of the 16 reviewed articles, 12 - scholarbank.nus.edu.sg · web viewit is well established that...
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Title: Compression-only cardiopulmonary resuscitation in improving bystanders’ cardiopulmonary resuscitation performance: a literature review
Word Counts: 4154
Keywords: bystanders’ cardiopulmonary resuscitation; compression-only cardiopulmonary
resuscitation; out-of-hospital cardiac arrest; cardiopulmonary resuscitation training
Authors’ names, credentials and affiliation:
1. Rachel Ko Jia Min, RN, Bachelor of Science (Nursing) (Hons). Email:
[email protected] Mailing address: Alice Lee Centre for Nursing Studies,
Yong Loo Lin School of Medicine, National University of Singapore. Level 2,
Clinical Research Centre, Block MD11 10 Medical Drive, Singapore 117597\
2. Vivien Wu Xi, RN, Med. Email: [email protected] Mailing address: Alice Lee
Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of
Singapore. Level 2, Clinical Research Centre, Block MD11 10 Medical Drive,
Singapore 117597
3. Swee Han Lin, Associate Professor and Senior Consultant (Emergency), Email:
[email protected]. Mailing address: Department of Emergency Medicine,
Block 1, Level 2, Outram Road, Singapore 169608
4. Wilson Tam Wai San, PhD, Assistant Professor, Statistician, Email: [email protected]. Mailing address: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore. Level 2, Clinical Research Centre, Block MD11 10 Medical Drive, Singapore 117597
5. Corresponding Author: Sok Ying Liaw, RN, PhD in Health Professional Education,
Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Singapore. Email:[email protected];
Mailing address: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore. Level 2, Clinical Research Centre, Block
MD11 10 Medical Drive, Singapore 117597
1
ABSTRACT
Background: Compression-only cardiopulmonary resuscitation (CPR) has been advocated as
a preferable approach for bystanders in an out-of-hospital cardiac arrest (OHCA) event as it
has been associated with an increased chance of survival. The elimination of mouth-to-mouth
(MTM) ventilation also addresses some of the barriers to performing CPR. The aim of this
study is to undertake a literature review investigating the effectiveness of compression-only
CPR in improving rescuers’ CPR performance as compared to standard CPR.
Methods: A literature search was conducted in the following databases: Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Science Direct, Scopus and PubMed from
January 2003 to January 2014, to include research studies that compared compression-only
CPR with standard CPR on participants above the age of 21, and reported quality of CPR
performance as the primary outcome.
Findings: Of the 3004 articles retrieved, 16 met the inclusion criteria. The reviewed studies
revealed that compression-only CPR requires a shorter time to initiate CPR and delivers a
higher number of total compressions. The depth of compressions in compression-only CPR
performed may be shallower than that of standard CPR due to greater rescuer fatigue. It
therefore remains inconclusive if compression-only CPR can deliver a higher number of
adequate compressions over extended periods of time. It is also unclear if simplified CPR can
improve skill retention level in the long run.
Conclusion: More studies are needed to determine whether compression-only CPR can
indeed help improve rescuers’ CPR performance. Future research efforts, together with
resuscitation policy and practice implications, are needed to further improve rescuers’ CPR
performance with the ultimate goal to enhance OHCA survival rates.
