Most hospitals and EMS systems in the U.S. require providers to maintain current certification in basic or advanced life support, with recertification occurring every two years. Most EMS providers and many health care workers perform CPR routinely, but in many institutions, biennial recertification is the only time devoted to a formal evaluation of skill proficiency and quality of CPR performed. Recently, quantitative measures of CPR quality have been developed using real-time feedback; however, the health care market has been slow to adopt this technology.
The CPR Improvement Working Group was formed in June 2008 to assess the use of CPR feedback to improve skill performance. In 2009, the group commissioned Ipsos, a global survey-based research company, to administer an international survey of health care professionals. Providers were surveyed if their primary place of employment was in a prehospital (EMS) or hospital setting and if they routinely performed CPR during the course of their clinical duties. If the provider worked in the hospital, their primary work had to be in the emergency department, intensive care unit or other critical care unit. A total of 1,023 qualified responses were obtained from respondents in the U.S., U.K., France and Germany.
The survey was designed to assess 1) provider perceptions of their CPR knowledge and ability, 2) recall of recent CPR performance, 3) adoption and implementation of CPR Guidelines, 4) attitudes toward the importance of CPR, 5) perceptions of CPR training and quality improvement, and 6) level of awareness and experience with CPR measurement and feedback systems (see Figure 1, below).
Survey Says …
Overall, the survey’s respondents had been credentialed to perform CPR for an average of 13 years, been in their current position for about seven years, and performed CPR approximately 300 times in their career and 23 times in the past 12 months. Based on self-reporting, three-quarters of health care professionals perceived their skill level in performing CPR to be quite high. Just over half of all health care professionals surveyed believed that previous studies of CPR quality found it to be excellent, very good or good.
Just over half (55%) of health care professionals agreed that CPR is extremely important to overall patient outcomes, and 75% agreed that compressions are extremely important in determining patient survival. Two-thirds strongly agreed that to improve clinical outcomes, it’s extremely important to have as few interruptions as possible while delivering compressions.
Overall, respondents stated that they were quite familiar with the 2005 AHA CPR Guidelines and believed they perform CPR according to standards; however, only 26% self-reported that their performed rate, depth and ratios were fully compliant with the 2005 CPR Guidelines.
Only 29% of health care professionals received regular feedback on their performance. Less than half reported that their organization provides training beyond requirements, but 93% believed that training is extremely valuable, and 76% would be willing to participate in additional training.
Only 15% of respondents reported access to CPR assistance devices with instantaneous feedback; however, 75% of health care professionals agreed that CPR performance technology can help improve CPR quality, and 65% agreed CPR feedback technology should be used.(1)
Performing chest compressions at the proper rate and depth is a key determinant of survival from cardiac arrest. Compression depth is associated with survival to hospital admission and discharge.(2) Deeper compressions before a shock are associated with increased defibrillation success, and longer interruptions of CPR before a shock are associated with reduced defibrillation success.(3) For both EMS providers and hospital staff, compression rate and depth have been shown to be inconsistent and often don’t comply with published recommendations, even when performed by well-trained personnel. In addition, the proportion of hands-off time for both EMS and hospital personnel resulting in no flow time has been reported to be unacceptably high.(4,5)
How can we economically train providers when they are between recertification courses? Sutton et al investigated the effectiveness of bedside “booster” CPR training to improve CPR-Guidelines compliance of hospital-based pediatric providers.(6) Before booster CPR instruction, most certified pediatric basic life support providers did not perform Guidelines-compliant CPR. After a two-minute bedside training session, CPR quality improved.
Does real-time feedback during CPR improve the performance of chest compressions and ventilations during in-hospital cardiac arrest? Dine et al examined the role of audiovisual feedback and immediate debriefing on CPR quality. Debriefing or feedback alone improved cardiopulmonary resuscitation quality, but the combination led to the doubling of participants providing compressions of adequate rate and depth (29% vs. 64%).
