Clinical paperCPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system☆
Introduction
Survival from cardiac arrest requires prompt execution of high-quality cardiopulmonary resuscitation (CPR), as well as rapid electrical defibrillation for pulseless ventricular fibrillation/tachycardia.1, 2, 3 Recent investigations have emphasized the importance of CPR and have suggested that delivery of chest compressions and ventilations may be more important, as initial therapy, than immediate defibrillation in many cases.4, 5 However, studies have demonstrated that the quality of CPR performance during actual cardiac arrest is poor, even when resuscitation efforts are conducted by healthcare professionals during both in-hospital and out-of-hospital cardiac arrest.6, 7, 8, 9, 10 These CPR discrepancies occur despite clearly stipulated published guidelines for CPR delivery and well-established programs for resuscitation training and certification.1
One possible solution to this problem is the use of monitoring and feedback during CPR to detect and correct deficiencies in real-time. Feedback has been shown to improve CPR quality during simulated cardiac arrest on manikins, but its effect during actual cardiac arrest is unknown.11, 12, 13, 14 We hypothesized that audiovisual feedback would improve CPR performance during in-hospital cardiac arrest.
Section snippets
Investigational defibrillator
An investigational monitor/defibrillator (IDE #G020121) with CPR-sensing and audiovisual feedback capability was used during all cardiac arrests from December 2002 to April 2004, with the feedback component disabled, and then from December 2004 to December 2005, with feedback enabled. Details of the sensing technology have been described and validated previously.6, 7, 15 The feedback component was developed in part from earlier work with CPR audio feedback in simulated resuscitation settings.11
Results
During the time period from December 2002 until April 2004, a total of 55 patients met the criteria for inclusion in this analysis as the “baseline” cohort, in that they (a) underwent resuscitation attempts using the study monitor/defibrillator without audiovisual feedback and (b) had simultaneous capture of all CPR variables to allow comparison to the subsequent feedback patient cohort. Using similar criteria for inclusion, 101 patients were included in the intervention group between December
Discussion
We have demonstrated modest improvements in the quality of CPR delivered during actual in-hospital cardiac arrests with the use of a CPR-sensing and feedback-delivering monitor/defibrillator. Chest compression rate, ventilation rate and NFF, as well as the distribution of these variables, improved during resuscitation efforts in the cohort of patients receiving real-time feedback. Our collaborators have found similar improvements in CPR quality using the same technology in the out-of-hospital
Conclusions
Recent work has highlighted the importance of CPR quality, and the updated consensus resuscitation guidelines have stipulated a need for initiatives to both monitor and improve CPR performance. We have demonstrated that a real-time CPR detection and audiovisual feedback system, incorporated into a clinical monitor/defibrillator, can improve CPR variables and reduce the variability in resuscitation performance. However, feedback specifics will be likely to require refinement to produce maximal
Conflict of interest
The study sponsor had no role in data collection, interpretation of results or manuscript preparation. Mr. Myklebust is an employee of the study sponsor and was involved in study conception and design. Drs. Abella and Becker have received honoraria and research support from Philips Medical Systems (Andover, MA) and Laerdal Medical Corporation (Stavanger, Norway). The other authors of the manuscript do not declare any conflicts of interest.
Acknowledgements
We thank Juned Siddique, PhD for statistical expertise during our work and Jason Alvarado for technical support. We also thank Michael Retzer and Lynne Harnish for their administrative assistance. Finally, we are grateful to the internal medicine house officers and critical care nursing staff of the University of Chicago Hospitals for their enthusiasm and diligence to patient care during our investigation. This work was supported by a grant from the Laerdal Medical Corporation (Stavanger,
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.10.027