2
INTRODUCTION
It is well established that in the American Heart Association and Emergency Cardiovascular
Care (AHA ECC) “Adult Chain of Survival” concept, the provision of early bystander
cardiopulmonary resuscitation (CPR) is crucial in improving survival outcomes in out-of-
hospital cardiac arrest (OHCA). The current CPR algorithm follows a C-A-B sequence
(Chest compressions, Airway, Breathing), where the lay rescuer provides compressions and
ventilations in a ratio of 30:2 until help arrives.1
Despite promulgation of its importance in successful resuscitation, the prevalence of
bystander CPR remains critically low worldwide, ranging from as low as 1% to 44%.2
Various studies have been carried out to explore the barriers rescuers face to performing
CPR. Reasons cited often include a fear of disease transmission related to performing MTM
ventilation, a lack of confidence, a fear of poor performance and potential legal
implications.3-5 OHCA survival rates vary widely around the world, ranging from 2% to 11%,
which is still an overall low. Poor survival outcomes also suggest a low quality of bystander
CPR performance.6
To address these concerns, AHA introduced the concept of simplifying standard CPR,
also known as “hands-only CPR” or “compression-only CPR”, which has been advocated as
a preferable alternative approach in an OHCA event.7 For discussion purposes, this review
will use the term “compression-only CPR”. The compression-only CPR removes the step of
MTM ventilation during the resuscitation process, and the lay rescuer performs compressions
solely at a rate of about 100 per minute. The elimination of MTM ventilation addresses some
of the barriers to performing CPR, and hence may improve bystander CPR rates.7,8 In the
recent decade, to justify the elimination of ventilations from the bystander CPR sequence,
several studies have been conducted to compare the effectiveness of compression-only CPR
with standard CPR.9-14
Recognizing the importance of delivery high quality of CPR performance in
improving the survival rates among OHCA cases,13-14 this review aims to present the best
available evidence on the effectiveness of compression-only CPR in improving rescuers’
CPR performance as compared to standard CPR. In order to evaluate the effectiveness of the
compression-only CPR, the individual components of CPR performance were studied, i.e.
time taken to initiate CPR, number and depth of compressions, rescuer fatigue, and retention
of skill. This is done by addressing the following PICO question: (Population) in adult
3
rescuers (above 21 years old), how does (Intervention) compression-only CPR compared to
(Control) standard CPR (Outcome) affect CPR performance? (Table 1).
METHOD
Search method and process
A literature search was conducted in the following databases: CINAHL, Science Direct,
Scopus and PubMed. The key search terms used in various combinations were
“cardiopulmonary resuscitation”, “resuscitation”, “CPR”, “compression focus”, “compression
only”, “continuous chest compression”, “bystander CPR” or “rescuer”. The reference lists of
each retrieved paper were also reviewed for additional relevant journals. The search was
limited to journals published from January 2003 to January 2014, as recent publications may
be more relevant to current CPR guidelines.
Inclusion and exclusion criteria
The inclusion criteria were the following: (1) articles published from January 2003 to January
2014; (2) primary research studies in which the intervention was compression-only CPR,
compared to standard CPR; (3) research conducted on any adult participants above the age of
21, including medical staff and lay people; (4) research conducted on manikin models; and
(5) English language publications. The exclusion criteria included (1) conference
proceedings, letters to editors and opinion articles; (2) animal studies; and (3) clinical studies
which compared compression-only CPR and standard CPR in terms of out-of-hospital cardiac
arrest survival outcomes.
Search outcomes and study characteristics
The review yielded 58 potential articles. Each journal article was then read in full text to
determine its relevance. The search process is illustrated in the PRISMA flow diagram
(Figure 1). A total of 42 articles were excluded. Finally, 16 articles were appraised by two
reviewers using the Joanna Briggs Institute critical appraisal checklist for experimental
studies.15 These articles were included in the review as they met the pre-determined
proportion of all criteria - more than six “Yes” out of the 10 criteria indicated in the checklist.
4
Of the 16 reviewed articles, 12 were studies that compared the effectiveness of
compression-only CPR teaching with standard CPR teaching. The remaining four compared
the effectiveness of compression-only CPR with standard CPR dispatcher instructions. While
five studies were conducted on healthcare professional or medical students, the rest of the
studies involved laypeople. A detailed summary of the included studies can be found in
supplementary table 1 (available online only). Findings of these studies were pooled together
and categorized into the following two themes for discussion – quality of skill performance
and retention of skill. The first theme is sub-categorized into the following three subthemes –
time taken to initiate CPR, quality of compression and rescuer fatigue.
Data synthesis
Meta-analysis was performed for the thematic outcomes if two or more studies
reported the same outcome using the same measurement. Mean difference was used as effect
measure and random effects model was used to pool the results from individual studies.16 The
combined estimated and the corresponding 95%. C.I. were presented in the forest plots.
