Understanding and improving low bystander CPR rates: a systematic review of the literature

Wearable devices for out-of-hospital cardiac arrest: A population survey on the willingness to adhere

Objectives

When an out-of-hospital cardiac arrest (OHCA) occurs, the first step in the chain of survival is detection. However, 75% of OHCAs are unwitnessed, representing the largest barrier to activating the chain of survival. Wearable devices have the potential to be "artificial bystanders," detecting OHCA and alerting 9-1-1. We sought to understand factors impacting users' willingness for continuous use of a wearable device through an online survey to inform future use of these systems for automated OHCA detection.

Methods

Data were collected from October 2022 to June 2023 through voluntary response sampling. The survey investigated user convenience and perception of urgency to understand design preferences and willingness to adhere to continuous wearable use across different hypothetical risk levels. Associations between categorical variables and willingness were evaluated through nonparametric tests. Logistic models were fit to evaluate the association between continuous variables and willingness at different hypothetical risk levels.

Results

The survey was completed by 359 participants. Participants preferred hand-based devices (wristbands: 87%, watches: 86%, rings: 62%) and prioritized comfort (94%), cost (83%), and size (72%). Participants were more willing to adhere at higher levels of hypothetical risk. At the baseline risk of 0.1%, older individuals with prior wearable use were most willing to adhere to continuous wearable use.

Conclusion

Individuals were willing to continuously wear wearable devices for OHCA detection, especially at increased hypothetical risk of OHCA. Optimizing willingness is not just a matter of adjusting for user preferences, but also increasing perception of urgency through awareness and education about OHCA.

A Cross-Sectional Analysis of Bystander Cardiopulmonary Resuscitation (CPR): Behavioural Changes in the COVID-19 Era

Objectives The coronavirus disease 2019 (COVID-19) pandemic has impacted public health systems and individuals' behaviour, with decreasing survival rates among out-of-hospital cardiac arrest (OHCA) patients. Bystander cardiopulmonary resuscitation (CPR) improves OHCA outcomes, which may have been affected by COVID-19. We sought to understand the impacts of COVID-19 on bystanders' willingness to administer CPR in three Canadian provinces. Methods Participants ≥ 18 years of age were surveyed online about their current and recalled pre-pandemic attitudes toward CPR and perceived transmission risk. We compared mean willingness to perform various CPR actions before and during the pandemic using paired t-tests. Differences in willingness across three provinces were assessed using analysis of variance (ANOVA) and Tukey's Honestly Significant Difference (HSD) test. We also conducted Chi-square tests to assess changes in willingness to perform CPR on children and older adults. Results Five hundred thirty-five participants were surveyed from October 1 to November 15, 2021. The mean age was 42.7 years (SD 14.5), and 60.2% were female. Participants reported less willingness to perform chest compressions on strangers during the pandemic compared to their recollections before the pandemic (mean willingness 86.2% vs. 94.3% prior, p<0.001). With personal protective equipment (PPE) available, particularly masks, willingness recovered to 91.3% (p<0.001). Willingness was higher in Nova Scotia (NS) than in British Columbia (BC) or Ontario (ON). Reluctance to assist older adults increased from 6.6% to 12.0% (p=0.020). Conclusions This study highlights changes in CPR willingness during the COVID-19 pandemic, underscoring the importance of PPE and offering insights into public health strategies pertaining to CPR during a pandemic.

Telephone-Cardiopulmonary Resuscitation Guided by a Telecommunicator: Design of a Guiding Algorithm for Telecommunicators

BACKGROUND

Out-of-hospital cardiac arrest is considered a global problem. In the last few years, there has been a growing interest in telephone-cardiopulmonary resuscitation guided by a telecommunicator. Indeed, several studies have demonstrated that it increases the chances of survival rate. This study focuses on the key points the operator should follow when performing telephone-cardiopulmonary resuscitation. The main objective of this paper is to design an algorithm to improve the telephone-cardiopulmonary resuscitation response protocol.

METHODS

The available evidence and the areas of uncertainty that have not been previously mentioned in the literature are discussed. All the information has been analyzed by two discussion groups. Later, a consensus was reached among all members. Finally, a response algorithm was designed and implemented in clinical simulation.

RESULTS

All the witnesses were able to recognize the OHCA, call for emergency assistance, follow all the operator's instructions, move the victim, and place their hands in the correct position to perform CPR.

DISCUSSION

The results of the pilot study provide us a basis for further experimental studies using randomization and experimental and control groups.

CONCLUSIONS

No standardized recommendations exist for the operator to perform telephone-guided CPR. For this reason, a response algorithm was designed.

The Knowledge, Attitudes, and Associated Factors Regarding First Aid Among the General Public in Saudi Arabia

BACKGROUND

Accidents may occur at any time and in any location. Unintentional accidents may have life-threatening consequences. Anyone with basic first aid knowledge can assess the situation and intervene to provide proper care. This research aims to assess public knowledge and attitudes toward first aid and its related aspects in Saudi Arabia.

METHODS

A cross-sectional online survey was conducted between April and May 2023 to investigate first aid knowledge, attitude, and associated factors among the general public of Saudi Arabia. This study's population consisted of Saudi Arabians aged at least 18 who are part of the general community. This research adapted and used a previously developed questionnaire to evaluate the general public's knowledge, attitudes, and other characteristics about first aid in Saudi Arabia. A binary logistic regression analysis was utilized to determine the variables that influence their knowledge and attitude.

RESULTS

A total of 1135 participants were involved in this study. Almost one-third of the study participants (36.0%) reported that they had received training in first aid. The vast majority of the study participants (94.5%) reported that they had heard of first aid before. The media was the most commonly reported source of information on first aid (37.6%). Choking (63.2%), breathing difficulty (61.7%), and fainting (56.7%) were the most commonly reported indications (injuries or accidents) that need first aid. The mean knowledge score for the study participants was 4.4 (SD: 2.8) out of 8 (55.0%), which represents a moderate level of knowledge of first aid. The mean attitude score for the study participants was 22.5 (SD: 2.7) out of 28 (80.4%), which reflects a positive attitude toward first aid. Binary logistic regression analysis identified that women, those who have a higher education level, medical students, those with a high monthly income (7500 Saudi Arabian rials (SAR) and above), and those who work in the healthcare sector were more likely to be knowledgeable about first aid (p<0.05). Participants aged 31 to 40 years and university students were more likely to have a positive attitude toward first aid (p<0.05).

CONCLUSION

This research highlights the need to educate the public about first aid and emergency treatment. Even though one-third of participants have received first aid training, ongoing training is necessary. First aid information, especially on social media, is often unreliable. Choking, difficulty breathing, and syncope are typical first aid conditions, and awareness of dealing with choking is needed. Gender, socioeconomic status, and education influenced first aid knowledge and attitudes. Women, medical students, and healthcare workers knew more about first aid. Most participants supported first aid provision. This research strongly suggests improving awareness, providing inexpensive first-aid training, and targeting specific populations to improve first-aid knowledge and attitudes.

Interaction between Bystander Sex and Patient Sex in Bystander Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrests

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) is a critical factor in improving out-of-hospital cardiac arrest (OHCA) survival. The aim of this study was to investigate the interaction effect of bystander sex and patient sex on the provision of bystander CPR.

METHODS

This was a retrospective cohort study using national OHCA registry in Korea. The inclusion criteria were adult bystander-witnessed OHCA patients with presumed cardiac etiology from January 2016 to December 2020. The primary outcome was the provision of bystander CPR. Multivariable logistic regression and interaction analysis were conducted to evaluate the impact of bystander sex on bystander CPR provision based on patient sex.

