Comparison Between Self-Deliberate Practice and Directed Learning Training Methods for Basic Life Support Knowledge and High-Quality Cardiopulmonary Resuscitation Skill Retention in Second-Year Medical Students 3 and 6 Months After Training.

Background: Cardiopulmonary resuscitation (CPR) requires well-trained medical personnel. Multiple learning methods can be done for CPR skills training. This study aimed to compare self-deliberate practice (SDP) method and directed learning (DL) method to improve basic life support (BLS) knowledge and CPR skill performance in medical students. Methods: This is an experimental, single-blind, randomized controlled trial study of 40 medical students from February to July 2019. Forty subjects were randomly assigned into SDP and DL groups through a voluntary sampling method. Both groups attended a 1-day course and then practiced once a month for 3 months. The DL group had practice sessions with assigned tutors, while the SDP group had to practice by themselves. Examination of BLS knowledge and CPR performance quality (compression depth, rate, and performance score) was collected before and after course lecture, after a skills training, 3 and 6 months after training. Results: Subject characteristics of both groups were comparable. Significant knowledge and skill improvement were found in the DL group and the SDP group when compared to their knowledge and skill before training. There were no significant differences between both groups in BLS knowledge and CPR performance quality in all examination periods. Conclusion: Both SDP and DL teaching methods show significant improvement and excellent retention in BLS knowledge and high-quality CPR performance. These two learning methods are both feasible and bring positive results for students. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01746-7.

Resuscitation Strategies for Maximizing Survival.

There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissue oxygenation, and continuous arterial monitoring are options for use early defibrillation are critical elements of resuscitation. Cardio-cerebral perfusion may be improved with the use of active compression-decompression CPR, an impedance threshold device, and head-up CPR. In refractory shockable arrest, if ECPR is not an option, consider changing defibrillator pad placement and/or double defibrillation, additional medication options, and possibly stellate ganglion block.

Under pressure: What individual characteristics lead to performance of high-quality chest compressions during CPR practice sessions?

Aim: Despite well-established protocols for cardiopulmonary resuscitation training, performance during real-life cardiac arrests can be suboptimal. Understanding personal characteristics which could influence performance of high-quality chest compressions could provide insight into the practice-performance gap. This study examined chest compression performance, while employing feedback and introducing code team sounds as an anxiety-inducing factor in registered nurses using a cardiopulmonary resuscitation training manikin. Methods: Participants included 120 registered nurses with basic life support certification randomized to one of the following groups: no feedback and no code team sounds, feedback without code team sounds, or feedback with code team sounds. Chest compression sessions occurred at baseline, 30-days and 60-days. Demographic variables and anxiety level were also collected. The primary outcome was chest compression performance, defined as average percent of time with correct rate and percent with correct depth as captured by the defibrillator. Statistical analysis included linear mixed effects analysis. Results: The effect of feedback on chest compression performance depended on the value of other parameters. The benefit of feedback on the primary outcome depended on: age, with feedback less beneficial among older participants (p = 0.0413); and time, with feedback more beneficial with repetition (p = 0.011). These interactions also affected the outcome percent of time with correct compression depth. Increased anxiety was associated with decreased percent correct compression depth (p < 0.001). Conclusion: Feedback emerged as important in determining chest compression performance. Chest compression quality was limited by the performer's age and anxiety level. Future research should focus on identifying factors related to individual characteristics which may influence chest compression performance.

Different Resting Methods in Improving Laypersons Hands-Only Cardiopulmonary Resuscitation Quality and Reducing Fatigue: A Randomized Crossover Study.