Heterogeneity was assessed by I2. All the analyses were computed using Review Manager 5.2
FINDINGS
Quality of skill performance
Time taken to initiate CPR
Five studies investigated the time taken to initiate compressions in both types of CPR; four
were randomized controlled trials that compared compression-only and standard CPR
dispatcher instructions 17-20 while one was a randomized study of a compression-only CPR
teaching intervention.21
All five studies reported unanimously that a shorter time is taken to initiate
compression in compression-only CPR.17-21 The study designs in the dispatcher studies were
similar – untrained participants were randomized to receive either compression-only or
standard CPR dispatcher instructions and were asked to manage a cardiac arrest victim. In
another study by Heidenreich, 21 which explored the ability of 53 medical students to deliver
80 compressions per minute in both compression-only and standard CPR, the time difference
in initiating compressions between the two CPR techniques was evaluated. Findings also
5
revealed that the time taken to initiate compressions in compression-only CPR was shorter by
25 seconds as compared to standard CPR.21 Results from these studies suggest that using
compression-only CPR means it takes a shorter time to initiate compressions than when using
standard CPR in both trained and untrained performers.
Three studies provided the data on the time taken to first compression for both the
compression-only or standard CPR group. 17, 19, 20 As Woollard reported the median and the
range of time taken to first compression, 20 the mean and standard deviation were computed
for the study using standard formula. 22 The forest plot is shown in Figure 2. The combined
mean difference of the time taken to first compression between the compression-only or
standard CPR was -39.2 secs (95% CI: -65.7, -12.7, p=0.004).
Quality of compression – number of compressions
Four studies compared the number of compressions performed between compression-only
and standard CPR. All of these studies showed a higher number of compressions delivered at
any time point by the compression-only CPR group during the test.18 20 23 24 This was reported
to be due to the presence of “hands off” moments, where compression was paused for
rescuers to perform MTM ventilation in standard CPR.17 21 24 25 26 With more frequent and
longer interruptions in standard CPR, some studies reported that compression-only CPR
could deliver approximately twice as many compressions per minute as compared to standard
CPR. 25
Two studies provided the data of the total number of compression in 2-minute period
and the combined mean difference between compression-only and standard CPR was 62.8
(95% C.I. 56.7, 69.0, p<0.001). This finding implies that the subjects in compression-only
CPR group were on average compressed 62.8 more than those in the standard CPR group (see
Figure 3). 26 33
Quality of compression – number and proportion of adequate compressions
Apart from evaluating the number of compressions delivered, three studies17 24 26 explored the
number or proportion of adequate compressions performed. Compressions that met the
recommended depth according to guidelines during the time when the study was undertaken
were considered “adequate” (e.g. more than 35mm).24 Two of these three studies reported that
compression-only CPR resulted in a higher number of adequate compressions.24 26
6
In a randomized crossover study by Heidenreich et al, 53 medical students were
randomized to perform either compression-only or standard CPR for nine minutes. The
researchers found that compression-only CPR delivered a significantly higher number of
adequate compressions in the first two minutes. Although the difference between both types
of CPR diminished after the second minute, the overall number of adequate compressions
was still higher in compression-only CPR than standard CPR.24 This study design was also
replicated in another study on 17 retired healthcare professionals. In contrast, this study
reported that standard CPR resulted in significantly more adequate compressions in all but
the first minute of the test. A significantly higher number of people also took rest breaks in
the compression-only CPR group as compared to standard CPR.27 Two studies by
Heidenreich et al, reported the number of compression in the first minute.
