Comparing three CPR feedback devices and standard BLS in a single rescuer scenario: A randomised simulation study

doi:10.1016/j.resuscitation.2013.10.028

Resuscitation

Volume 85, Issue 4, April 2014, Pages 560-566

https://doi.org/10.1016/j.resuscitation.2013.10.028 Get rights and content

Abstract

Background

Efficiently performed basic life support (BLS) after cardiac arrest is proven to be effective. However, cardiopulmonary resuscitation (CPR) is strenuous and rescuers’ performance declines rapidly over time. Audio-visual feedback devices reporting CPR quality may prevent this decline. We aimed to investigate the effect of various CPR feedback devices on CPR quality.

Methods

In this open, prospective, randomised, controlled trial we compared three CPR feedback devices (PocketCPR^®, CPRmeter^®, iPhone app PocketCPR^®) with standard BLS without feedback in a simulated scenario. 240 trained medical students performed single rescuer BLS on a manikin for 8 min. Effective compression (compressions with correct depth, pressure point and sufficient decompression) as well as compression rate, flow time fraction and ventilation parameters were compared between the four groups.

Results

Study participants using the PocketCPR^® performed 17 ± 19% effective compressions compared to 32 ± 28% with CPRmeter^®, 25 ± 27% with the iPhone app PocketCPR^®, and 35 ± 30% applying standard BLS (PocketCPR^® vs. CPRmeter^® p = 0.007, PocketCPR^® vs. standard BLS p = 0.001, others: ns). PocketCPR^® and CPRmeter^® prevented a decline in effective compression over time, but overall performance in the PocketCPR^® group was considerably inferior to standard BLS. Compression depth and rate were within the range recommended in the guidelines in all groups.

Conclusion

While we found differences between the investigated CPR feedback devices, overall BLS quality was suboptimal in all groups. Surprisingly, effective compression was not improved by any CPR feedback device compared to standard BLS. All feedback devices caused substantial delay in starting CPR, which may worsen outcome.

Introduction

Cardiac events are a leading cause of death worldwide, despite our best life support efforts, and outcome after cardiac arrest is still poor.1, 2, 3 Several investigations strongly suggest that efficiently performed basic life support (BLS) is the only sufficient and immediately available treatment for cardiac arrest and may improve long term outcome.1, 4 However, rescuers’ cardiopulmonary resuscitation (CPR) performance – particularly external chest compression quality – decreases rapidly over time.⁵ Thus a number of devices providing audio-visual feedback during chest compressions (CPR feedback devices) have been introduced in an effort to improve BLS quality.2, 4, 6, 7 Such CPR feedback devices can be used by medical staff and trained laypersons alike even if manual defibrillators or automated external defibrillators (AED) are not available, or defibrillators without CPR feedback are used.8, 9, 10

These devices seek to become a clinical standard, but at present, data on the improvement of resuscitation quality using such devices are insufficient, and no direct comparison of such CPR feedback devices has been performed. Because of the lack of performance data, we compared three CPR feedback devices (Zoll PocketCPR^®, Laerdal CPRmeter^®, iPhone app Zoll PocketCPR^®) with standard BLS without feedback in simulated single-rescuer BLS without a defibrillator in an 8-minute scenario.

In a previous study on CPR feedback devices integrated into an AED we showed an improvement in effective compression of about 15% compared to standard BLS.⁶ The aim of our current study was to investigate whether standalone CPR feedback devices improve CPR quality compared to standard BLS.

Therefore, our 0-hypothesis was that CPR feedback devices would not improve chest compression efficiency compared to standard BLS in a group of trained lay rescuers over time.

Section snippets

Study protocol

This open, prospective, randomized, controlled parallel group study was approved by the Ethics Committee of the Medical University of Vienna (EK No. 1676/2012). Over a period of four weeks, we recruited 240 medical students at the compulsory BLS course in their fifth semester of medical school. Exclusion criteria were upper extremity injuries and pregnancy. All study participants received standardized BLS training prior to the investigation. It was communicated to the study participants that

Results

Out of 244 potential study participants, one was ineligible for our investigation due to pregnancy and three due to previous musculoskeletal upper extremity injuries (Fig. 1). Demographic characteristics of the 240 study participants in the 4 study groups are shown in Table 1. No dropouts occurred after randomization. There was no significant difference in real life CPR experience and resuscitation training between the groups. The mean time of the study participants’ training, until they felt

Discussion

This study investigated the efficiency of chest compressions comparing three CPR feedback devices (Zoll PocketCPR^®, Laerdal CPRmeter^®, the iPhone app Zoll PocketCPR^®) and standard BLS without feedback in a simulated setting. We confirmed our 0-hypothesis that chest compression efficiency did not improve through the application of any of the standalone CPR feedback devices compared to standard BLS.

The effective compression (EC), a compound parameter to easily compare chest compression quality,

Conclusion

Despite several differences between the CPR feedback devices and standard BLS, none of the devices achieved an improvement in EC or ECR as markers for chest compression quality compared to standard BLS without feedback. CPR quality with the PocketCPR^® was even significantly reduced due to insufficient decompression and incorrect compression point.