OBJECTIVE: To determine the effects of different resting methods with various rest-start points or rest-compression ratios on improving cardiopulmonary resuscitation (CPR) quality and reducing fatigue during continuous chest compressions (CCC) in 10-min hands-only CPR scenario. METHODS: This prospective crossover study was conducted in 30 laypersons aged 18-65. Trained participants were randomized to follow different orders to perform following hands-only CPR methods: (1) CCC, 10-min CCC; (2) 4+6, 4-min CCC + 6-min of 10-s pause after 60-s compressions; (3) 2+8 (10/60), 2-min CCC + 8-min of 10-s pause after 60-s compressions; (4) 5/30, 2-min CCC + 8-min of 5-s pause after 30-s compressions; (5) 3/15, 2-min CCC + 8-min of 3-s pause after 15-s compressions. CPR quality (depth, rate, hands-off duration, chest compression fraction (CCF)) and participants' fatigue indicators (heart rate, blood pressure, rating of perceived exertion (RPE)) were compared among methods of different rest-start points and different rest-compression ratios with CCC. RESULTS: Twenty-eight participants completed all methods. All resting methods reduced the trend of declining compression depth and the trend of increasing RPE while maintaining CCF of more than 86%. In methods with different rest-start points, the 2+8 method showed no difference in overall CPR quality or fatigue, but better CPR quality of every minute than 4+6 method. In methods with different rest-compression ratios, the 3/15 method showed the best CPR quality and the highest heart rate increment. CONCLUSION: During prolonged hands-only CPR, appropriate transient rests were associated with higher CPR quality and lower subjectively perceived fatigue in laypersons.

Can hospital adult code-teams and individual members perform high-quality CPR? A multicenter simulation-based study incorporating an educational intervention with CPR feedback.

AIMS: A multicenter simulation-based research study to assess the ability of interprofessional code-teams and individual members to perform high-quality CPR (HQ-CPR) at baseline and following an educational intervention with a CPR feedback device. METHODS: Five centers recruited ten interprofessional teams of AHA-certified adult code-team members with a goal of 200 participants. Baseline testing of chest compression (CC) quality was measured for all individuals. Teams participated in a baseline simulated cardiac arrest (SCA) where CC quality, chest compression fraction (CCF), and peri-shock pauses were recorded. Teams participated in a standardized HQ-CPR and abbreviated TeamSTEPPS® didactic, then engaged in deliberate practice with a CPR feedback device. Individuals were assessed to determine if they could achieve ≥80% combined rate and depth within 2020 AHA guidelines. Teams completed a second SCA and CPR metrics were recorded. Feedback was disabled for assessments except at one site where real-time CPR feedback was the institutional standard. Linear regression models were used to test for site effect and paired t-tests to evaluate significant score changes. Logistic univariate regression models were used to explore characteristics associated with the individual achieving competency. RESULTS: Data from 184 individuals and 45 teams were analyzed. Baseline HQ-CPR mean score across all sites was 18.5% for individuals and 13.8% for teams. Post-intervention HQ-CPR mean score was 59.8% for individuals and 37.0% for teams. There was a statistically significant improvement in HQ-CPR mean scores of 41.3% (36.1, 46.5) for individuals and 23.2% (17.1, 29.3) for teams (p < 0.0001). CCF increased at 3 out of 5 sites and there was a mean 5-s reduction in peri-shock pauses (p < 0.0001). Characteristics with a statistically significant association were height (p = 0.01) and number of times performed CPR (p = 0.01). CONCLUSION: Code-teams and individuals struggle to perform HQ-CPR but show improvement after deliberate practice with feedback as part of an educational intervention. Only one site that incorporated real-time CPR feedback devices routinely achieved ≥80% HQ-CPR.

Physiological Response of Quality Cardiopulmonary Resuscitation, Crossover Trial on Mannequin in Extreme Temperature Conditions.

BACKGROUND: To determine the relationship between physiological fatigue and the quality of cardiopulmonary resuscitation (CPR) in trained resuscitators in hostile thermal environments (extreme cold and heat) simulating the different conditions found in an out-of-hospital cardiorespiratory arrest. METHODS: Prospective observational study involving 60 students of the health sciences with training in resuscitation, who simulated CPR on a mannequin for 10 min in different thermal environments: thermo-neutral environment (21 °C and 60% humidity), heat environment (41 °C and 98% humidity) and cold environment (-35 °C and 80% humidity). Physiological parameters (heart rate and lactic acid) and CPR quality were monitored. RESULTS: We detected a significant increase in the number of compressions per minute in the "heat environment" group after three minutes and in the mean rate after one minute. We observed a negative correlation between the total number of compressions and mean rate with respect to mean depth. The fraction of compressions (proportion of time in which chest compressions are carried out) was significant over time and the mean rate was higher in the "heat environment". Physiological parameters revealed no differences in heart rate depending on the resuscitation scenario; however, there was a greater and faster increase in lactate in the "heat environment" (significant at minute 3). The total proportion of participants reaching metabolic fatigue was also higher in the "heat environment". CONCLUSIONS: A warm climate modifies metabolic parameters, reducing the quality of the CPR maneuver.

