manikin-based randomised controlled study

OBJECTIVES

To determine the effect of a free smartphone application (TCPRLink) that provides real-time monitoring and audiovisual feedback on chest compressions (CC) on trained layperson telephone-assisted cardiopulmonary resuscitation (T-CPR) performance.

DESIGN

A manikin-based randomised controlled study.

SETTING

This study was conducted at a multidisciplinary university and a community centre in China.

PARTICIPANTS

One hundred and eighty-six adult participants (age 18-65 years) with T-CPR training experience were randomly assigned to the TCPRLink (n=94) and T-CPR (n=92) groups with age stratification.

INTERVENTIONS

We compared the participants' performance for 6 min of CC in a simulated T-CPR scenario both at the baseline and after 3 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the CC rate and proportion of adequate CC rate (100-120 min^-1). The secondary outcomes included the proportion of participants counting the CC rhythm, time to first CC, CC depth, hands-off time and CC full-release ratio.

RESULTS

Participants in the TCPRLink feedback group more consistently performed CC with higher rate, both initially and 3 months later (median 111 (IQR 109-113) vs 108 (103-112) min^-1, p=0.002 and 111 (109-113) vs 108 (105-112) min^-1, p<0.001, respectively), with less need to count the rhythm (21.3% vs 41.3%, p=0.003% and 7% vs 22.6%, p=0.004, respectively) compared with the T-CPR group. There were no significant differences in time to the first CC, hands-off time or CC full-release ratio. Among 55-65 year group, the CC depth was deeper in the TCPRLink group than in the TCPR group (47.1±9.6 vs 38.5±8.7 mm, p=0.001 and 44.7±10.1 vs 39.3±10.8 mm, p=0.07, respectively).

CONCLUSIONS

The TCPRLink application improved T-CPR quality in trained laypersons to provide more effective CCs and lighten the load of counting out the CC with the dispatcher in a simulated T-CPR scenario. Further investigations are required to confirm this effectiveness in real-life resuscitation attempts.

Efficacy of a five-minute compression-only cardiopulmonary resuscitation class compared to thirty-minute instruction among college students

Objective

To determine if 5-minute compression-only cardiopulmonary resuscitation (CCO-CPR) instruction is as effective as 30-minute instruction in improving participant knowledge and comfort with performing CCO-CPR as well as teaching CPR quality and responsiveness to an Out of Hospital Cardiac Arrest (OHCA).

Methods

A prospective randomized controlled trial of university undergraduates was performed. Participants were randomized to either a 5-minute (experimental) or 30-minute (control) CCO-CPR instruction class. Pre- and post-testing was performed with a written and simulation test. Measurements collected assessed rate and depth of compressions, time to call 911, and time to start chest compressions. Prior to instruction, subjects’ baseline measurements of CPR performance were evaluated during a standardized sudden death scenario using a Laerdal Skillreporter^TM mannequin. The written test and scenario were repeated after either the five or 30 ​minute CCO-CPR instruction using the same outcome measures. Statistical tests of association for categorical variables were assessed using the chi-square test and the independent samples t-test was utilized for continuous variables. All tests were two-sided and the level of significance was set at α ​= ​0.05.

Results

Among the 59 participants, 28 received 5 ​minutes of instruction and 31 received 30 ​minutes. Fifteen (25.4%) individuals reported prior CPR training. Post intervention, all measurements reached statistically significant improvements in each group but there was no difference between the two groups improvement in depth of compressions (experimental group: 41.8 ​mm, 95% CI 36.6–43.4 vs control group: 46.5 ​mm, 95% CI 40.9–48.3, p ​= ​0.06), compressions per minute (114.3 cpm, 95% CI 105.5–122.0 vs 121.1 cpm, 95% CI 115.1–131.4, p ​= ​0.10), time to starting chest compressions (13.5 vs 12.4 ​sec, p ​= ​0.45), or time to calling 911 (8.34 vs 7.65 ​sec, p ​= ​0.58). Further, there was a statistically significant improvement in participants that said they would probably or definitely perform CCO-CPR in real life after both interventions but no difference between the groups (100% of the experimental group and 93.5% of the control group p ​< ​0.49).

Conclusion

Five-minute instruction is not inferior to 30-minute instruction at teaching undergraduate students how to perform quality bystander CCO-CPR.

Basic life support knowledge in Germany and the influences of demographic factors

BACKGROUND

In the developed world, cardiovascular diseases still contribute to mortality and morbidity, leading to significantly increased deaths in recent years. Thus, it is necessary for a layperson to provide the best possible basic life support (BLS) until professional help is available. Since information on current BLS knowledge in Germany is not available, but necessary to be able to make targeted improvements in BLS education, we conducted this study.

METHODS

A cohort survey using convenience sampling (non-probability) method was conducted with questions found in emergency medicine education. People coming to the emergency room of two big university hospitals located in the South (Munich) and western part (Cologne) of Germany were asked to participate in the survey between 2016 and 2017. Primary outcome measures were the proportion of correct answers for each emergency scenario in relationship to age, region, profession and first-aid training.