RESULTS

The study included 24,919 patients with OHCA, 58.2% with male-bystanders and 41.8% with female-bystanders. Female bystanders were less likely to perform bystander CPR than male bystanders (68.0% vs. 78.8%, adjusted OR (95% CI): 0.62 (0.58-0.66)). Among patients with CPR-trained bystanders, female bystanders had lower odds of bystander CPR (0.85 (0.73-0.97)). In the interaction analysis between bystander and patient sex, a significant difference was observed in the likelihood of bystander CPR according to the patient sex. Female bystanders had lower odds of bystander CPR than male bystanders for male patients (0.47 (0.43-0.50)). However, there were no significant differences between male and female bystanders for female patients (0.91 (0.88-1.07)).

CONCLUSION

Female bystanders have a lower likelihood of providing bystander CPR than male bystanders. Additionally, an interaction was observed between bystander sex and patient sex in the providing bystander CPR, with the association being more pronounced in male OHCA patients.

Racial, ethnic, and socioeconomic disparities in out-of-hospital cardiac arrest within the United States: Now is the time for change

This review highlights the current evidence on racial, ethnic, and socioeconomic disparities in cardiac arrest outcomes within the United States. Several studies demonstrate that patients from Black, Hispanic, or lower socioeconomic status backgrounds suffer the most from disparities at multiple levels of the resuscitation pathway, including in the provision of bystander cardiopulmonary resuscitation, defibrillator usage, and postresuscitation therapies. These gaps in care may altogether lead to lower survival rates and worse neurological outcomes for these patients. A multisystem, culturally sensitive approach to improving cardiac arrest outcomes is suggested in this article.

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study

BACKGROUND

T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival.

OBJECTIVE

To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan.

METHODS

A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant.

RESULTS

There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.).

CONCLUSION

Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Can high school students teach their peers high quality cardiopulmonary resuscitation (CPR)?

Background

If adolescents can teach each other cardiopulmonary resuscitation (CPR) during school hours, this may be a cost-effective approach to CPR training. The aim of this study was to evaluate CPR quality among students trained by student instructors in CPR.

Material and methods

Three high schools participated. Recruited student instructors (SIs) were given a two-day course by professional instructors. Theoretic knowledge was acquired through an e-learning program. The SIs then trained fellow students in a 90-minute practical CPR session during physical education classes. All participants performed a 4-minutes test of CPR performance. Data was collected using Little Anne QCPR manikins with QCPR classroom software (Laerdal Medical Inc, Norway). Statistical equivalence in CPR performance was assessed applying the two one-sided tests (TOST)-procedure.

Results

Eight professional instructors trained 76 SIs who trained approximately 2650 students in CPR. The number of available tests for analysis of student performance was 982. The compression rates were within guideline recommendations for SIs (mean 110.6, SD 5.4) and students (mean 118.6, SD 8.6). The corresponding numbers for mean compression depth were 7.2 cm (SD 0.7) and 7 cm (SD 1.0). Students demonstrated greater variation in mouth-to-mouth (MTM) skills, with only 41% performing at least 15 successful ventilations during the test. Except for the total number of MTM ventilations (mean difference −5.6), CPR performance was deemed statistically equivalent between professional instructors, SIs and students.

Conclusions

High school students can be trained as CPR instructors and teach fellow students CPR with good quality, with some variation in MTM-ventilation skills.

Understanding the Importance of the Lay Responder Experience in Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association

Bystander cardiopulmonary resuscitation (CPR) is critical to increasing survival from out-of-hospital cardiac arrest. However, the percentage of cases in which an individual receives bystander CPR is actually low, at only 35% to 40% globally. Preparing lay responders to recognize the signs of sudden cardiac arrest, call 9-1-1, and perform CPR in public and private locations is crucial to increasing survival from this public health problem. The objective of this scientific statement is to summarize the most recent published evidence about the lay responder experience of training, responding, and dealing with the residual impact of witnessing an out-of-hospital cardiac arrest. The scientific statement focuses on the experience-based literature of actual responders, which includes barriers to responding, experiences of doing CPR, use of an automated external defibrillator, the impact of dispatcher-assisted CPR, and the potential for postevent psychological sequelae. The large body of qualitative and observational studies identifies several gaps in crucial knowledge that, if targeted, could increase the likelihood that those who are trained in CPR will act. We suggest using the experience of actual responders to inform more contextualized training, including the implications of performing CPR on a family member, dispelling myths about harm, training and litigation, and recognition of the potential for psychologic sequelae after the event.

How do naloxone-based interventions work to reduce overdose deaths: a realist review

BACKGROUND

Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone; however, the role of context and mechanisms for its use has not been explored. This realist systematic review aims to identify a theory of how naloxone works based on the contexts and mechanisms that contribute to the success of the intervention for improved outcomes.

METHODS

Pre-registered at PROSPERO, this realist review followed RAMESES standards of reporting. Keywords included 'naloxone' and ' opioid overdose'. All study designs were included. Data extraction using 55 relevant outputs based on realist logic produced evidence of two middle-range theories: Naloxone Bystander Intervention Theory and Skills Transfer Theory.

RESULTS

Harm reduction and/or low threshold contexts provide a non-judgemental approach which support in-group norms of helping and empower the social identity of the trained and untrained bystander. This context also creates the conditions necessary for skills transfer and diffusion of the intervention into social networks. Stigma and negative attitudes held by first responders and stakeholders involved in the implementation process, such as police or GPs, can prohibit the bystander response by inducing fear in responding. This interferes with skills transfer, naloxone use and carriage of naloxone kits.

CONCLUSIONS

The findings provide theoretically informed guidance regarding the harm reduction contexts that are essential for the successful implementation of naloxone-based interventions. Peer-to-peer models of training are helpful as it reinforces social identity and successful skills transfer between bystanders. Health systems may want to assess the prevalence of, and take steps to reduce opioid-related stigma with key stakeholders in contexts using a low threshold training approach to build an environment  to support positive naloxone outcomes.

TRIAL REGISTRATION

PROSPERO 2019 CRD42019141003.

The impact of bystander cardiopulmonary resuscitation on patients with out-of-hospital cardiac arrests

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death around the world. Bystander cardiopulmonary resuscitation (CPR) is an independent factor to improve OHCA survival. However, the prevalence of bystander CPR remains low worldwide. Community interventions such as mandatory school CPR training or targeting CPR training to family members of high-risk cardiac patients are possible strategies to improve bystander CPR rate. Real-time feedback, hands-on practice with a manikin, and metronome assistance may increase the quality of CPR. Dispatcher-assistance and compression-only CPR for untrained bystanders have shown to increase bystander CPR rate and increase survival to hospital discharge. After return of spontaneous circulation, targeted temperature management should be performed to improve neurological function. This review focuses on the impact of bystander CPR on clinical outcomes and strategies to optimize the prevalence and quality of bystander CPR.

Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study

BACKGROUND

Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA.

OBJECTIVE

Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population.

METHODS

Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross-affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, "essential BLS knowledge," which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables.

