Wake up, CPR providers: High-quality CPR is wanted and needed!
Pub Date: Tuesday, June 25, 2013
Author: Kjetil Sunde, MD, PhD
Affiliation: Oslo University Hospital, Oslo, Norway
Citation: Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M; on behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013: published online before print June 25, 2013, 10.1161/CIR.0b013e31829d8654.
The German surgeon, Dr. Friedrich Maass, described what we now know as chest compressions, as they were done on a young patient in cardiac arrest in 1892: “...one steps to the left side of the patient facing his head, and presses deep in the heart region with strong movements,” ”…the frequency of compressions is 120 or more a minute,” “…the effectiveness of the efforts is recognized from the artificially produced carotid pulse and constriction of the pupils…” and ”…it is expedient to make as few pauses as possible.”1 As early as 121 years ago, this healthcare provider was goal-directed and focused on the quality of cardiopulmonary resuscitation (CPR), using feedback and minimizing interruptions. Where are we now? Has the resuscitation world moved forward? The papers published in 2005 describing the overall inconsistent and substandard CPR quality among professional rescuers and healthcare providers (for both out-of-hospital and in-hospital cardiac arrest)2,3 showed the opposite: we have been sleeping. These studies served as eye-openers to all of us and really addressed the importance of focusing on high-quality CPR. Unfortunately, many healthcare providers and responsible authorities within EMS systems and hospitals forget or do not even think about this today. It is therefore timely and of utmost importance that the American Heart Association addresses this topic through a consensus statement by Meaney et al: “CPR Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital”4. This is a very relevant and necessary statement to all CPR providers at any level, both inside and outside hospitals.
There are two tasks in the early resuscitation process associated with improved outcomes after cardiac arrest: early CPR and early defibrillation.5 Whereas defibrillation is dependent on a shockable rhythm, and the quality of defibrillation is mainly related to the defibrillator used and its software and timing of the shocks5, CPR quality is totally provider-dependent. Survival is linked to CPR quality6,7. When rescuers compress at a depth of less than 38 mm, survival-to-discharge rates after out-of-hospital arrest are reduced by 30%6. Similarly, when rescuers compress too slowly, return of spontaneous circulation (ROSC) after in-hospital cardiac arrest falls from 72% to 42%7. As a consequence, if chest compressions are too shallow, too slow, or too fast, with leaning and with a lot of interruptions resulting in long pauses, the blood flow to the victim’s brain and heart will be markedly reduced. Since a lot of patients with initial ventricular fibrillation (VF) require repetitive shocks8, and more than 60-80% of cardiac arrest patients today present with a non-shockable rhythm5, long periods of CPR are frequently required in a resuscitation attempt. Thus, the end result is dependent on the quality of CPR during prolonged resuscitations. Moreover, in the hospital setting, survival is dependent on the time and location of the arrest9. Again, human factors play a decisive role in the destiny of cardiac arrest victims; therefore, we should be able to solve this, or at least strive to improve!
By publishing this consensus statement, the AHA addresses key areas of CPR quality: metrics of CPR performance; monitoring, feedback, and integration of the patient’s response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels4. It should be noted that all these can be adopted into local systems of care only if the responsible authorities identify and understand the problem, and if the providers are willing to focus and train to become better. Athletes undergo goal-directed and systematic training to become better, to win, to become champions--why can’t we have higher expectations and require higher skills from our healthcare providers before they are allowed to perform CPR on cardiac arrest victims? It’s up to us in the resuscitation community, including relevant organizations like the AHA, to specify the goals and skills required of healthcare providers and professional rescuers who perform CPR on cardiac arrest victims. Our patients deserve that!
The attitude of professional CPR providers is equally important and might be a difficult obstacle to overcome. In a paper from 2007, 55% of the paramedics believed that too-deep chest compressions could cause serious injury to the patient; 39% believed that compressing to Guidelines-recommended depth resulted in severe patient injury; approximately 25% felt that the potential benefits of compressing to the Guidelines depth could not justify the injuries it would cause; and breaking ribs made 54% feel very uncomfortable10. Importantly, these are facts from paramedics out in the field, and these attitudes will of course impact negatively on the quality of CPR. Again, we are responsible for addressing this problem within each system and among all providers and responsible authorities, and it is our mission to convince and teach them about the importance of pushing deep enough, fast enough (but not too fast) without interruptions, regardless of whether a rib is broken or not!
Survival rates after out-of-hospital cardiac arrest (OHCA) vary greatly around the world11. As an example, participating centers in the Resuscitation Outcomes Consortium (ROC) Epistry had survival rates from OHCA ranging from 3% to 16%12. These survival differences can partly be explained by different definitions of OHCA11, but are mainly due to the overall quality of the local Chain of Survival13. Identifying and improving weak links in the Chain of Survival has increased survival througout the world14-17. CPR quality is one of many aspects that can be improved. It will make a huge impact on the results of randomized trials, especially if the interventions tested are those supposed to impact on hemodynamics during CPR. In an experimental pig study, there were no hemodynamic effects of epinephrine when administered together with poor-quality CPR, as opposed to the positive effects achieved when good-quality CPR was administered18. So, before recruiting patients into randomized trials, the local Chain of Survival should be challenged and optimized to get the most accurate results from these trials. An overall goal should be to document and report CPR quality randomized clinical trials.
High-quality CPR must be focused on and challenged among all providers and within all systems taking care of cardiac arrest patients. CPR circulates the only flow achieveable before ROSC in patients with cardiac arrest, and this must be optimized. To site the AHA statement from Meaney et al: “To maximize survival from cardiac arrest, the time has come to focus efforts on optimizing the quality of CPR specifically, as well as the performance of resuscitation processes in general”4. Maximal survival is a cardiac arrest victim walking out of the hospital neurologically intact and back to a normal life. To all CPR providers: Take the challenge! Improve CPR quality! Let’s do it!
- Maas F. Die Methode der Wiederbelebung bei Herztod nach Chloroformeinatmung. Berlin Klin Wochenshr 1892; 12: 265-268.
- Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O'Hearn N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305-310.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association