RESULTS

Altogether 1003 people (504 from Cologne; 499 from Munich) took part in the questionnaire. 54.7% were female and 45.3% were male aging from 19 to 52 with a mean of 37.2 years. Although over 90% had taken part in first aid training, many people were lacking first aid knowledge, with less than 10% choosing the correct frequency for chest compression. Hereby demographic factors had a significant influence (p<0.05) in the given answers (Friedmann-and-Wilcoxon Test).

CONCLUSION

Overall, results of our survey indicate a clear lack of BLS knowledge. With this information, targeted measures for improving BLS knowledge should be conducted. Additionally, further studies on the feasibility and efficiency of teaching methods are needed.

Using a Mobile Phone Application Versus Telephone Assistance During Cardiopulmonary Resuscitation: A Randomized Comparative Study

INTRODUCTION

In recent years, the way CPR instructions are given has changed because of the development of new technology that allows bystanders who witness a cardiac arrest to be guided in performing CPR. This study aimed to compare the effectiveness of using a mobile phone application (app) versus telephone operator assistance in performing cardiopulmonary resuscitation (CPR) techniques in simulated settings.

METHODS

A comparative study was performed with 2 intervention groups: (1) mobile phone app and (2) telephone assistance. A total of 128 students participated and were distributed randomly into each intervention group. A CPR observation checklist and standard CPR quality parameter measurements were used for data collection.

RESULTS

The group that used the app obtained better results than the group that had telephone assistance on 5 items during CPR observation: checking if the area is secure (X²(1) = 26.81; P < 0.05), asking for help (X²(1) = 66.07; P < 0.05), opening of airways (X²(1) = 12.03; P < 0.05), checking for breathing (X²(1) = 6.10; P < 0.05), and contacting emergency services (X²(1) = 12.41; P < 0.05). Regarding the skill level of CPR, no statistically significant differences were found when comparing the 2 intervention groups (X²(1) = 0.91; P = 0.33). As for the parameters measured, there were only statistically significant differences found in the item compression fraction (U = 1,593.00; Z = -2.16; P < 0.05), with the group that used the app obtaining better results.

DISCUSSION

Better outcomes were observed in recognizing if the area was safe, asking for help, opening up the airways, checking for breathing, and calling emergency services in the mobile phone app group. However, the results indicated that there were no differences in the CPR parameters, except compression fraction, when the app was used as opposed to being guided by telephone.

Verbal Motivation vs. Digital Real-Time Feedback during Cardiopulmonary Resuscitation: Comparing Bystander CPR Quality in a Randomized and Controlled Manikin Study of Simulated Cardiac Arrest

OBJECTIVE

The use of smartphone applications increases bystander CPR quality as well as the use of telephone CPR protocols. The present prospective, randomized, controlled manikin trial analyses the effects of a smartphone application (PocketCPR©) on CPR quality in a bystander CPR scenario compared to a dispatcher-assisted telephone CPR with the additional use of a metronome and verbal motivation. Methods: 150 laypersons were included to perform 8-minute CPR on a manikin. Volunteers were randomly assigned to one of three groups: (1) dispatcher-assisted telephone CPR (telephone-group), (2) dispatcher-assisted telephone CPR combined with the smartphone-application (telephone + app-group) and (3) dispatcher-assisted telephone CPR with additional verbal motivation ("push harder, release completely," every 20 seconds, starting after 60 seconds) and a metronome with 100 min^-1 (telephone + motivation-group). Results: Median compression depth did not differ significantly between the study groups (p = 0.051). However, in the post hoc analysis median compression depth in the telephone + motivation-group was significantly elevated compared to the telephone + app-group (59 mm [IQR 47-67 mm] vs. 51 mm [IQR 46-57 mm]; p = 0.025). The median number of superficial compressions was significantly reduced in the telephone + motivation-group compared to the telephone + app-group (70 [IQR 3-362] vs. 349 [IQR 88-538]; p = 0.004), but not compared to the telephone-group (91 [IQR 4-449]; p = 0.707). In contrast to the other study groups, median compression depth of the telephone + motivation-group increased over time. Chest compressions with correct depth were found significantly more often in the telephone + app-group compared to the other study groups (p = 0.011). Median compression rate in the telephone + app-group was significantly elevated (108 min^-1 [IQR 96-119 min^-1]) compared to the telephone-group (78 min^-1 [IQR 56-106 min^-1]; p < 0.001) and the telephone + motivation-group (99 min^-1 [IQR 91-101 min^-1]; p < 0.001). Conclusions: The use of a smartphone application as well as verbal motivation by a dispatcher during telephone CPR leads to higher CPR quality levels compared to standard telephone CPR. Thereby, the use of the smartphone application mainly shows an increase in compression rate, while increased compression rate with simultaneously increased compression depth was only apparent in the telephone + motivation-group.