The use of prefilled adrenaline syringes improves cardiopulmonary resuscitation quality-high-fidelity simulator-based study.

BACKGROUND: In some countries, adrenaline is available only in glass ampoules. However, simplification of cardiopulmonary resuscitation (CPR) by introducing prefilled syringes may ensure more efficient CPR. The aim of this study was to investigate the impact of different forms of adrenaline on the CPR quality. METHODS: In a randomized cross-examination simulation study, 100 two-person paramedical teams took part in two 10-minute scenarios of sudden cardiac arrest (SCA) in a pulseless electrical activity mechanism (PEA). In the first scenario the set of medicines contained glass ampoules (group ST) with adrenaline, in the second prefilled syringes (group AMPS). The parameters of the CPR quality [correct number and depth of chest compressions (CC), no flow time, chest recoil, time to apply supraglottic airways device (SAD)] were compared. RESULTS: In group AMPS the first dose of adrenaline was administered after 114.2±28.3 seconds after the initiation of CPR whereas after 178.1±62.6 seconds in group ST (P<0.001). Chest compression fraction (CCF) was higher (81.8%±6.1%) in group AMPS than in group ST (71.2%±7.5%). Paramedics performed CC at better frequency, to a preferred depth and in an appropriate place in group AMPS. Faster decision to apply SAD (131.7±34.0 s in group AMPS and 220.3±81.5 s in group ST) ensured faster achievement of airway patency in this group (181.5±48.7 vs. 271.2±101.5 s). CONCLUSIONS: Prefilled syringes with crucial drugs during CPR may significantly improve the quality of CPR performed by two-person teams.

Association of chest compression and recoil velocities with depth and rate in manual cardiopulmonary resuscitation.

AIM: Maximum velocity during chest recoil has been proposed as a metric for chest compression quality during cardiopulmonary resuscitation (CPR). This study investigated the relationship of the maximum velocities during compression and recoil phases with compression depth and rate in manual CPR. METHODS: We measured compression instances in out-of-hospital cardiac arrest recordings using custom Matlab programs. Each compression cycle was characterized by depth and rate, maximum compression and recoil velocities (CV and RV), and compression and recoil durations (total and effective). Mean compression and recoil velocities were computed as depth divided by compression and recoil durations, respectively. We correlated CV and RV with their corresponding mean velocities (total and effective), characterized by Pearson's correlation coefficient. RESULTS: CV/RV were strongly correlated with their corresponding mean velocities, with a median r of 0.83 (0.77-0.88)/0.82 (0.76-0.87) in per patient analysis, 0.86/0.88 for all the population. Correlation with mean effective velocities had a median r of 0.91 (0.87-0.94)/0.92 (0.89-0.94) in per-patient, 0.92/0.94 globally (p < 0.001). Total and effective compression and recoil durations were inversely proportional to compression rate. We observed similar RV values among compressions regardless of whether they were compliant with recommended depth and rate. Conversely, we observed different RV values among compressions having the same depth and rate, but presenting very distinct compression waveforms. CONCLUSION: CV and RV were highly correlated with compression depth and compression and recoil times, respectively. Better understanding of the relationship between novel and current quality metrics could help with the interpretation of CPR quality studies.

A nationwide investigation of CPR courses, books, and skill retention.

INTRODUCTION: Survival from Out-of-Hospital Cardiac Arrest is highly associated with bystander cardiopulmonary resuscitation. The quality of bystander CPR is influenced by citizens attending Basic Life Support (BLS) courses and the quality of these courses. The purpose of the study was to investigate content, quality and compliance with the European Resuscitation Council (ERC) guidelines in national Danish BLS courses and the skill retention. METHODS: Books from 16 different course providers were analyzed for compliance with guidelines using the principle of mutually exclusive and collectively exhaustive questioning. Observation of 56 BLS courses were conducted using an evaluation sheet, with a five-point Likert scale including theoretical, technical, and non-technical skills. BLS skills of participants were assessed with a follow-up test 4-6 months after a course using a modified Cardiff Test. RESULTS: Analysis of the books, showed compliance with ERC guidelines of 69% on the examined items. Courses using ERC educational structure and having maximum six participants per instructor were associated with high quality in the course observations and a better follow-up test. Especially, the use of automated external defibrillator showed significant odds ratio (OR) of 21.8 (95% CI 4.1-114.7) to 31.3 (95% CI 3.7-265.1) of achieving high quality on courses with similar results in the follow-up test. CONCLUSION: National BLS courses had significant variation in the content of books, and compliance to ERC guidelines during courses and in skills retention 4-6 months after the courses. This study can be used to further improve and standardize BLS courses.