RESULTS

The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P<.001) and 6-question score (mean 3.0, SD 1.1 vs mean 2.0, SD 1.0; P<.001). Participants who were younger or already trained scored consistently better. Although the phone number of the emergency medical dispatch center was well known in both groups (medical students, 75/80, 94% vs lay people, 51/62, 82%; P=.06), most participants were unable to identify the criteria used to recognize OHCA, and almost none were able to correctly reorganize the BLS sequence. Medical students felt more confident than lay people in their ability to perform resuscitation (mean 4.7, SD 2.2 vs mean 3.1, SD 2.1; P<.001). Female gender and older age were associated with lower confidence, while participants who had already attended a BLS course prior to taking the questionnaire felt more confident.

CONCLUSIONS

Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered.

Using the theory of planned behavior to understand intentions to perform bystander CPR among college students

The purpose of this study was to determine the extent to which the Theory of Planned Behavior (TPB) accounts for variability in intention to perform cardiopulmonary resuscitation (CPR) and to explore which constructs in the TPB most strongly predict intention to perform CPR among college students. Participants: Undergraduate college students (N = 588, 51% women) recruited between September and November 2016. Methods: A cross-sectional survey design. Results: Attitude was the strongest predictor of intention to perform CPR (β = 0.381, p < .001), followed by subjective norm (β = 0.303, p < .001), and perceived behavioral control (β = 0.167, p < .001). The TPB accounted for 51% of the variance in intention to perform CPR (F[3, 536] = 186, p < .001). Conclusion: Attitude and subjective norm are the strongest predictors of intention to perform CPR among college students. Resuscitation trainings that highlight positive outcomes and social norms associated with performing CPR may help bystanders form intentions to perform CPR in an emergency.

Experiences and Psychological Influences in Lay Rescuers Performing Bystander Cardiopulmonary Resuscitation: A Qualitative Study

BACKGROUND

Bystander-initiated cardiopulmonary resuscitation (CPR) and the use of automated external defibrillation (AED) is pivotal in the community chain of survival, but little is known regarding the bystander experience of performing CPR and AED, and their psychological infl uence from the incidents in the Asian community. This qualitative study was conducted to explore the experiences of lay rescuers who had performed CPR and AED in public locations in Taiwan.

METHODS

Lay rescuers who had provided initial CPR and defi brillation with AED in public locations across Taiwan in 2015 were selectively recruited from Taiwan Public AED Registry for a semi-structured interview.

RESULTS

Nine participants were included in the study, and event-to-interview duration was within 1 year (n = 4) and 1-2 years (n = 5). The major fi ndings from the study were: (1) the lay rescuers possessed helping traits and high motivation; (2) the lay rescuers reported certain aspects of rescue reality that differed much from prior training and expectations, including diffi culty in the depth of chest compression, and uncertainties in real emergency situations; (3) the lay rescuers gained positive personal fulfi llment in sharing their experience and receiving positive feedback from others, and were willing to help next time, although they experienced a short-term negative psychological impact from the event.

CONCLUSIONS

This study provides valuable information on strategies to increase layperson CPR rates and effectiveness in CPR training. Measures should be taken to increase layperson's confi dence and situation awareness, reduce training-reality discrepancy, build up a support system to avoid negative psychological effects, and prepare lay rescuers for the next resuscitation.

Evolution of Bystander Intention to Perform Resuscitation Since Last Training: Web-Based Survey

BACKGROUND

Victims of out-of-hospital cardiac arrest (OHCA) have higher survival rates and more favorable neurological outcomes when basic life support (BLS) maneuvers are initiated quickly after collapse. Although more than half of OHCAs are witnessed, BLS is infrequently provided, thereby worsening the survival and neurological prognoses of OHCA victims. According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it. This intention is determined by three distinct dimensions: attitude, subjective normative beliefs, and control beliefs. We hypothesized that there could be a decrease in one or more of these dimensions even shortly after the last BLS training session.

OBJECTIVE

The aim of this study was to measure the variation of the three dimensions of the intention to perform resuscitation according to the time elapsed since the last first-aid course.

METHODS

Between January and April 2019, the two largest companies delivering first-aid courses in the region of Geneva, Switzerland sent invitation emails on our behalf to people who had followed a first-aid course between January 2014 and December 2018. Participants were asked to answer a set of 17 psychometric questions based on a 4-point Likert scale ("I don't agree," "I partially agree," "I agree," and "I totally agree") designed to assess the three dimensions of the intention to perform resuscitation. The primary outcome was the difference in each of these dimensions between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. Secondary outcomes were the change in each dimension using cutoffs at 1 year and 2 years, and the change regarding each individual question using cutoffs at 6 months, 1 year, and 2 years. Univariate and multivariable linear regression were used for analyses.

RESULTS

A total of 204 surveys (76%) were analyzed. After adjustment, control beliefs was the only dimension that was significantly lower in participants who took the questionnaire more than 6 months after their last BLS course (P<.001). Resisting diffusion of responsibility, a key element of subjective normative beliefs, was also less likely in this group (P=.001). By contrast, members of this group were less afraid of disease transmission (P=.03). However, fear of legal action was higher in this group (P=.02).

CONCLUSIONS

Control beliefs already show a significant decrease 6 months after the last first-aid course. Short interventions should be designed to restore this dimension to its immediate postcourse state. This could enhance the provision of BLS maneuvers in cases of OHCA.

Comparison between dispatcher-assisted bystander CPR and self-led bystander CPR in out-of-hospital cardiac arrest (OHCA)

INTRODUCTION

Bystander cardiopulmonary resuscitation (CPR) is an important prognostic factor for outcome in out-of-hospital cardiac arrest (OHCA). The dispatcher-assisted (DA) bystander CPR program has increased the rate of bystander CPR by targeting bystanders with a lower level of CPR training. We evaluated the effects of dispatcher-assisted bystander CPR and self-led bystander CPR.

METHODS

A retrospective analysis was performed using a nationwide OHCA database from 2014 to 2018. Adult EMS-treated OHCA patients with presumed cardiac origin were enrolled. OHCAs were classified into 3 groups according to the type of bystander CPR (DA bystander CPR vs. self-led bystander CPR vs. no bystander CPR) provided. The primary outcome was good neurologic recovery at hospital discharge. A multivariable logistic regression model was used to estimate the association between the type of bystander CPR and outcomes.

RESULTS

A total of 91,557 eligible OHCA patients was enrolled in the final analysis. The proportion of patients with favorable neurologic outcomes was highest with self-led bystander CPR (9.0% for self-led bystander CPR, 5.2% for DA bystander CPR and 3.2% for no bystander CPR, p < 0.01). Self-led bystander CPR was associated with better neurological recovery than DA bystander CPR (aOR with 95% CI (DA-CPR as reference): 0.63 (0.58-0.69) for no bystander CPR, 1.28 (1.17-1.40) for self-led bystander CPR).

CONCLUSION

Although DA CPR was associated with better neurologic outcomes than no bystander CPR, good neurologic outcomes were most strongly associated with self-led bystander CPR.

In out-of-hospital cardiac arrest, is the positioning of victims by bystanders adequate for CPR? A cohort study

OBJECTIVES

Outcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome.

DESIGN

Prospective observational cohort study.

SETTING

Metropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest.

PARTICIPANTS

Bystanders of all OHCAs occurring during a 12-month period (July 2006-July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months.

RESULTS

Positioning of victims at EMS arrival was 'supine on firm surface' in 64 cases (32.0%), 'recovery position (RP)' in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when 'supine position' had been applied, 13.5% with 'RP' and 6.1% with 'other positions unsuitable for CCs'; a statistically significant association could not be shown (p=0.740, Fisher's exact test). However, after 'effective CCs' favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02).