The results from both studies suggested that rescuer fatigue is more likely to affect
older people. Age was identified as a factor that may limit the effectiveness of compression-
only CPR to a shorter time period.24 Variations in response to fatigue were also reported in
different age groups. While younger rescuers tend to reduce compression depth, an older
population may take breaks and perform fewer numbers of compressions with shallower
depth.26
In a similar study, Nishiyama et al recruited 243 laypeople and randomly assigned
them to either the compression-only or standard CPR group, each with prior training
provided. Each test session lasted two minutes and the researchers reported that the net
number of appropriate chest compressions was higher in the compression-only CPR group. 26
However, a study by Hong et al28 reported otherwise. They compared the time-dependent
changes in compression depth for both compression-only and standard CPR in 852
participants, comprising both hospital workers and laypeople. The study found that the mean
proportion of correct compression depth decreased more significantly throughout the time
sectors in compression-only CPR as compared to standard CPR.28
Although the population in the Nishiyama et al study was more representative of a
general population, the test period of two minutes might not have been lengthy enough to
allow for fatigue to take effect.26 Deterioration in adequate chest compressions after two
minutes has been reported by other studies, hence a longer test period would have allowed the
researchers to better assess bystander CPR performance while taking fatigue into
consideration.24
7
The outcomes from the reviewed studies were inconclusive due to incongruent
findings. It is unclear if compression-only CPR results in a higher number and proportion of
adequate compressions. This has been found to be associated with rescuer fatigue, which is in
turn dependent on a host of individual characteristics, such as age and gender.24 Rescuer
fatigue is also largely dependent on the time duration of the test. Such factors may account
for the wide variability in the results reported across the studies.
Adequate number of compression in the first minute was reported in two studies but
the combined result (see Figure 4) was not significant with mean difference 2.53 (95% C.I. -
23.9 to 28.9, p=0.85). 24, 27 Adequate number of compression in 2-minute period was reported
by two other studies and the pooled mean difference was 31.9 with 95% C.I. from 21.0 to
42.9. The findings imply that the subjects in compression-only CPR group were on average
adequately compressed 31.9 more than those in the standard CPR group (see Figure 5). 26, 33
Rescuer fatigue
Six articles explored the effect of rescuer fatigue in both compression-only and standard
CPR. An analysis of these articles demonstrated that rescuer fatigue affects compression-only
CPR to a greater extent. Trowbridge et al measured fatigue in 20 female participants through
objective and subjective measures.29 The study reported that compression-only CPR required
greater effort, was harder to sustain and thus involved greater rescuer fatigue.28 Other studies
measured fatigue by investigating the net number of adequate chest compressions or the
proportion of adequate chest compressions, which is the number of adequate chest
compression expressed as a fraction over the total number of compressions performed. 24 27 28 30
Most reviewed studies reported a greater decrease in the number of adequate
compressions in compression-only CPR.27 28 Although the methodologies in measuring
fatigue varied among these studies, a greater rescuer fatigue was observed in compression-
only CPR. This may be due to the fact that compression-only CPR has no pauses during chest
compressions to deliver MTM ventilations. Such pauses can function as “rest time” for the
rescuer, thus with the absence of this “rest time”, it is harder to maintain the effectiveness of
compressions.29
In contrast to the abovementioned studies, a randomized trial conducted by Neset et
al investigated the perceived exertion of 64 elderly laypeople performing compression-only
and standard CPR. The researchers reported that the perceived exertion was rated to be only
8
mild to moderate in the compression-only CPR group.31 Such variability in results may be
due to the presence of feedback given during the test to facilitate CPR performance, as
feedback could have mitigated the negative effects of fatigue.
