CPR Performance Does Not Follow Guidelines

CHICAGO - New research indicates that CPR performed outside the
hospital and in the hospital often does not meet or adhere to standard
guidelines, according to 2 studies in the January 19 issue of JAMA.

The importance of CPR (cardiopulmonary resuscitation) for survival of
cardiac arrest patients has been demonstrated, according to background
information in the article. There are indications that the quality of
CPR performance influences the outcome. When tested on mannequins, CPR
quality performed by lay rescuers and health care professionals tends
to deteriorate significantly within a few months after training, but
little is known about the quality of actual clinical performance of CPR
on patients.

CPR guidelines recommend target values for chest compressions,
ventilations, and CPR-free intervals allowed for rhythm analysis and
defibrillation. There is little information on adherence to these
guidelines during advanced cardiac life support during out-of-hospital
cardiac arrest.

In the first study, Lars Wik, M.D., Ph.D., of Ulleval University
Hospital, Oslo, Norway and colleagues examined the performance of
paramedics and nurse anesthetists during out-of-hospital advanced
cardiac life support (ACLS) by continuously monitoring all chest
compressions and ventilations during resuscitation episodes using
online defibrillators.  The study included 176 adult patients with
out-of-hospital cardiac arrest treated by paramedics and nurse
anesthetists in Stockholm, Sweden, London, and Akershus, Norway,
between March 2002 and October 2003. The defibrillators were modified
to measure chest compressions and ventilations, in addition to standard
event and electrocardiographic recordings.

The primary outcome measure was adherence to international guidelines
for CPR. Target values for compression rate were 100 to 120/min; for
depth, 38 to 52 mm; and for ventilation rate, 2 ventilations for every
15 compressions before intubation and 10/min to 12/min after
intubation.

The researchers found that chest compressions were not given 48 percent
of the time without spontaneous circulation; this percentage was 38
percent when subtracting the time necessary for electrocardiographic
analysis and defibrillation. Combining these data with an average
compression rate of 121/min when compressions were given resulted in an
average compression rate of 64/min. Average compression depth was 34
mm, 28 percent of the compressions had a depth of 38 mm to 51 mm, and
the compression part of the duty cycle was 42 percent.  An average of
11 ventilations were given per minute. Sixty-one patients (35 percent)
had return of spontaneous circulation, and 5 of 6 patients discharged
alive from the hospital had normal neurological outcomes.

"Whether some of these deficiencies can be improved by specific focus
during training needs attention. Through better understanding of the
mistakes made in a real-life cardiac arrest situation, training courses
might be designed to focus on these aspects. Another approach would be
to develop online tools that prompt the rescuer to improved
performance. Audiotapes giving instructions on chest compression rate
have been reported to improve the compression rate during cardiac
arrest in patients," the authors write.

"If our study represents how CPR is delivered during resuscitation
from out-of-hospital cardiac arrest in other communities, there is a
great opportunity to improve CPR quality and, hopefully, patient
survival by focusing on delivery of chest compressions of correct depth
and rate, with minimal 'hands-off' periods," the researchers
conclude.

(JAMA. 2005;293:299-304.

Editor's Note: For funding and financial disclosure information,
please see the JAMA article.

Quality of In-Hospital CPR May Fail To Meet Guidelines

In the second report, Benjamin S. Abella, M.D., M.Phil., of the
University of Chicago Hospitals, Chicago, and colleagues conducted a
study to determine whether well-trained hospital staff perform CPR
compressions and ventilations according to guideline recommendations.

According to background information in the article, survival from
cardiac arrest remains low despite the introduction of CPR over 50
years ago. The delivery of CPR, with correctly performed chest
compressions and ventilations, exerts a significant survival benefit.
Conversely, interruptions in CPR or failure to provide compressions
during cardiac arrest have been noted to have a negative impact on
survival in animal studies. Consensus guidelines clearly define how CPR
is to be performed, but the parameters of CPR in actual practice are
not routinely measured, nor has the quality been known.  Recent studies
have challenged the notion that CPR is uniformly performed according to
established international guidelines.

This study examined in-hospital cardiac arrests at the University of
Chicago Hospitals from December 11, 2002 until April 5, 2004. Using a
monitor/defibrillator with novel additional sensing capabilities, the
researchers recorded parameters of CPR quality including chest
compression rate, compression depth, ventilation rate and the fraction
of arrest time without chest compressions (no-flow fraction; NFF).

Data were collected from 67 in-hospital arrests. The researchers found
that analysis of the first 5 minutes of each resuscitation by 30 second
segments revealed that chest compression rates were less than 90
compressions per minute in 28.1 percent of segments. Compression depth
was too shallow for 37.4 percent of compressions. Ventilation rates
were high, with 60.9 percent of segments containing a rate of more than
20/min. A total of 27 patients (40.3 percent) achieved return of
spontaneous circulation and 7 (10.4 percent) were discharged from the
hospital.

"There are several potential practical solutions for helping to
improve poor CPR quality. The first involves mechanical devices that
can provide chest compressions reliably at a set rate and depth. These
devices may generate better hemodynamic characteristics than manual
chest compressions. Another solution is to improve monitoring and
feedback to reduce human error during manual CPR, by using devices such
as [a certain type of] CO2 monitors and 'smart defibrillators',
which can measure CPR characteristics and provide audio feedback to
alert rescuers to errors such as incorrect chest compression or
ventilation rate," the authors write.

(JAMA. 2005;293:305-310.

Editor's Note: For funding and financial disclosure information,
please see the JAMA article.

Editorial: Cardiopulmonary Resuscitation in the Real World -  When
Will the Guidelines Get the Message?

In an accompanying editorial, Arthur B. Sanders, M.D., and Gordon A.
Ewy, M.D., of the University of Arizona College of Medicine, Tucson,
comment on the studies in this week's JAMA on CPR.

"... the clinical data, including the 2 studies in this issue of
JAMA, imply that current resuscitation guidelines are not being
followed, and other observational studies indicate that performing
high-quality CPR is important for resuscitation success. Clearly, the
quality of real-world CPR must be improved. In the past such
inadequacies have been dismissed as an education/training problem. This
assumed that health care professionals and laypersons do not adequately
learn and retain CPR skills, which leads to medical errors when CPR is
performed. But perhaps it is not a question of how well rescuers are
being taught and learn the material. In reality, the training courses
for health care professionals get more complex with each revision of
the guidelines. Some of the skills taught, such as 2 breaths in 5
seconds, are impossible to deliver."

"Many patients in cardiac arrest do not receive high-quality CPR, and
this observation may affect the success of the resuscitation efforts.
This represents a shortcoming of the guidelines development process and
current training systems. The CPR and Emergency Cardiovascular Care
(ECC) Guidelines are too complex, resulting in patients not receiving
known benefits such as chest compressions for extended periods. It is
time to reconsider some of the policies and processes used in
guidelines development such as the inclusion of previous
recommendations without evidence to support them. It is time to
simplify the CPR guidelines and educational programs so that all
patients who sustain cardiac arrest can receive optimal treatment. It
is time to give rescuers and health care professionals the knowledge
and skills that can be readily used in the real world to improve the
resuscitation of patients in cardiac arrest," they conclude.

(JAMA. 2005;293:363-365.

Editor's Note: Drs. Sanders and Ewy have served as members of the
Emergency Cardiac Care Committee, have been involved in the development
of previous versions of the ECC and CPR Guidelines, and will
participate in the 2005 International Consensus on Science Conference
and in development of the 2005 guidelines.