CONCLUSION

In OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.

The Baby Shark (Songs Heard Affecting Resuscitation Kinetics) study

Previous research has examined the utilisation of musical cues to improve the performance of cardiopulmonary resuscitation (CPR) delivered in training environments. We postulated a musical cue that is both contemporary and transcends cultures may improve CPR performance. Our aim was to establish whether chest compressions are performed with improved rate and depth if a song of a fixed beat (PinkFong's 'Baby Shark' with a tempo of 115 beats per minute (bpm) and 15 beats in each verse) is played to a healthcare professional immediately before undertaking CPR compared to whale noises (a non-metronomic rhythm). 58 Participants of a paediatric conference (majority doctors) were randomly assigned to listen to a minute of Baby Shark (28) or whale song (30) and then undertake a minute of CPR. There was no significant difference in the mean compression rate between the Baby Shark and control groups, with the groups achieving 121 and 125 bpm, respectively (p=0.18). In relation to compression depth within the target zone, the Baby Shark group had more compressions completed within the target zone (55%) than the control group (39%) although this difference was not significant (p=0.08). Listening to Baby Shark prior to undertaking simulated CPR does not improve overall performance, but there is a potential tendency to improve adequate compression depth which may be beneficial in training exercises.

Importance of "Telephone Cardiopulmonary Resuscitation" in out-of-Hospital Cardiac Arrest in India

Background:

Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality in developing countries such as India. Most cardiac arrests happen outside the hospital and are associated with poor survival rates due to delay in recognition and in performing early cardiopulmonary resuscitation (CPR). Community CPR training and telephone CPR (T-CPR) in the dispatch centers have been shown to increase bystander CPR rates and survival.

Objectives:

The aim of this study is to identify the significance of T-CPR in OHCA and to discuss its implementation in the health system to improve OHCA outcomes in India.

Materials and Methods:

A descriptive research study methodology was adopted following a literature search.

Results:

The search criterion “Cardiovascular diseases” resulted in 162, “Out-side hospital cardiac arrest” in 50; For a comprehensive overview, these publications were evaluated looking for data on T-CPR incidence, criteria for detecting OHCA by emergency medical dispatchers, sensitivity and specificity, and BCPR.

Conclusion:

This current research stresses the scale and seriousness of the implementation of T-CPR in OHCA in India.

Assessment of Community Interventions for Bystander Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis

IMPORTANCE

Outcomes from out-of-hospital cardiac arrests (OHCAs) remain poor. Outcomes associated with community interventions that address bystander cardiopulmonary resuscitation (CPR) remain unclear and need further study.

OBJECTIVE

To examine community interventions and their association with bystander CPR and survival after OHCA.

DATA SOURCES

Literature search of the MEDLINE, Embase, and the Cochrane Library databases from database inception to December 31, 2018, was conducted. Key search terms included cardiopulmonary resuscitation, layperson, basic life support, education, cardiac arrest, and survival.

STUDY SELECTION

Community intervention studies that reported on comparisons with control and differences in survival following OHCA were included. Studies that focused only on in-hospital interventions, patients with in-hospital cardiac arrest, only dispatcher-assisted CPR, or provision of automated external defibrillators were excluded.

DATA EXTRACTION AND SYNTHESIS

Pooled odds ratios (ORs) and 95% CIs were estimated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

Thirty-day survival or survival to hospital discharge and bystander CPR rate.

RESULTS

A total of 4480 articles were identified; of these, 15 studies were included for analysis. There were broadly 2 types of interventions: community intervention alone (5 studies) and community intervention combined with changes in health services (10 studies). Four studies involved notification systems that alerted trained lay bystanders to the location of the OHCA in addition to CPR skills training. Meta-analysis of 9 studies including 21 266 patients with OHCA found that community interventions were associated with increased survival to discharge or 30-day survival (OR, 1.34; 95% CI, 1.14-1.57; I2 = 33%) and greater bystander CPR rate (OR, 1.28; 95% CI, 1.06-1.54; I2 = 82%). Compared with community intervention alone, community plus health service intervention was associated with a greater bystander CPR rate compared with community alone (community plus intervention: OR, 1.74; 95% CI, 1.26-2.40 vs community alone: OR, 1.06; 95% CI, 0.85-1.31) (P = .01). Survival rate, however, was not significantly different between intervention types: community plus health service intervention OR, 1.71; 95% CI, 1.09-2.68 vs community only OR, 1.26; 95% CI, 1.05-1.50 (P = .21).

CONCLUSIONS AND RELEVANCE

In this study, while the evidence base is limited, community-based interventions with a focus on improving bystander CPR appeared to be associated with improved survival following OHCA. Further evaluations in diverse settings are needed to enable widespread implementation of such interventions.

Barriers to bystander CPR in deprived communities: Findings from a qualitative study

STUDY AIM

Rates of out of hospital cardiac arrest are higher in deprived communities. Bystander Cardiopulmonary Resuscitation (BCPR) can double the chance of survival but occurs less often in these communities in comparison to more affluent communities. People living in deprived communities are, therefore, doubly disadvantaged and there is limited evidence to explain why BCPR rates are lower. The aim of this paper is to examine the barriers to administering BCPR in deprived communities.

METHOD

Mixed method qualitative study with ten single sex focus groups (n = 61) conducted in deprived communities across central Scotland and 18 semi-structured interviews with stakeholders from the UK, Europe and the USA.

RESULTS

Two key themes related to confidence and environmental factors were identified to summarise the perceived barriers to administering BCPR in deprived communities. Barriers related to confidence included: self-efficacy; knowledge and awareness of how, and when, to administer CPR; accessing CPR training; having previous experience of administering BCPR; who required CPR; and whether the bystander was physically fit to give CPR. Environmental barriers focused on the safety of the physical environment in which people lived, and fear of reprisal from gangs or the police.

CONCLUSIONS

Barriers to administering BCPR identified in the general population are relevant to people living in deprived communities but are exacerbated by a range of contextual, individual and environmental factors. A one-size-fits-all approach is not sufficient to promote 'CPR readiness' in deprived communities. Future approaches to working with disadvantaged communities should be tailored to the local community.

Disparities in Bystander Cardiopulmonary Resuscitation Performed by a Family Member and a Non-family Member

Background

Although bystander cardiopulmonary resuscitation (BCPR) plays an essential role in out-of-hospital cardiac arrest (OHCA) care, little is known about the bystander-patient relationship in the actual setting. This study aimed to assess the disparities in BCPR performed by a family member and that performed by a non-family member.

Methods

This population-based observational study involved all adult patients with witnessed OHCAs of medical origin in Niigata City, Japan, between January 2012 and December 2016, according to the Utstein style. We used logistic regression analysis to assess the association between the witnessing person and the probability of providing BCPR. Next, among those who received BCPR, we sought to investigate the difference between BCPR performed by family and that performed by non-family members in terms of whether those who witnessed the arrests actually performed BCPR.

Results

During the study period, 818 were eligible for this analysis, with 609 (74.4%) patients witnessed by family and 209 (25.6%) patients witnessed by non-family members. Multivariable logistic regression analysis showed that OHCA patients witnessed by family were less likely to receive BCPR compared to those witnessed by non-family members (260/609 [42.7%] versus 119/209 [56.9%], P = 0.017). Among the witnessed patients for whom BCPR was performed, the proportion of BCPR actually performed by a family member was lower than that performed by a non-family member (242/260 [93.1%] versus 116/119 [97.5%], P = 0.011).

