“Putting It All Together” to Improve Resuscitation Quality

In 2015 the American Heart Association launched the Resuscitation Quality Improvement^Ⓡ (RQI^Ⓡ) Program to address the urgent need to improve in-hospital cardiac arrest survival through a novel competency-based model for health care provider (HCP) cardiopulmonary resuscitation (CPR) training. This innovation differs from the traditional Basic Life Support (BLS) training model by providing self-directed, low-dose, high-frequency CPR skill activities with the objectives of skills mastery and retention. A program implementation study was conducted at the first hospital in the state of Illinois to adopt RQI in 2016.

The study was designed to evaluate implementation of the RQI program, CPR performance during RQI simulation sessions, and participant impressions at a community hospital. Quantitative data were evaluated based on psychomotor compression and ventilation performance. Quantitative and qualitative data were evaluated based on a perceptual CPR confidence and program satisfaction survey.

Statistical analysis demonstrates significant improvement in HCPs’ quarterly psychomotor CPR skill performance over a one-year period in first compression score, and first and highest ventilation score per quarterly session. The number of attempts to pass the ventilation skill session decreased between the first and fourth quarter. Survey results of HCPs’ program perceptions 30 months post–RQI implementation indicate satisfaction with the RQI program and an increase in CPR skill confidence.

Findings demonstrate that the RQI program for ongoing verification of BLS skill and knowledge provides improvements in HCPs’ CPR psychomotor competence and confidence/satisfaction using an efficient and sustainable method at a community hospital.

Evaluar la capacidad del personal lego (estudiantes universitarios) para usar un desfibrilador externo automatizado (DEA).

Estudio cuasiexperimental de medidas repetidas de muestreo no probabilístico con grupo control.

Estudiantes de formación de profesorado de la Universidad de Santiago de Compostela.

La muestra estuvo compuesta por 129 sujetos, 69% mujeres y 31% hombres, de entre 19 y 47 años (media 23,2 ± 4,7), cuyo criterio de inclusión fue el no tener conocimientos previos sobre DEA.

Se tomaron los tiempos empleados en aplicar una descarga sobre un maniquí con DEA sin formación (T0); tras una explicación teórico-práctica inferior a 1 minuto (T1) y tras 6 meses del proceso formativo (T2).

La variable de resultado principal fue el tiempo empleado en aplicar una descarga. Se definió la variable «efecto de mejora» mediante la diferencia absoluta de tiempo entre T1 y T0, y la variable «efecto de grado de olvido» como la diferencia absoluta entre T1 y T2.

Las medias de tiempos fueron: T0 = 67,7 s; T1 = 44,2 s; T2 = 45,9 s. Se redujo el tiempo para realizar una descarga tras la explicación formativa (T1 < T0) (−23,4 s; p < 0,001). El T2 es inferior a T0 (−21,8 s; p < 0,001), pero mayor que T1 (1,6 s; p = 0,002). El efecto de mejora fue significativo (p < 0,001), al igual que el grado de olvido (p = 0,002).

Se demostró el fácil manejo del DEA, ya que personas sin formación fueron capaces de aplicar una descarga. El tiempo de administración de descarga se redujo tras una pequeña formación. Este tiempo apenas aumentó pasados 6 meses.

To evaluate layperson (university student) ability to use an automated external defibrillator (AED).

A repeated measures quasi-experimental study with non-probabilistic sampling and a control group was carried out.

Teacher training degree students at the University of Santiago de Compostela (Spain).

The sample consisted of 129 subjects (69% women and 31% men), between 19-47 years of age (mean 23.2 ± 4.7 years). As inclusion criterion, the subjects were required to have no previous knowledge of AED.

Times to apply defibrillation with an AED to a mannequin were recorded untrained (T0), after a theoretical and practice explanation lasting less than one minute (T1), and 6 months after the training process (T2).

The primary endpoint was the time taken to deliver a defibrillation discharge. The “improvement effect” variable was defined by the absolute time difference between T1 and T0, while the “degree of forgetfulness effect” variable was defined as the absolute difference between T1 and T2.

The mean times were T0 = 67.7 s; T1 = 44.2 s; T2 = 45.9 s. The time to apply defibrillation was reduced after explanation training (T1 < T0) (−23.4 s; P < .001). T2 proved shorter than T0 (−21.8 s; P < .001) but longer than T1 (1.6 s; P = .002). The improvement effect was significant (P < .001), in the same way as the degree of forgetfulness (P = .002).

Easy handling of AED was demonstrated, since untrained people were able to deliver a discharge. Defibrillation time was reduced after brief training. This time barely increased after 6 months.

Medical teams with limited experience in performing advanced life support (ALS) or with a low frequency of cardiopulmonary resuscitation (CPR) while on duty, often have difficulty complying with CPR guidelines.

This study evaluated whether the quality of CPR of trained medical students, who served as an example of teams with limited experience in ALS, could be improved with device assistance. The primary outcome was the hands-off time (i.e., the percentage of the entire CPR time without chest compressions). The secondary outcome was seven time intervals, which should be as short as possible, and the quality of ventilations and chest compressions on the mannequin.