Closing the Gap
Health care providers believe they are proficient at performing CPR, but objective evidence shows that there are significant deficiencies in chest compressions. Providers recognize the need for real-time feedback and are willing to participate in debriefing sessions. Focused debriefing after resuscitation can be used to improve CPR quality and hopefully increase initial resuscitation success. Automated feedback using quantitative detectors during resuscitation has been shown to improve CPR performance. EMS medical directors and hospital administrators should thus implement programs for debriefing after every resuscitation attempt, and should dedicate resources to provide real-time feedback to rescuers. Intuitively, assigning one of the rescuers to qualitatively monitor compression rate and depth and to monitor hands-off time should improve CPR performance; however, the effectiveness of this type of qualitative feedback has not been demonstrated.
Real-time feedback is an example of concurrent quality improvement, whereas debriefing is an example of retrospective quality improvement. How can hospitals and EMS systems engage in prospective quality improvement? Simulation technology is one option that is widely used in medical education. Wayne et al showed that simulation-based educational programs for advanced cardiac life support (ACLS) resulted in a sevenfold increase in the likelihood of an adherent ACLS response compared with traditional CPR training.(8)
Andreatta et al found that a simulation-based mock code program was associated with a significant improvement in pediatric patient outcomes following cardiac arrest compared with outcomes before the mock code program was implemented.(9)
The American Board of Medical Specialties (ABMS) assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians. In 2000, those boards agreed to modify their recertification programs to a continuous professional development program, the ABMS Maintenance of Certification program. To maintain certification, the physician is subjected to ongoing competency measurement to demonstrate continuing learning and proficiency in their particular specialty.
Those involved in CPR training have the opportunity to model CPR training after the ABMS programs and employ the principles of ongoing training. The evidence shows that simulation-based training, real-time feedback and systematic debriefing all improve CPR quality, which translates into improved survival. Hospitals and EMS systems should adopt these proven strategies to improve their cardiac arrest survival rates.
These programs can be implemented as part of existing continuing education, without major expense or commitment of resources. Implementation of programs designed to maintain proficiency should not replace, but enhance, biennial recertification programs. Just as ABMS requires physicians to pass an exam at regular intervals, health care systems should continue to use the two-year recertification classes as a means to assess provider knowledge and verify the application of new CPR Guidelines.
CPR is a skill that must be practiced to maintain proficiency. Hospital and EMS leaders should work in unison to support quality improvement programs—including debriefings—designed to improve CPR performance and adopt technology capable of real-time feedback. Such programs will result in better CPR and improve the likelihood that a victim of cardiac arrest will survive.
1. Ipsos: Multi-National Attitudes Among Health-Care Professionals Concerning CPR. Online survey. 2009.
2. Kramer-Johansen J, Myklebust H, Wik L, et al: “Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: A prospective interventional study.” Resuscitation. 2006;71(3):283–292.
3. Edelson DP, Abella BS, Kramer-Johansen J, et al: “Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest.” Resuscitation. 2006;71(2):137–145.
4. Wik L, Kramer-Johansen J, Myklebust H, et al: “Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.” JAMA. 2005;293(3):299–304.
5. Abella BS, Alvarado JP, Myklebust H, et al: “Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.” JAMA. 2005;293(3):305–310.
6. Sutton RM, Niles D, Meaney PA, et al: “‘Booster’ training: Evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of pediatric basic life support providers during simulated cardiac arrest.” Pediatric Critical Care Medicine. July 9, 2010 [Epub ahead of print].
7. Dine CJ, Gersh RE, Leary M, et al: “Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing.” Critical Care Medicine. 2008;36(10):2817–2822.
8. Wayne DB, Didwania A, Feinglass J, et al: “Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study.” Chest. 2008;133(1):56–61 [Epub June 15, 2007].
9. Andreatta P, Saxton E, Thompson M, Annich G: “Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates.” Pediatric Critical Care Medicine. June 24, 2010 [Epub ahead of print].
This article originally appeared in an editorial supplement to December 2010 JEMS, FireRescue, Journal of Emergency Nursing and ACEP News as Perception vs. Reality: High-quality CPR & the roadmap to improved survival from cardiac arrest.