Conclusions

In this community-based observational study, we found that a witnessing family member is less likely to perform BCPR than a witnessing non-family member.

Impact of Bystander Cardiopulmonary Resuscitation and Dispatcher Assistance on Survival After Out-of-Hospital Cardiac Arrest Among Adult Patients by Location of Arrest

We investigated the impact of bystander-initiated cardiopulmonary resuscitation (CPR), dispatcher assistance (DA), and location of arrest on survival and outcomes after out-of-hospital cardiac arrest (OHCA).From a nationwide population-based registry of OHCA patients in Japan, we enrolled adult patients with bystander-witnessed OHCA of medical origin between 2013 and 2015. The primary outcome measure was a neurologically favorable outcome, defined by cerebral performance category 1 or 2. Multivariable logistic regression analysis was used to assess the effects of bystander CPR and DA by location of arrest. A total of 104,621 cases were included (15,984 bystander CPR without DA [15.3%], 40,087 bystander CPR with DA [38.3%], and 48,550 no bystander CPR [46.4%]). In public locations, both the bystander-CPR-with-DA group (22.9% [1,068/4,665]; adjusted odds ratio (AOR), 1.62; 95% confidence interval (CI), 1.43-1.85) and the bystander-CPR-without-DA group (25.8% [918/3,557]; AOR, 1.43; 95% CI, 1.24-1.65) had neurologically favorable outcomes compared with the no-bystander-CPR group (9.9% [610/6,133]). In residential locations, the AORs were 1.44 (95% CI, 1.22-1.70) in the bystander-CPR-without-DA group and 1.60 (95% CI, 1.45-1.77) in the bystander-CPR-with-DA group. However, in nursing homes, bystander CPR was not associated with improved outcomes of OHCA, regardless of the implementation of DA.Bystander CPR with or without DA had better outcomes after OHCA in residential and public locations but not in nursing homes.

Mapping the public first-aid training landscape: a scoping review

While the public can play a vital role in saving lives during emergencies, intervention is only effective if people have the skills, confidence, and willingness to help. This review employs a five-stage framework to systematically analyse first aid and emergency helping literature from 22 countries (predominately in Asia, Australia, Europe, and the United States). The review covers 54 articles that investigate public first-aid knowledge and uptake of first-aid training (40); public confidence in first-aid skills and willingness to help during an emergency (21); and barriers to or enablers of learning first aid and delivering first aid in an emergency (25). The findings identify high levels of perceived knowledge, confidence, and willingness to help, supporting the contention that the public can play a vital role during an emergency. However, the findings also point to low uptake levels, low tested skill-specific knowledge, and barriers to learning first aid and helping, indicating that the first-aid training landscape is in need of improvement.

Confidence and willingness among laypersons in the UK to act in a head injury situation: a qualitative focus group study

OBJECTIVES

To explore factors influencing confidence and willingness among laypersons in the UK to act in a head injury situation, in order to inform first aid education offered by the British Red Cross.

DESIGN

Qualitative focus group study.

SETTING

South East England.

PARTICIPANTS

Forty-four laypersons (37 women, 7 men) were purposively recruited from the general public using snowball sampling, into one focus group each for six population groups: parents of young children (n=8), informal carers of older adults (n=7), school staff (n=7), sports coaches (n=2), young adults (n=9) and 'other' adults (n=11). The median (range) age group across the sample was 25-34 years (18-24, 84-95). Participants were from Asian (n=6), Black (n=6), Mixed (n=2) and White (n=30) ethnic backgrounds.

RESULTS

The majority of participants described being confident and willing to act in a head injury scenario if that meant calling for assistance, but did not feel sufficiently confident or knowledgeable to assist or make decisions in a more involved way. Individuals' confidence and willingness presented as fluid and dependent on an interplay of situational and contextual considerations, which strongly impacted decision-making: prior knowledge and experience, characteristics of the injured person, un/observed head injury, and location and environment. These considerations may be framed as enablers or barriers to helping behaviour, impacting decision-making to the same extent as-or even more so than-the clinical signs and symptoms of head injury. An individual conceptual model is proposed to illustrate inter-relationships between these factors.

CONCLUSIONS

Our findings show that confidence and willingness to act in a head injury scenario are dependent on several contextual and situational factors. It is important to address such factors, in addition to knowledge of clinical signs and symptoms, in first aid education and training to improve confidence and willingness to act.

Good Samaritan Law and bystander cardiopulmonary resuscitation: Cross-sectional study of 1223 first-aid learners in Hong Kong

Background:

Similar to many Asian cities, there is no statutory provision for the determination of the duty borne by bystander first aiders when assisting victims in Hong Kong.

Objectives:

The aim of this study was to explore the views of a Good Samaritan Law by first-aid learners in Hong Kong.

Methods:

A cross-sectional survey was conducted among first-aid course participants from the two largest training providers in Hong Kong using a self-administered questionnaire.

Results:

In total, 1223 questionnaires were completed and returned. Only 12.1% (147/1211) of participants have ever heard of Good Samaritan Law. After a short description of Good Samaritan Law was provided, 71.4% (848/1188) agreed or strongly agreed on a Likert-type scale that a Good Samaritan Law is necessary; 95.2% (1148/1223) support the enactment of a Good Samaritan Law in Hong Kong.

Conclusion:

The majority of first-aid learners in Hong Kong supported the enactment of Good Samaritan Law. Overcoming the fear of litigation and improving bystander cardiopulmonary resuscitation rate is a priority for improving survival rates from sudden cardiac arrest in Hong Kong.

A centralized system for providing dispatcher assisted CPR instructions to 9-1-1 callers at multiple municipal public safety answering points

BACKGROUND

Dispatcher CPR instruction increases the odds of survival. However, many communities do not provide this lifesaving intervention, often citing the barriers of limited personnel, funding, and liability.

OBJECTIVE

Describe the implementation of a novel centralized dispatcher CPR instruction program that serves seven public safety answering points (PSAPs).

METHODS

Seven municipal PSAPs that did not previously provide dispatcher instructions implemented our program. Using a 30-min self-directed video, 84 PSAP dispatchers were trained to utilize a two-question protocol to identify and transfer suspected out-of-hospital cardiac arrest (OHCA) cases to a central communication center. At this central communication center, a trained communicator delivered CPR instructions to the caller. The 26 central communicators were trained with a 2-h in-person didactic session followed by a 2-h practice session. We collected and analyzed data from recordings of communicator-to-caller interactions.

RESULTS

169 calls were transferred to the central communication center. Of those, 106 needed CPR instructions and 56 of those callers performed chest compressions (53%). The county-wide EMS documented bystander CPR rate was 20% the prior year. The 63 remaining transferred calls were non-OHCA calls. Of the calls where CPR was needed and performed, 11 victims survived to hospital discharge (20%); the countywide survival rate was 12%.

CONCLUSIONS

Using a central communication center for instructions allowed us to train and maintain a smaller group of communicators, leading to less cost and more experience for those communicators, while limiting the burden on PSAP dispatchers.

Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study

INTRODUCTION

Simulation-based medical education (SBME) improves medical knowledge compared with no intervention. In traditional SBME, more time is spent debriefing than practicing skills. Rapid cycle deliberate practice (RCDP) simulation allows learners to practice skills repetitively, receive brief interspersed feedback, and has been shown to improve individual performance of resuscitation skills in simulation; it has not been compared with traditional simulation methods.

