The editors invited the contributors to this monograph and a few guests to answer some questions about the delivery of CPR. We’ve compiled their responses in the following pages.
Q: Has the fact that the quality of CPR improves survival from cardiac arrest fully filtered down to all emergency medical providers? If no, how could this be accomplished?
Marion Leary: I do not believe it has filtered down. I think the main people who need to really understand the data surrounding these issues and the effect poor CPR has on outcome are the training officers for emergency medical services. There seems to be a misconception in some EMS systems that patients who code are not salvageable; therefore, they may not even attempt to revive these patients, or if they do, the CPR performed is very poor. If the officers doing the training actually believed they could make a difference, it would trickle down and improve outcomes.
Deborah Walsh: No, I don’t believe the importance of CPR quality has filtered down to all emergency medical providers. Despite receiving CPR retraining every two years, practices necessary for quality CPR are not consistently carried out; this has been well documented in the literature. Although current CPR classes provide the needed skills, they do not provide information to attendees regarding each of the components important to quality CPR (e.g., the importance of depth, rate, pause minimization and appropriate ventilations) or reinforce the impact of each on outcomes. Indeed, many CPR instructors are unaware of current scientific findings.
Because most emergency medical providers attend CPR courses every two years for recertification, a good way of spreading the word would be to incorporate current scientific findings about the components of quality CPR into all CPR health care provider courses. Emergency medical providers want to deliver the best care. Providing them with the powerful findings related to CPR quality as well as hands-on skills practice may better prepare them to provide quality CPR.
Norma Battaglia: Within the Tucson (Ariz.) Fire Department, continuous cardiac compressions at 100 compressions/minute and passive oxygenation via OPA and NRB have been the standard since 2003. Within our region, other departments continue to adopt the practice, based on EMS medical director preference. The hospitals seem to be the last to adopt these changes, but even they are changing protocols or at least accepting of the EMS initiatives.
The adoption of regional practice standards and continued publication of outcome data would improve the distribution and spread of information.
Robert E. O’Connor: I believe that most emergency medical providers are aware that the quality of CPR is directly associated with survival from cardiac arrest. I believe that providers know that they need to perform CPR with compressions at the proper depth and at the proper rate. I also believe that most providers know they need to minimize hands-off time in order to reduce interruptions to CPR. That said, I think the techniques needed to ensure that chest compressions are performed properly with no (or minimized) interruptions have not filtered down to all emergency medical providers. It’s one thing to know what to do intellectually, but it’s quite another concept to apply in the clinical setting.
Ben Abella: I think the message that high-quality CPR makes a big difference in outcomes has yet to really hit home among many providers, both in EMS and in the hospital setting. The research is there to prove it; what we need now is more effort placed in education and “leading by example”—if health care providers could see the difference in outcomes that some agencies have accrued through aggressive quality improvement in CPR, they might start to look beyond the data.
Ben Bobrow: The CPR quality message is getting through to EMS providers and EMS systems; however, the change in practice could be faster and more complete. The second and more important issue is how to put this fact into everyday practice. This can be accomplished through more frequent and focused psychomotor skills and simulation CPR training along with the expectation that all emergency medical providers will consistently provide high-quality CPR.
Q: What is the optimal training and retraining formula to ensure competency in high-quality CPR?
ML: After every cardiac arrest, the event should be reviewed with the responders to see what went right and what went wrong. It would not be unreasonable for EMS systems to have a feedback device with which the responders’ CPR performance is analyzed to determine quality. It is also not unreasonable for such devices to be used for practice and chest compression competencies.
DW: At this point, I don’t think we’ve reached an optimal formula for training/retraining practices. Optimal training would involve frequent training using devices that provide immediate feedback and recording of CPR quality. It’s difficult for trainees as well as for CPR instructors to know whether they are performing quality compressions without some measurement of those compressions. At one time, Recording Annies were commonly used during training sessions, but they later fell out of favor. It may be time to resurrect these training devices, which measure compression and ventilation parameters.
It’s clear that in order to maintain skills and knowledge, frequent review and hands-on practice are essential. Although just-in-time training is becoming popular and shows promise in the hospital setting, it’s not always feasible for CPR training in the emergency department setting and is impossible in the prehospital setting. However, many fire departments perform drills in which equipment and/or procedures are reviewed each shift. Incorporating CPR practice and review into these drills as low-fidelity simulations at least quarterly would refresh hands-on skills and keep CPR quality rationales at the forefront. These simulations should occur at the ambulance base and involve assessment of the victim on scene, movement to and resuscitation in the ambulance, and movement to and arrival at the hospital.
