Lyngby, Rasmus (2022) Cardio-pulmonary-resuscitation quality in out-of-hospital cardiac arrest : real-time feedback and post-event debriefing. (PhD thesis), Kingston University, .
Abstract
Background Out-of-hospital cardiac arrest (OHCA) is frequently reported as a major health problem with low survival. According to the European Resuscitation Council, survival depends on optimal performance by bystanders and emergency medical services (EMS), with guideline-adherent chest compressions and ventilation as the key components in the resuscitation effort. To ensure and improve cardiopulmonary resuscitation (CPR) quality, real-time feedback on chest compression and ventilation have been made available to EMS providers. In contrast, despite their availability, clinical debriefings have been infrequently used. Previous studies and reviews have reported different conclusions on the effect and association of real-time feedback and clinical performance debriefings in the clinical setting. This thesis investigates the use of real-time feedback and post-event clinical debriefings by EMS for OHCA and examines whether the interventions have an effect on or are associated with CPR quality improvement and patient outcomes. Methods Three different methods were applied. A systematic review with meta-analysis was performed to explore the knowledge base and effects of real-time feedback and clinical debriefings solely in the context of OHCA. A prospective cohort study was conducted to investigate the quality of chest compressions performed by Copenhagen EMS and the association of CPR quality improvement with the implementation of real-time feedback and post-event clinical debriefings for OHCA. A randomised simulation trial investigated the effect of real-time ventilation feedback in a pre-clinical environment. Results The systematic review identified 9,464 studies, with 61 eligible for full-text screening. Eight studies were included in the meta-analysis. Analysis revealed that real-time feedback improved compression depth (mean difference (MD) = 0.19; 95 % confidence interval (CI) [0.08, 0.29]) and rate (MD = 5.56; 95 % CI [3.19, 7.94]), whereas post-event feedback improved depth (MD = 0.50; 95 % CI [0.36, 0.64]) and compression fraction (MD = 7.11; 95 % CI [5.85, 8.36]). Feedback had no significant effect on the return of spontaneous circulation (ROSC); (real-time feedback: risk ratio (RR) = 1.05; 95 % CI [0.92, 1.19]; post-event feedback: RR = 1.24; 95 % CI [0.71, 2.17]), sustained return of spontaneous circulation (sROSC); (real-time feedback RR = 1.10; 95 % CI [0.87, 1.38]; post-event feedback: no studies), or survival to hospital discharge (StD(; (real-time feedback: RR = 1.15; 95 % CI [0.66, 2.00]; post-event feedback: RR = 1.24; 95 % CI [0.65, 2.37]). The included studies were of low to very low quality. The CPR feedback cohort study included 1,545 patients and showed that real-time and post-event feedback was significantly associated with improvement in compression rate (p = 0.03) and compression fraction (p < 0.001) but not compression depth when measured in cm (p = 0.7). When measured as a proportion within guideline recommendations, a significant association was found for compression depth (p = 0.001) and compression rate (p <0.001). The performance improvements did not translate into significant improvements in ROSC (Odds ratio (OR) [95 % CI] = 1.08 [0.84, 1.39]), sROSC (1.00 [0.77, 1.31], or StD (0.91 [0.64, 1.30]. Post-hoc analysis revealed that feedback intervention significantly improved the combination of rate and depth in one compression (p = 0.0001). The study was not powered for patient outcomes. The ventilation study included 64 paramedics and found that real-time feedback significantly improved guideline adherence for ventilation rate (p < 0.0001) and tidal volume (p < 0.0001) as individual components. The improvement in guideline adherence remained significant when combining guideline-adherent ventilation rate and tidal volume in one ventilation (p < 0.0001). Conclusions On the basis of studies of low to very low quality, the systematic review concluded that real-time and post-event feedback must be combined to improve CPR quality significantly. Neither real-time nor post-event feedback had a significant effect on patient outcomes. The CPR feedback cohort study concluded that real-time feedback and clinical debriefings were associated with improved EMS CPR quality, but this did not translate into patient outcomes. The results also indicate that the current consensus on high-quality CPR and guidelines need additional components and combined measurements to reflect CPR quality. The ventilation study concluded that real-time ventilation feedback increased guideline compliance for ventilation rate and tidal volume in a simulated OHCA setting. The final conclusion is that real-time and post-event feedback improved CPR quality, but the improved performance did not translate into better patient outcomes. It was also concluded that the current measurement of high-quality CPR in guidelines need additional components to be measured. Further research is needed to understand the lack of translation of improved CPR quality to patient outcomes.
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