OBJECTIVE

The aim of the study was to compare traditional and RCDP SBME.

METHODS

Four pediatric resuscitation cases (3 for teaching and 1 for testing) were developed. For the RCDP arm, traditional cases were deconstructed into sequences of progressively difficult rounds. The last RCDP round served as the traditional arm scenario.Learners received 1 type of instruction on 2 separate days. Pretest and posttest performance during simulation were video recorded and scored using the Simulation Team Assessment Tool; satisfaction surveys were collected.

RESULTS

Pretest team performance was similar in both groups. Simulation Team Assessment Tool score improvement for RCDP was 7.2% (95% confidence interval, 3.4% to 11%) and traditional was 0.8% (95% confidence interval, -11% to 13%). The difference in improvement of the human factors subscore was statistically significant; RCDP improved 10.2% and traditional improved 1.7% (P = 0.013). The RCDP technique was well received by learners but caused fatigue.

CONCLUSIONS

This pilot study showed a trend toward greater improvement in team performance and significantly greater improvement for human factors with RCDP compared with traditional simulation. Future studies comparing RCDP with other methods are needed to identify best practices and applications of RCDP, including which learners and learning objectives are best suited to RCDP.

Dispatcher-assisted cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest: A structured evaluation of communication issues using the SACCIA® safe communication typology

AIM

To evaluate communication issues during dispatcher-assisted cardiopulmonary resuscitation (DACPR) for paediatric out-of-hospital cardiac arrest in a structured manner to facilitate recommendations for training improvement.

METHODS

A retrospective observational study evaluated DACPR communication issues using the SACCIA^® Safe Communication typology (Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation). Telephone recordings of 31 cases were transcribed verbatim and analysed with respect to encoding, decoding and transactional communication issues.

RESULTS

Sixty SACCIA communication issues were observed in the 31 cases, averaging 1.9 issues per case. A majority of the issues were related to sufficiency (35%) and accuracy (35%) of communication between dispatcher and caller. Situation specific guideline application was observed in CPR practice, (co)counting and methods of compressions.

CONCLUSION

This structured evaluation identified specific issues in paediatric DACPR communication. Our training recommendations focus on situation and language specific guideline application and moving beyond verbal communication by utilizing the smart phone's functions. Prospective efforts are necessary to follow-up its translation into better paediatric DACPR outcomes.

Characteristics Associated with First Aid and Cardiopulmonary Resuscitation Training and Use in Queensland, Australia

INTRODUCTION

First aid, particularly bystander cardiopulmonary resuscitation (CPR), is an important element in the chain of survival. However, little is known about what influences populations to undertake first aid/CPR training, update their training, and use of the training.

OBJECTIVES

The aim of this study was to explore the characteristics of people who have first aid/CPR training, those who have updated their training, and use of these skills.

METHODS

As part of the 2011 state-wide, computer-assisted telephone interviewing (CATI) survey of people over 18 years of age living in Queensland, Australia, stratified by gender and age group, three questions about first aid training, re-training, and skill uses were explored.

RESULTS

Of the 1,277 respondents, 73.2% reported having undertaken some first aid/CPR training and 39.5% of those respondents had used their first aid/CPR skills. The majority of respondents (56.7%) had not updated their first aid/CPR skills in the past three years, and an additional 2.5% had never updated their skills. People who did not progress beyond year 10 in school and those in lower income groups were less likely to have undertaken first aid/CPR training. Males and people in lower income groups were less likely to have recently updated their first aid/CPR training. People with chronic health problems were in a unique demographic sub-group; they were less likely to have undertaken first aid/CPR training but more likely to have administered first aid/CPR.

CONCLUSION

Training initiatives that target people on the basis of education level, income group, and the existence of chronic health problems might be one strategy for improving bystander CPR rates when cardiac arrest occurs in the home.Franklin RC, Watt K, Aitken P, Brown LH, Leggat PA. Characteristics associated with first aid and cardiopulmonary resuscitation training and use in Queensland, Australia. Prehosp Disaster Med. 2019;34(2):155-160.

Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review

AIM

To determine whether training history (including number of times and duration since last training), knowledge, self-efficacy or willingness are associated with cardiopulmonary resuscitation (CPR) psychomotor skills.

METHODS

Eight databases were systematically searched from January 2005 to February 2018 for articles that involved adult layperson participants and explored an association between training history, knowledge, self-efficacy or willingness and CPR psychomotor skills or survival outcomes after real CPR attempts.

RESULTS

Thirty-four articles with a total of 35,421 participants were included. CPR training was found to improve psychomotor skills, compared to no training, and any previous training was associated with better skills, compared to no previous training, however only the use of a popular song promoted meaningful retention of a specifically targeted skill, compared to standard training methods. Skills deteriorated within 3 months, then plateaued from 3 to 6 months. Self-efficacy was weakly associated with skill level, however knowledge was not associated with skill level. No studies assessed the association between willingness and psychomotor skills.

CONCLUSION

All laypeople should attend an instructor-led CPR training session with real-time or delayed feedback to improve CPR skills. Training sessions should utilise combinations of validated skill-specific training strategies, preferably including popular songs and feedback to help ensure skills retention. Refresher training, which focusses on skills and self-confidence rather than knowledge, should be undertaken every 3-6 months, although this timeframe needs further validation. All future studies assessing CPR psychomotor skills should adhere to a standardised reporting outcome list (proposed in this paper) to ensure consistency and comparability of results.

Characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates in England

Aims

The aim of the project was to identify the neighbourhood characteristics of areas in England where out-of-hospital cardiac arrest (OHCA) incidence was high and bystander cardiopulmonary resuscitation (BCPR) was low using registry data.

Methods and results

Analysis was based on 67 219 cardiac arrest events between 1 April 2013 and 31 December 2015. Arrest locations were geocoded to give latitude/longitude. Postcode district was chosen as the proxy for neighbourhood. High-risk neighbourhoods, where OHCA incidence based on residential population was >127.6/100 000, or based on workday population was >130/100 000, and BCPR in bystander witnessed arrest was <60% were observed to have: a greater mean residential population density, a lower workday population density, a lower rural-urban index, a higher proportion of people in routine occupations and lower proportion in managerial occupations, a greater proportion of population from ethnic minorities, a greater proportion of people not born in UK, and greater level of deprivation. High-risk areas were observed in the North-East, Yorkshire, South-East, and Birmingham.

Conclusion

The study identified neighbourhood characteristics of high-risk areas that experience a high incidence of OHCA and low bystander resuscitation rate that could be targeted for programmes of training in cardiopulmonary resuscitation and automated external defibrillator use.

Determining the motivations of family members to undertake cardiopulmonary resuscitation training through grounded theory

AIMS

To explore the motivation of family members of patients at high risk for sudden cardiac death for undertaking cardiopulmonary resuscitation (CPR) training.

BACKGROUND

Home cardiac arrests are associated with poor outcomes because few family members learn CPR. Little is known about factors that motivate family members to participate in CPR training.

DESIGN

We used grounded theory to establish a theoretical framework to explore the motivational factors for learning CPR among family members.

METHODS

Twelve participant observations and 42 semi-structured interviews with family members of different behaviours towards CPR training were conducted from December 2013 - November 2016. Data were analysed using constant-comparisons, situational analysis, and encoding.