Similarly, emergency department educators should refresh personnel on components of CPR quality and provide hands-on practice on a quarterly basis.
BA: The key is that psychomotor skills need refreshing and practice. Books, theoretical material, exams—these can never replace the value of practicing and receiving feedback on performance.
BB: CPR is a complex psychomotor skill, and we know that CPR skills deteriorate quickly (in as short as a few weeks) after initial training; so, likely, more frequent scenario-based, hands-on training would improve CPR delivery. Clearly, more hands-on simulation training needs to be stressed in any CPR training session.
Q: Can you offer examples of best practices in training?
NB: Scenario-based skills practice that involves individual EMS providers as well as their entire responding crew of two, four or six firefighters, engineers, paramedics and/or EMT-basics allows roles and responsibilities to be determined in the lab setting and implemented in the field.
RO: The best practices in training involve repetition of brief instructional sessions in a clinical setting. This ongoing training can be performed following rounds, at shift change or some other convenient time. Ideally, this training involves hands-on participation by health care providers.
Another best practice is a debriefing after any resuscitation effort.
The key to skill maintenance is frequent practice in self-assessment. By keeping the session brief, the learner focuses on the basics.
DW: It’s important to train frequently and with feedback if possible. Effective examples of training include techniques used by Edelson et al and Niles et al.(1,2)
Edelson’s group provided training to the hospital code team, which consisted of orientation to the device, review of the 2005 AHA Guidelines and low-fidelity code simulations with manikins on a hospital unit on the first day of their resuscitation call. A device with immediate audiovisual feedback and data recording capabilities was used for the training as well as in all actual resuscitations that took place in the institution during the course of their call. Transcripts were downloaded from the defibrillator and used to construct a debriefing presentation; cases were reviewed by the code teams weekly in a debriefing format. CPR quality metrics and attainment of ROSC was improved for those who participated in the debriefing sessions.
Niles’ group used “just-in-time” and “just-in-place” principles to refresh psychomotor aspects of CPR with pediatric intensive care personnel using a portable feedback device with immediate audiovisual feedback. Those caring for the most critically ill patients most likely to arrest were trained daily at the bedside until skill success—as guided by the feedback device, which was programmed to the 2005 Guidelines—was attained. CPR quality metrics were demonstrated more quickly in those receiving refreshers more than two times per month.
Both of these demonstrated improvement in CPR skills. There are several common themes with these techniques, including frequency of hands-on skills practice, immediate feedback regarding accuracy and a just-in-time, just-in-place component to the training.
BA: I look to places like Seattle, where EMS takes special pride in high-quality resuscitation care, and I see that building a culture of excellence takes effort from the top; that is, EMS leadership must recognize the importance of this and invest time and resources to provide adequate education and quality assurance programs. Without EMS medical directors and other leaders stressing that cardiac arrest is a battle that can be won and putting their efforts behind those sentiments, it will be hard to make the necessary strides.
BB: There are clearly pockets of excellence across the country where high-quality resuscitation and good patient outcomes are the expectation, not the exception. The common thread is experience and rehearsal and that everyone in the organization has an expectation that each cardiac arrest patient receives the best quality resuscitation.
Q: What historical practices need to be changed?
ML: Intubation in the field is one practice that might need to be changed. A number of studies have indicated a link to reduced survival, and it clearly delays much needed chest compressions. Responders should be focusing more on quality CPR and early defibrillation, and less on other things that may not be as helpful to these patients during the immediate event.
DW: There should be less emphasis on advanced procedures in the field and more emphasis on good chest compressions, rapid defibrillation and rapid transport by EMS systems. Likewise, in the hospital it’s still common to encounter pauses in good chest compressions for procedures that are not immediately needed. More emphasis should be placed on minimizing chest compression interruptions.
RO: One historical practice that needs to be changed is the overreliance on lecture and didactic training. CPR is a psychomotor skill that must be practiced in order to achieve proficiency. I believe that training or retraining needs to take place in the clinical setting with hands-on practice combined with instruction to maximize learning.