Meta-analysis was not conducted for rescuer fatigue as it was measured by various
different outcomes including decline in quality of compression,30 decline in compression
force,29 compression depth,31 compression rate,28 total number of adequate compression.24, 27
For the last two studies, meta-analysis could not be conducted because they only presented
the results using bar charts. 24, 27
Retention of skill
Four studies compared CPR skill retention level in both compression-only and standard CPR. 25 26 32 33 Two studies reported overall low skill retention in both compression-only and
standard CPR.26 32 In the study by Swor et al, participants were tested on their CPR skills three
months after receiving training. The researchers found that there was overall low skill
retention in both types of CPR. 32 However, the assessment of skill retention in this study was
challenging as no formal “exit testing” was done immediately after training. Hence, the
absence of an immediate outcome to establish baseline makes it hard to compare the CPR
performances at both time points in order to determine the level of retention. In addition, as
the population sample in this study is relatively old with a mean age of 71.5 years, the results
may not be transferable in other settings as learning and skill retention abilities may vary
across ages.32
Nishiyama et al also conducted a study on 243 lay participants to assess the level of
skill retention. The resuscitation skills of the participants were evaluated immediately and
one month after training. This study found that there was a similar decrease in the net number
and proportion of adequate chest compressions in both groups; therefore suggesting that skill
retention levels are equal in both types of CPR and one is not superior to the other. Findings
in both of these studies suggested that retention is poor regardless of the type CPR technique
that has been taught and skill deterioration can occur as soon as one month after training. 26
In contrast, a prospective study conducted by Heidenreich et al investigated skill
retention levels between compression-only and standard CPR. The study sample comprised a
much younger population comprising 53 first-year medical students. They were asked to
demonstrate both compression-only and standard CPR at three time points – immediately
9
after training, six and 18 months post training. The study reported that there was a decline in
standard CPR performance throughout the 18 months, whereas minimal decline was observed
in compression-only CPR.25 Similarly, a more recent study conducted by Nishiyama et al
compared skill retention amongst 146 college students six months and one year post CPR
training. This study found that students in the compression-only CPR group performed a
significantly higher number and proportion of adequate chest compressions one year after
training, lending support to the superiority of compression-only CPR. 33
The results in these reviewed studies may differ due to different characteristics among
the studies’ sample populations, such as the mean age of the participants and whether or not
they are medically trained. In addition, the multiple testing sessions over a time period of 18
months might have allowed the students to “practice” performing CPR, thus masking true
degradation and the actual level of skill retention.25, 33
Meta-analysis was not conducted for the retention of skills as the studies measured the
outcome using different instrument/scale at different time points including one month by
number of adequate compression, 26 three months by skill performance, 32 six and eighteen
months by number of compressions, 25 six months and one year by various resuscitation skills. 33
DISCUSSION
The review summarized current evidence on the effectiveness of compression-only CPR in
improving CPR performance. Survival rates decrease by 7–10% for every minute that passes
between collapse and defibrillation if no CPR is provided; hence it is crucial for
compressions to be initiated as soon as possible from the time of collapse.34 The reviewed
studies have all shown that compression-only CPR required a shorter time to initiate CPR as
compared to standard CPR. However, these studies were conducted prior to the current
standard CPR. The previous standard CPR guideline required rescuers to deliver two rescue
breaths before compressions.1 Therefore, this required more time for standard CPR to initiate
compression. Following current guidelines, there is a need for future research to shift its
focus and compare the interruptions to compressions rather than the time taken for CPR
initiation between the two CPR techniques. 3
High-quality CPR requires compressions to be performed at an adequate depth and
rate and with minimal interruption.7 In standard CPR, MTM ventilation often results in
10
frequent and lengthy interruptions during compressions in standard CPR; thus compression-
only CPR can deliver a significantly higher number of compressions per minute.35
However, compression-only CPR has several limitations. Studies have shown that
rescuer fatigue affects compression-only CPR more than standard CPR. In compression-only
CPR, the depth of compression declined more rapidly over time.24, 28 Although compression-
only CPR can deliver a higher number of compressions, there may be fewer adequate
compressions as compared to standard CPR. It is not known which factor of compression –
number or adequacy – has a stronger impact on successful resuscitation.24 Notably, clinical
studies have reported that the total number of compressions delivered per minute can improve
survival.36 37 Thus, compression-only CPR may compensate for its lack of depth in
compressions with a higher number of compressions being performed.27
Rescuer fatigue can have a greater effect on the bystander performing compression-
only CPR due to the absence of “rest time”. Consequently, the effectiveness of compressions
can be limited to a certain time period.24 This time period is associated with rescuer fatigue,
which is in turn dependent on a range of the rescuer’s characteristics, such as age, gender and
physical fitness.38 As previous studies have reported incongruent results, the effectiveness of
compression-only CPR for a prolonged duration and its efficacy in increasing CPR skill
retention remain unknown.