FINDINGS

A motivation-behaviour theoretical framework for learning CPR was constructed. We identified meeting inner needs as the core category to demonstrate motivation. Security motivation and responsibility motivation emerged as main categories, which demonstrate that seeking a sense of security and shouldering family responsibility were important considerations for family members to learn CPR. These two motivations produced high-engagement behaviours of family members to learn CPR.

CONCLUSIONS

The motivations we identified-deriving from a sense of security and family responsibility-are the main reasons family members would learn CPR and, therefore, should be understood by medical professionals. Understanding these motivations may help in the formulation of customized CPR training that further meets the needs of family members. For example, motivational interventions that are integrated with a family-based CPR course can be designed to improve the participation of family members and the sustainability of the course.

Traumatic cardiac arrest is associated with lower survival rate vs. medical cardiac arrest - Results from the French national registry

INTRODUCTION

The survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts.

MATERIAL & METHODS

National case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching.

RESULTS

Compared with medical OHCA (n = 40,878) trauma victims (n = 3209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]).

CONCLUSIONS

The survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.

Easy-to-learn cardiopulmonary resuscitation training programme: a randomised controlled trial on laypeople's resuscitation performance

INTRODUCTION

Simplifying the learning of cardiopulmonary resuscitation (CPR) is advocated to improve skill acquisition and retention. A simplified CPR training programme focusing on continuous chest compression, with a simple landmark tracing technique, was introduced to laypeople. The study aimed to examine the effectiveness of the simplified CPR training in improving lay rescuers' CPR performance as compared to standard CPR.

METHODS

A total of 85 laypeople (aged 21-60 years) were recruited and randomly assigned to undertake either a two-hour simplified or standard CPR training session. They were tested two months after the training on a simulated cardiac arrest scenario. Participants' performance on the sequence of CPR steps was observed and evaluated using a validated CPR algorithm checklist. The quality of chest compression and ventilation was assessed from the recording manikins.

RESULTS

The simplified CPR group performed significantly better on the CPR algorithm when compared to the standard CPR group (p < 0.01). No significant difference was found between the groups in time taken to initiate CPR. However, a significantly higher number of compressions and proportion of adequate compressions was demonstrated by the simplified group than the standard group (p < 0.01). Hands-off time was significantly shorter in the simplified CPR group than in the standard CPR group (p < 0.001).

CONCLUSION

Simplifying the learning of CPR by focusing on continuous chest compressions, with simple hand placement for chest compression, could lead to better acquisition and retention of CPR algorithms, and better quality of chest compressions than standard CPR.

Description of Abnormal Breathing Is Associated With Improved Outcomes and Delayed Telephone Cardiopulmonary Resuscitation Instructions

Background

Emergency 9‐1‐1 callers use a wide range of terms to describe abnormal breathing in persons with out‐of‐hospital cardiac arrest (OHCA). These breathing descriptors can obstruct the telephone cardiopulmonary resuscitation (CPR) process.

Methods and Results

We conducted an observational study of emergency call audio recordings linked to confirmed OHCAs in a statewide Utstein‐style database. Breathing descriptors fell into 1 of 8 groups (eg, gasping, snoring). We divided the study population into groups with and without descriptors for abnormal breathing to investigate the impact of these descriptors on patient outcomes and telephone CPR process. Callers used descriptors in 459 of 2411 cases (19.0%) between October 1, 2010, and December 31, 2014. Survival outcome was better when the caller used a breathing descriptor (19.6% versus 8.8%, P<0.0001), with an odds ratio of 1.63 (95% confidence interval, 1.17–2.25). After exclusions, 379 of 459 cases were eligible for process analysis. When callers described abnormal breathing, the rates of telecommunicator OHCA recognition, CPR instruction, and telephone CPR were lower than when callers did not use a breathing descriptor (79.7% versus 93.0%, P<0.0001; 65.4% versus 72.5%, P=0.0078; and 60.2% versus 66.9%, P=0.0123, respectively). The time interval between call receipt and OHCA recognition was longer when the caller used a breathing descriptor (118.5 versus 73.5 seconds, P<0.0001).

Conclusions

Descriptors of abnormal breathing are associated with improved outcomes but also with delays in the identification of OHCA. Familiarizing telecommunicators with these descriptors may improve the telephone CPR process including OHCA recognition for patients with increased probability of survival.

Incorporating cardiopulmonary resuscitation training into a cardiac rehabilitation programme: A feasibility study

Background:

Patients with a cardiac history are at future risk of cardiac events, including out-of-hospital cardiac arrest. Targeting cardiopulmonary resuscitation (CPR) training to family members of cardiac patients has long been advocated, but is an area in need of contemporary research evidence. An environment yet to be investigated for targeted training is cardiac rehabilitation.

Aim:

To evaluate the feasibility of providing CPR training in a cardiac rehabilitation programme among patients, their family members and staff.

Methods:

A prospective before and after study design was used. CPR training was delivered using video self-instruction CPR training kits, facilitated by a cardiac nurse. Data was collected pre-training, post-training and at one month.

Results:

Cardiac patient participation rates in CPR classes were high ( n = 56, 72.7% of eligible patients) with a further 27 family members attending training. Patients were predominantly male (60.2%), family members were predominantly female (81.5%), both with a mean age of 65 years. Confidence to perform CPR and willingness to use skills significantly increased post-training (both p<0.001). Post training participants demonstrated a mean compression rate of 112 beats/min and a mean depth of 48 mm. Training reach was doubled as participants shared the video self-instruction kit with a further 87 people. Patients, family members and cardiac rehabilitation staff had positive feedback about the training.

Conclusions:

We demonstrated that cardiac rehabilitation is an effective and feasible environment to provide CPR training. Using video self-instruction CPR training kits enabled further training reach to the target population.

Improvement of lay rescuer chest compressions with a novel audiovisual feedback device : A randomized trial

BACKGROUND

Bystander actions and skills determine among others the outcome of out-of-hospital cardiac arrest. However, the depth and rate of chest compressions (CC) are difficult to estimate for laypeople and poor CC quality may result. Our study aimed to evaluate the impact of a new feedback device on CC performance by laypeople. The percentage of CC with both correct rate and correct depth of all CC served as primary endpoint.

METHODS

Forty-eight subjects with no medical background performed 2 min of CC on a manikin with and without a novel feedback device (TrueCPR™, Physio-Control, Redmond, Wash.). The device uses a novel, non-accelerometer-based technology. Participants were randomized into two groups. Group 1 performed a 2-min CC trial first with audiovisual feedback followed by a trial with no feedback information, while group 2 performed the task in reverse order.

RESULTS

The absolute percentage of CC with correct rate and depth was significantly higher with the use of the device (59 ± 34% vs. 15 ± 21%, p < 0.0001). The longest interval without correct CC was significantly decreased (76.5 s vs. 27.5 s, p < 0.0001).

CONCLUSION

The quality of CC carried out by laypeople is significantly improved with the use of a new feedback device. The device may be useful for cardiopulmonary resuscitation (CPR) by laypeople and for educational purposes.

Retention of Basic Life Support in Laypeople: Mastery Learning vs. Time-based Education

OBJECTIVE

To compare the effectiveness of a mastery learning (ML) versus a time-based (TB) BLS course for the acquisition and retention of BLS knowledge and skills in laypeople.

METHODS

After ethics approval, laypeople were randomized to a ML or TB BLS course based on the American Heart Association (AHA) Heartsaver course. In the ML group, subjects practiced and received feedback at six BLS stations until they reached a pre-determined level of performance. The TB group received a standard AHA six-station BLS course. All participants took the standard in-course BLS skills test at the end of their course. BLS skills and knowledge were tested using a high-fidelity scenario and knowledge questionnaire upon course completion (immediate post-test) and after four months (retention test). Video recorded scenarios were assessed by two blinded, independent raters using the AHA skills checklist.