CPR performance in the presence of audiovisual feedback or football shoulder pads.

OBJECTIVE: The initiation of cardiopulmonary resuscitation (CPR) can be complicated by the use of protective equipment in contact sports, and the rate of success in resuscitating the patient depends on the time from incident to start of CPR. The aim of our study was to see if (1) previous training, (2) the presence of audiovisual feedback and (3) the presence of football shoulder pads (FSP) affected the quality of chest compressions. METHODS: Six basic life support certified athletic training students (BLS-ATS), six basic life support certified emergency medical service personnel (BLS-EMS) and six advanced cardiac life support certified emergency medical service personnel (ACLS-EMS) participated in a crossover manikin study. A quasi-experimental repeated measures design was used to measure the chest compression depth (cm), rate (cpm), depth accuracy (%) and rate accuracy (%) on four different conditions by using feedback and/or FSP. Real CPR Help manufactured by ZOLL (Chelmsford, Massachusetts, USA) was used for the audiovisual feedback. Three participants from each group performed 2 min of chest compressions at baseline first, followed by compressions with FSP, with feedback and with both FSP and feedback (FSP+feedback). The other three participants from each group performed compressions at baseline first, followed by compressions with FSP+feedback, feedback and FSP. RESULTS: CPR performance did not differ between the groups at baseline (median (IQR), BLS-ATS: 5.0 (4.4-6.1) cm, 114(96-131) cpm; BLS-EMS: 5.4 (4.1-6.4) cm, 112(99-131) cpm; ACLS-EMS: 6.4 (5.7-6.7) cm, 138(113-140) cpm; depth p=0.10, rate p=0.37). A statistically significant difference in the percentage of depth accuracy was found with feedback (median (IQR), 13.8 (0.9-49.2)% vs 69.6 (32.3-85.8)%; p=0.0002). The rate accuracy was changed from 17.1 (0-80.7)% without feedback to 59.2 (17.3-74.3)% with feedback (p=0.50). The use of feedback was effective for depth accuracy, especially in the BLS-ATS group, regardless of the presence of FSP (median (IQR), 22.0 (7.3-36.2)% vs 71.3 (35.4-86.5)%; p=0.0002). CONCLUSIONS: The use of audiovisual feedback positively affects the quality of the depth of CPR. Both feedback and FSP do not alter the rate measurements. Medically trained personnel are able to deliver the desired depth regardless of the presence of FSP even though shallower chest compressions depth can be seen in CPR with FSP. A feedback device must be introduced into the athletic training settings.

Improving quality in measuring time to initiation of CPR during in-hospital resuscitation.

OBJECTIVE: Time from the onset of "low or no flow" indicators of cardiac failure to initiation of cardiopulmonary resuscitation is an important quality metric thought to improve the likelihood of survival and preservation of end organ function. We hypothesized that delays in initiation of chest compressions were under recognized during in-hospital resuscitation and aimed to develop a system which identifies the actual time of deterioration during cardiac events. METHODS: Retrospective review on prospectively identified resuscitation records and monitor data were compared. Return of spontaneous circulation, survival, and changes in functional status of patients pre- and post-events with chest compressions were collected as outcome measures. RESULTS: Between October 2012 and April 2015, 59 events which met eligibility criteria occurred in either our pediatric cardiac or general pediatric intensive care units. The median time from event onset to initiation of chest compressions was 47s(s) (interquartile range (IQR) 28-80s) as assessed using monitor data, while the resuscitation record reported a median time of 0s (IQR 0-60s), reflecting the time from recognition to initiation of chest compressions. According to the resuscitation record, 81% vs. 63% of events achieved the quality standard of less than one minute depending on which review method was used (p=0.04). CONCLUSIONS: There is a significant difference between time of deterioration to initiation of chest compressions and the time of recognition to initiation of chest compressions. Resuscitation records should be modified to include more information about the actual timing of patient deterioration.