BA: I think the most important change has to be one of culture or attitude. Historically, cardiac arrest was rarely survivable, leading many to become discouraged in providing aggressive care. But that is hardly the case today. With improvements in CPR, AEDs, post-resuscitation care, cardiac arrest survival rates can be much higher than they are in many communities presently.
BB: The tradition of therapeutic nihilism [i.e., a belief that cardiac arrest is always fatal] is the main concept that changes quickly in EMS systems that focus on high-quality CPR and produce survivors. Other common and long-held practices that need to be changed are:
1. Prioritizing other interventions over chest compressions and allowing prolonged interruptions to compressions;
2. Thinking that high-quality CPR can be done while moving a patient; and
3. Believing that individual providers can continue CPR without changing rescuers.
Q: What do you see as obstacles to proper CPR performance by trained rescuers inside and outside the hospital, and what are the barriers to measuring and using feedback devices?
ML: The obstacles for in-hospital personnel, especially on the floors, is that these responders don’t see cardiac arrest events very often, so when they do, they either don’t know what to do or their CPR quality is suboptimal. If we want survival to change, feedback devices or mechanical CPR devices and frequent CPR refresher training need to be incorporated into every hospital system and every EMS system.
DW: Frequent, unavoidable obstacles in the out-of-hospital setting that impact the quality of CPR include a limited number of providers available to perform CPR and difficulties related to a moving stretcher, ambulance or helicopter. Studies have shown deterioration of chest compression performance by rescuers over time. Requiring one or even two providers to perform CPR in the field can greatly impact quality, especially with long transport times. The motion inherent in transport can add to this difficulty as the compressor strives to maintain his or her balance in order to perform quality compressions. These could both be remedied with automated compression devices. However, many devices can be time-consuming and laborious to apply and are costly to purchase.
Both inside and outside the hospital, the urgency of the situation can affect perceptions of the team regarding the quality of CPR delivered (i.e., perception of good CPR quality that is actually inadequate or vice versa). This may be especially true with less experienced providers or those who infrequently perform CPR. Training for and use of measurement/feedback devices would be helpful in resolving this issue.
Probably the most significant obstacle to delivering quality CPR both inside and outside the hospital is inadequate knowledge of what comprises CPR quality as well as the impact it has on patient outcomes. Components of quality CPR should be communicated and reinforced during all hands-on training sessions, and training should occur more often than the current two-year cycle.
NB: It’s a challenge to change the “it’s the way we’ve always done it” mindset. EMS practice has driven hospital practice in this arena, so there are “experts” in both areas who are following different guidance.
Community education about the new hands-only CPR has been key to the acceptance of this methodology within our community.
RO: Some obstacles to proper CPR performance by trained rescuers include an inability to monitor CPR performance for proper rate and depth of compression. It’s very difficult for the code chief to focus attention solely on the performance of CPR.
Prioritization of resources is also a barrier to proper CPR performance. During the initial minutes of resuscitation, there’s a lot of activity, including securing the airway, obtaining information from bystanders, obtaining intravenous access and controlling the scene. This makes for a chaotic environment and makes it difficult to perform proper CPR.
BA: Legal issues are certainly an important concern with any quality recording and improvement project, but providing excellent care is always the best antidote to medical-legal worries.
BB: We know that CPR quality without feedback is commonly suboptimal and is significantly improved with feedback. This fact should give providers confidence that they are doing the absolute best for their patients and families, and bystanders on scene can quickly recognize that. Clear, detailed documentation of high-quality CPR is the best defense against medico-legal issues.
Q: What quality measures can be incorporated into training and CPR delivery to ensure the best results?
ML: A lot of this can be fixed by aggressive education campaigns. You don’t need a feedback device to help rescuers know that they should be pressing hard, fast and deep. Although feedback devices would be great, ideally, that’s not practical for all systems. Also, medical staff and rescuers should have to practice their CPR skills on a regular basis; this would not only build up that skill set for them during a real event, but would instill confidence as well.
DW: Optimally, feedback devices should be available for training as well as during actual cardiac arrest events, and events recorded by the device should be reviewed by those involved in the resuscitation. When these are not available, training should involve hands-on CPR demonstration and practice, emphasizing the rationale for each component of quality CPR. Just-in-time training should be used when possible inside the hospital, and CPR should be reviewed/practiced via low-fidelity simulation at least quarterly.