RESULTS

Forty-three subjects were included in analysis (23ML;20TB). For primary outcome, subjects' performance did not change after four months, regardless of the teaching modality (TB from (median[IQR]) 8.0[6.125;8.375] to 8.5[5.625;9.0] vs. ML from 8.0[7.0;9.0] to 7.0[6.0;8.0], p = 0.12 for test phase, p = 0.21 for interaction between effect of teaching modality and test phase). For secondary outcomes, subjects acquired knowledge between pre- and immediate post-tests (p < 0.005), and partially retained the acquired knowledge up to four months (p < 0.005) despite a decrease between immediate post-test and retention test (p = 0.009), irrespectively of the group (p = 0.59) (TB from 63.3[48.3;73.3] to 93.3[81.7;100.0] and then 93.3[81.7;93.3] vs. ML from 60.0[46.7;66.7] to 93.3[80.0;100.0] and then 80.0[73.3;93.3]). Regardless of the group after 4 months, chest compression depth improved (TB from 39.0[35.0;46.0] to 48.5[40.25;58.0] vs. ML from 40.0[37.0;47.0] to 45.0[37.0;52.0]; p = 0.012), but not the rate (TB from 118.0[114.0;125.0] to 120.5[113.0;129.5] vs. ML from 119.0[113.0;130.0] to 123.0[102.0;132.0]; p = 0.70). All subjects passed the in-course BLS skills test. Pass/fail rates were poor in both groups at both the simulated immediate post-test (ML = 1/22;TB = 0/20; p = 0.35) and retention test (ML pass/fail = 1/22, TB pass/fail = 0/20; p = 0.35). The ML course was slightly longer than the TB course (108[94;117] min vs. 95[89;102] min; p = 0.003).

CONCLUSIONS

There was no major benefit of a ML compared to a TB BLS course for the acquisition and four-month retention of knowledge or skills among laypeople.

Are sociodemographic characteristics associated with spatial variation in the incidence of OHCA and bystander CPR rates? A population-based observational study in Victoria, Australia

BACKGROUND

Rates of out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (CPR) have been shown to vary considerably in Victoria. We examined the extent to which this variation could be explained by the sociodemographic and population health characteristics of the region.

METHODS

Using the Victorian Ambulance Cardiac Arrest Registry, we extracted OHCA cases occurring between 2011 and 2013. We restricted the calculation of bystander CPR rates to those arrests that were witnessed by a bystander. To estimate the level of variation between Victorian local government areas (LGAs), we used a two-stage modelling approach using random-effects modelling.

RESULTS

Between 2011 and 2013, there were 15 830 adult OHCA in Victoria. Incidence rates varied across the state between 41.9 to 104.0 cases/100 000 population. The proportion of the population over 65, socioeconomic status, smoking prevalence and education level were significant predictors of incidence in the multivariable model, explaining 93.9% of the variation in incidence among LGAs. Estimates of bystander CPR rates for bystander witnessed arrests varied from 62.7% to 73.2%. Only population density was a significant predictor of rates in a multivariable model, explaining 73% of the variation in the odds of receiving bystander CPR among LGAs.

CONCLUSIONS

Our results show that the regional characteristics which underlie the variation seen in rates of bystander CPR may be region specific and may require study in smaller areas. However, characteristics associated with high incidence and low bystander CPR rates can be identified and will help to target regions and inform local interventions to increase bystander CPR rates.

Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital Discharge: A Multicenter Pragmatic Trial

BACKGROUND

Cardiopulmonary resuscitation (CPR) training rates in the United States are low, highlighting the need to develop CPR educational approaches that are simpler, with broader dissemination potential. The minimum training required to ensure long-term skill retention remains poorly characterized. We compared CPR skill retention among laypersons randomized to training with video-only (VO; no manikin) with those trained with a video self-instruction kit (VSI; with manikin). We hypothesized that VO training would be noninferior to the VSI approach with respect to chest compression (CC) rate.

METHODS AND RESULTS

We performed a prospective, cluster randomized trial of CPR education for family members of patients with high-risk cardiac conditions on hospital cardiac units, using a multicenter pragmatic design. Eight hospitals were randomized to offer either VO or VSI training before discharge using volunteer trainers. CPR skills were assessed 6 months post training. Mean CC rate among those trained with VO compared with those trained with VSI was assessed with a noninferiority margin set at 8 CC per min; as a secondary outcome, mean differences in CC depth were assessed. From February 2012 to May 2015, 1464 subjects were enrolled and 522 subjects completed a skills assessment. The mean CC rates were 87.7 (VO) CC per min and 89.3 (VSI) CC per min; we concluded noninferiority for VO based on a mean difference of -1.6 (90% confidence interval, -5.2 to 2.1). The mean CC depth was 40.2 mm (VO) and 45.8 mm (VSI) with a mean difference of -5.6 (95% confidence interval, -7.6 to -3.7). Results were similar after multivariate regression adjustment.

CONCLUSIONS

In this large, prospective trial of CPR skill retention, VO training yielded a noninferior difference in CC rate compared with VSI training. CC depth was greater in the VSI group. These findings suggest a potential trade-off in efforts for broad dissemination of basic CPR skills; VO training might allow for greater scalability and dissemination, but with a potential reduction in CC depth.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01514656.

Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition

Objective

We compared training using a voice advisory manikin (VAM) with an instructor-led (IL) course in terms of acquisition of initial cardiopulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines.

Methods

This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and distributed them randomly into two groups: the IL group (n=41) and the VAM group (n=37). In the IL-group, participants were trained in “single-rescuer, adult CPR” according to the American Heart Association’s Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes.

Results

The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; P=0.396).

Conclusion

Both methods, the IL training using a practice-while-watching video and the VAM training, facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Telephone-assisted CPR: A literature review

Introduction

Despite numerous efforts, out-of-hospital cardiac arrest (OHCA) survival has not significantly increased in recent decades. The first telephone-assisted cardiopulmonary resuscitation (T-CPR) studies were published in the 1980s, but only in the last decade has T‑CPR been implemented in dispatch centers. T‑CPR is still not available in all dispatch centers and no national or international T‑CPR recommendations are available.

Methods

Studies from PubMed were identified and evaluated. Preliminary information from the European Dispatch Center Survey (EDiCeS) is also included.

Results

In all, 42 studies were included. T‑CPR is implemented in 87.6 % of those dispatch centers which have joined the not-yet published EDiCeS. According to German Resuscitation Registry data, about 10 % of OHCA patients received T‑CPR in 2014. Agonal breathing is the leading cause for nonrecognition of OHCA by the dispatcher. Sensitivity of OHCA recognition by the dispatcher is about 75 %, whereby 8–45 % of these patients were not in cardiac arrest. The time interval from call to first compression is 140–328 s. Instructing rescue breathing by telephone is time consuming, leads to extensive hands-off times, and often to ineffective ventilation; therefore, rescue breathing is not indicated in adults with primary cardiac arrest. Studies showed improved survival with standardized T‑CPR implementation.

Conclusion

T-CPR is established in many dispatch centers. However, emergency call interrogation and T‑CPR vary between dispatch centers and are often performed without evaluation. International recommendations with standardized quality control are necessary and may lead to improved survival.