We compared standard CPR equipment to an interactive device with visual and acoustic instructions for ALS workflow measures to guide briefly trained medical students through the ALS algorithm in a full-scale mannequin simulation study with a randomized crossover study design. The study equipment consisted of an automatic external defibrillator and ventilator that were electronically linked and communicating as a single system. Included were regular medical students in the third to sixth years of medical school of one class who provided written informed consent for voluntary participation and for the analysis of their CPR performance data. No exclusion criteria were applied. For statistical measures of evaluation we used an analysis of variance for crossover trials accounting for treatment effect, sequence effect, and carry-over effect, with adjustment for prior practical experience of the participants.

Forty-two medical students participated in 21 CPR sessions, each using the standard and study equipment. Regarding the primary end point, the study equipment reduced the hands-off time from 40.1% (95% confidence interval [CI] 36.9–43.4%) to 35.6% (95% CI 32.4–38.9%, p = 0.031) compared with the standard equipment. Within the prespecified secondary end points, study equipment reduced the time interval until the first rescuer changeover from 273 s (95% CI 244–302 s) to 223 s (95% CI 194–253 s, p = 0.001) and increased the percentage of ventilations with a correct tidal volume of 400–600 mL from 34.3% (95% CI 19.0–49.6%) to 60.9% (95% CI 45.6–76.2%, p = 0.018).

The assist device increased the rescuers' CPR quality. CPR providers with limited experience or a limited frequency of CPR performance (i.e., rural Emergency Medical Services crew) may potentially benefit from this assist device.

We evaluated the association between chest compression release velocity (CCRV) and outcomes after out-of-hospital cardiac arrest (OHCA).

CPR quality was measured using a defibrillator with accelerometer-based technology (E Series, ZOLL Medical) during OHCA resuscitations by 2 EMS agencies in Arizona between 10/2008 and 06/2013. All non-EMS-witnessed adult (≥18 years) arrests of presumed cardiac etiology were included. The association between mean CCRV (assessed as an appropriate measure of central tendency) and both survival to hospital discharge and neurologic outcome (Cerebral Performance Category score = 1 or 2) was analyzed using multivariable logistic regression to control for known and potential confounders and multiple imputation to account for missing data.

981 OHCAs (median age 68 years, 65% male, 11% survival to discharge) were analyzed with 232 (24%) missing CPR quality data. All-rhythms survival varied significantly with CCRV [fast (≥400 mm/s) = 18/79 (23%); moderate (300–399.9 mm/s) = 50/416 (12%); slow (<300 mm/s) 17/255 (7%); p < 0.001], as did favorable neurologic outcome [fast = 14/79 (18%); moderate = 43/415 (10%); slow = 11/255 (4%); p < 0.001]. Fast CCRV was associated with increased survival compared to slow [adjusted odds ratio (aOR) 4.17 (95% CI: 1.61, 10.82) and moderate CCRV [aOR 3.08 (1.39, 6.83)]. Fast CCRV was also associated with improved favorable neurologic outcome compared to slow [4.51 (1.57, 12.98)]. There was a 5.2% increase in the adjusted odds of survival for each 10 mm/s increase in CCRV [aOR 1.052 (1.001, 1.105)].

CCRV was independently associated with improved survival and favorable neurologic outcome at hospital discharge after adult OHCA.

To investigate the effect of medical student involvement on the quality of actual cardiopulmonary resuscitation (CPR).

A digital video-recording system was used to record and analyze CPR procedures for adult patients from March 2011 to September 2012.

Twenty-six student-involved and 40 non–student-involved cases were studied. The chest compression rate in the student-involved group was significantly higher than that in the non–student-involved group (P < .001). The proportion of compressions at “above 110 cpm” was higher in the student-involved group (P = .021), whereas the proportion at “90-110 cpm” was lower in the student-involved group (P = .015). The ratio of hands-off time to total manual compression time was significantly lower in the student-involved group than in the non–student-involved group (P = .04). In contrast, the student-involved group delivered a higher ventilation rate compared with the non–student-involved group (P = .02). The observed time delay to first compression and first ventilation were very similar between the groups. There were no significant differences between the groups in either return of spontaneous circulation or time from survival to discharge.

Student-involved resuscitation teams were able to perform good CPR, with higher compression rates and fewer interruptions. However, the supervision from medical staff is still needed to ensure appropriate chest compression and ventilation rate in student-involved actual CPR in the emergency department.

It has been known for many years that interrupting chest compressions during cardiopulmonary resuscitation (CPR) from out-of-hospital cardiac arrest (OHCA) leads directly to negative outcomes. Interruptions in chest compressions occur for a variety of reasons, including provider fatigue and switching of compressors, performance of ventilations, placement of invasive airways, application of CPR devices, pulse and rhythm determinations, vascular access placement, and patient transfer to the ambulance. Despite significant resuscitation guideline changes in the last decade, several studies have shown that chest compressions are still frequently interrupted or poorly executed during OHCA resuscitations. Indeed, the American Heart Association has made great strides to improve outcomes by placing a greater emphasis on uninterrupted chest compressions. As highly trained health care providers, why do we still interrupt chest compressions? And are any of these interruptions truly necessary?

This article aims to review the clinical effects of both high-quality chest compressions and the effects that interruptions during chest compressions have clinically on patient outcomes.

The causes of chest compression interruptions are explored from both provider and team perspectives. Current and future methods are introduced that may prompt the provider to reduce unnecessary interruptions during chest compressions.

New and future technologies may provide promising results, but the greatest benefit will always be a well-directed, organized, and proactive team of providers performing excellent-quality and continuous chest compressions during CPR.