BA: The emphasis has to be on the basics of chest compressions—high-quality performance of both compression rate and depth. Providers who cannot afford feedback devices can still attain excellent compression quality; it requires practice and feedback during refreshers and training courses.
BB: Although there is a vast difference between training and actual CPR performance, more frequent training is one solution to not having real-time CPR feedback. Another is having a team member whose sole charge is ensuring that rescuers performing CPR are rotating regularly, are not fatigued and are delivering the proper rate and depth of compressions, minimizing all interruptions and allowing full chest recoil with each compression.
Q: Could we develop a core benchmark for pre- and in-hospital CPR?
ML: Absolutely, starting with the basics: Quality CPR metrics—appropriate chest compression rate and depth, pre-shock pause times, no-flow times and then of course, ROSC and survival-to-discharge numbers.
RO: Yes. Any core benchmarks for prehospital and in-hospital CPR need to be identical. Current CPR Guidelines specify proper rate and depth of compression; however, a benchmark that needs to be developed is the maximum recommended hands-off interval. All of these benchmarks are quantitative and measurable.
BA: Yes, I believe that benchmarks of quality are attainable. CPR report cards should become a standard item in EMS care, and I believe that providers ultimately will come to appreciate such a report card; everyone feels better when they provide excellent care.
Q: What have hospitals learned about CPR performance that can help prehospital teams and vice versa?
DW: Training programs utilized in hospitals involving feedback, simulation and debriefing have proven to be very effective in improving CPR quality and patient outcomes. Integrating these into prehospital settings, as well as ensuring adequate personnel on all cardiac arrest calls, may help improve CPR in the field. However, it’s important to keep in mind that EMS providers have unique challenges that are not typical in the hospital setting, which may limit their ability to use the equipment/techniques shown to be effective in hospitals.
Multiple studies in prehospital settings have shown the importance of chest compressions prior to defibrillation in cases of cardiac arrest with downtimes greater than four to five minutes. Further, they have shown that initial passive ventilation via a nonrebreather mask and oral airway, and delay of assisted ventilation and intubation in order to obtain rhythm analysis and shocks, if warranted, are not harmful to patients and may be a better method by which to treat them.(3,4) This information could easily be applied in the hospital for arrests with unknown downtimes.
NB: Hospitals are very good at maintaining records of protocol changes, practice guidance, standards of care and training records. This provides consistency and a historical record that is critical in evaluating and determining practice changes. EMS is quick to adopt what works, and the practice guidance is more fluid. This responsiveness allows practice to change and improve over a shorter time frame but consistency in practice is more difficult to maintain.
RO: Both groups have recognized the need to rotate the person performing CPR every few minutes. In the prehospital setting, resources may be scarce and performance of CPR competes with other necessities. One thing that hospital personnel can learn about CPR performance from the prehospital teams is the important of basic CPR. Properly performed basic CPR is likely more important than any drug administration or airway control even in the inpatient setting. Prehospital teams too often transfer patients with CPR in progress and could learn from the in-hospital team by working all cardiac arrests on scene, and transporting patients only after they have achieved ROSC.
BA: By no means is this a challenge for EMS alone. Hospitals also have a long way to go to improve CPR and resuscitation quality. It’s less about what hospitals have learned and more about what we can all learn together—hospital and EMS providers alike.
BB: There is an enormous gap between the CPR we think we are providing and the CPR we are actually doing during resuscitation attempts both inside and outside the hospital. Rescuers need to practice and function as a team and incorporate the best technology available during resuscitation attempts to achieve the best outcomes for our patients.
1. Edelson DP, Litzinger B, Arora V, et al: “Improving in-hospital cardiac arrest process and outcomes with performance debriefing.” Archives of Internal Medicine. 2008;168(10):1063–1069.
2. Niles D, Sutton RM, Donoghue A, et al: “Rolling refreshers: A novel approach to maintain CPR psychomotor skill competence.” Resuscitation. 2009;80:909–912.
3. Kellum MJ, Kennedy KW, Barney R, et al: “Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.” Annals of Emergency Medicine. 2008;52(3):244–252.
4. Bobrow BJ, Clark LL, Ewy GA, et al: “Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.” JAMA. 2008;299(10):1158–1165.
This article originally appeared in an editorial supplement to December 2010 JEMS, FireRescue, Journal of Emergency Nursing and ACEP News as The Experts Weigh In: A CPR quality improvement roundtable.