A limitation that most of the reviewed experimental studies noted is the lack of
realism in their intervention design.19 20 25 26 28 33 Most studies adopted a case-based scenario,
whereby elements of the test such as the recording manikin and test duration did not mimic
that of a realistic OHCA event. The recording manikin used was in its standard clothing and
laid freely accessible to the study participants, which is unlikely to happen in reality.39 Some
studies tested CPR performance for two minutes, which was not realistic considering that
ambulance response times are generally longer than two minutes.24 The lack of realism
implies that the stress of an OHCA event is not replicated during the test.31 Thus, results from
these studies cannot be said to be applicable in an actual medical emergency, as CPR
performance may vary under different levels of stress and there may be more room for
error.21 33 “Effective” CPR performed on a manikin may not be clinically meaningful;
therefore, future research could aim to study rescuers’ ability to perform CPR under more
realistic conditions. For example, by using a simulated test scenario, the physical and
emotional demands of an OHCA event can be more realistically presented and CPR
performances can be clinically meaningful to a greater extent.25 26
11
In addition, the details of the compression-only CPR testing were not included; most
studies did not explicitly state if study participants in the compression-only CPR group
performed continuous compressions throughout the test duration or whether breaks were
implemented during the cycle. This ambiguity concerning the rest period may account for the
variation in results as studies have shown that providing breaks at a particular time during
continuous chest compressions can help reduce fatigue, hence maintaining compression depth
for an extended period of time.40 Future studies investigating the effect of rescuer fatigue in
compression-only CPR can help build evidence for the ideal rescuer-changing strategy (e.g.
switching rescuers at an interval of two minutes) and hopefully maintain high-quality chest
compressions over time.
A number of studies also had a selection bias, as study participants were medical
students or healthcare workers. 25 27 28 They do not resemble a lay population, as they possess a
strong medical background and increased exposure to CPR experience. CPR training has
mostly been tailored to the needs of this niche group of people who are professionally obliged
to perform CPR. Limited studies have been conducted on laypeople, thus there is a need for
more studies to explore and better understand the psychology behind the “helping behavior”
of laypeople in an emergency situation.41 Such studies will help provide insight on the
facilitators and barriers to performing CPR and potentially provide direction on current CPR
training and education.16 41
LIMITATIONS
This literature review has limitations. Although the search strategy was undertaken carefully
and systematically, it might not have identified all of the relevant literature. We did not
search non-electronic literature, and non-English articles were excluded. Next, the reviewers
were not blinded to the authorship of the studies during the process of critical appraisal,
however, none of the reviewers were affiliated to any authors of the reviewed studies.
Finally, this review has relatively small number of eligible articles that met the inclusion
criteria and their methodological approaches could have introduced bias.
12
CONCLUSION
This literature review has sought to present the best available evidence on the effectiveness of
compression-only CPR in improving bystander CPR performance. It revealed that
compression-only CPR requires a shorter time to initiate CPR and delivers a higher number
of total compressions. The depth of compressions performed may be shallower than that of
standard CPR due to greater rescuer fatigue. However, due to the paucity of existing studies,
it remains inconclusive if compression-only CPR can deliver a higher number of adequate
compressions in extended periods of time. It is also unclear if simplified CPR can improve
skill retention level in the long run. Evidently, more randomized studies are needed to
determine whether compression-only CPR can indeed help improve rescuers’ CPR
performance. These studies could be conducted on laypeople and the quality of chest
compression could be evaluated over a longer period of time. Future research efforts,
together with resuscitation policy and practice implications, are needed to further improve
rescuers’ CPR performance with the ultimate goal to enhance OHCA survival rates.
13
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Table 1: PICO Comprehensive review
Categories Criteria
Population Adult participants who are above the age of 21 and of any sex, ethnic background, social status and geographical area. Medical students and healthcare workers who learn compression-only CPR are also included in the study.
Intervention Experimental studies that focus on bystander CPR using either “hands-on CPR” or “compression-only CPR” as intervention.
Control Standard CPR using compression and ventilation in a ratio of 30:2
Outcome CPR performance including time taken to initiate CPR and quality of compression
Rescuer fatigue in bystander CPR CPR skill retention
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