All CPR feedback devices caused delay in CPR start and may worsen outcome. PocketCPR^® was the only device that significantly improved chest

Conflict of interest statement

None of the authors has a conflict of interest. The Laerdal CPRmeter^® was provided by Laerdal free of charge during the period of the study. Apart from this, only departmental support was used for the study. Neither Zoll Medical nor Laerdal reviewed or revised the manuscript at any stage.

Acknowledgements

We would like to thank all medical students for their participation in our study. In addition, we would like to thank Prof. Wilhelm Behringer for providing a Thumper^®, Florian Schachinger, Julian Voitl and Paul Bsuchner who helped with the data collection and Emily Lemon for the English proofreading.

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Cited by (63)

Using real-time device-based visual feedback in CPR recertification programs: A prospective randomised controlled study
2023, Nurse Education Today
Receiving regular training to maintain CPR skills is critical for in-service health-care professionals, especially because motor skills diminish over time.
To compare the effects of real-time device-based visual feedback and conventional instructor-based feedback on the chest compression skills and self-efficacy of nurses receiving a CPR recertification program.
A prospective randomised controlled study with repeated measurements was conducted according to the CONSORT 2010 guidelines.
A total of 109 nurses were recruited, and 98 nurses were eligible for random allocation. The control group (CG, n = 49) was advised by instructors for skill correction, and the experimental group (EG, n = 49) adjusted their skills according to on-screen real-time feedback data. The study outcomes were CPR performance metrics and self-efficacy that were assessed immediately after the training session (T1) and retested after 12 weeks (T2).
In the EG, the percentage of the appropriate rate, depth, and chest recoil at T1 significantly improved by 24.47 % (P < .001), 19.63 % (P < .001), and 11.52 % (P = .001), respectively. The EG exhibited significantly higher chest compression total scores at T1, and the difference remained significant at T2 (P < 0.001). Moreover, the self-efficacy in the EG significantly improved at T1 (2.76; P < .001) and T2 (2.58; P < .001).
Compared with instructor-based feedback, real-time device-based visual feedback improved chest compression quality and CPR self-efficacy.
Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data
2022, Journal of Emergency Nursing
Citation Excerpt :
Furthermore, there was one clinical study that evaluated handheld visual feedback device measurements using video analysis; they found that because of poor interrater agreement they were not able to compare the measures.32 Simulation studies have compared the measured rates and depths by different devices using manikins with built-in chest compression analysis sensors and found that the rate measurements were comparable.33–36 Despite the emerging literature, there is an absence of data comparing the CPRmeter 2 with LifePak20 measured rates or comparison of multiple cross device measurements in a clinical setting.
High-quality cardiopulmonary resuscitation is foundational to cardiac arrest care. Visual feedback devices can improve chest compression quality, but are infrequently used. Quality improvement data were examined to determine whether handheld visual feedback and backboard use improved chest compression quality, whether resuscitation team size affected resuscitation indicators, and whether feedback sources are comparable.
From August 2019 to December 2020, data from 50 resuscitations were collected using a handheld device (n = 35), defibrillator (n = 23), and surveys (n = 35) and shared with providers. Aggregated and individual case data, along with education and research, were distributed to staff as quality improvement measures.
The mean duration of resuscitation was 1080 compressions (SD = 858); there were no differences in the durations of resuscitations that did or did not use handheld feedback; 50% of resuscitations used handheld feedback and had more compressions at target rate (74.68% vs 42.18%, t₍₂₁₎ = 2.99, P = .007). Moreover, 25% of resuscitations used backboards; these had more chest compressions at target depth (72.92% vs 48.73%, t₍₂₅₎ = 2.08, P = .048). Team size was not associated with duration of resuscitation or chest compressions quality. There was no improvement in other quality indicators (leadership, family presence, or debriefing) during the data collection period. Feedback sources (defibrillator and feedback device) had good agreement and correlation (r = 0.77, P = .01).
Incorporating handheld feedback and backboards improved chest compressions quality. Further work to improve the frequency of device use and to examine their relationship to patient-specific outcomes is needed. Study is needed to find interventions that improve other teamwork metrics, inclusion of family during the resuscitation, referral for tissue donation, and rates of postevent debriefing.
Just showing is not enough: First-person-view-videos as a feedback tool in resuscitation simulation
2022, Studies in Educational Evaluation
Theory and evidence suggest beneficial effects of integrating first-person-view (FPV) videos as a feedback method in resuscitation simulation training. However, systematic research on this instructional approach is scarce. We aimed to determine the feasibility of supplementing feedback with FPV videos for simulation-based learning and its effect on cardiopulmonary resuscitation (CPR) performance. In our randomized controlled trial conducted in a simulation-based course on CPR, each participant’s FPV video was recorded using a head-mounted camera and videos were shown before post-simulation debriefing. Feasibility was tested in 27 simulated CPR scenarios randomized to FPV feedback combined with instructor-led debriefing (intervention; 14 scenarios) versus instructor-led debriefing only (control; 13 scenarios). In terms of CPR (effective compression ratio [ECR]) and team performance (Team Emergency Assessment Measure [TEAM]), improvements were observed for ECR (pre-test: 0.13 ± 0.11 vs post-test 0.19 ± 0.11) and TEAM score (pre-test: 16.6 ± 7.2 vs post-test: 25.4 ± 9.2). However, improvements did not differ significantly between intervention and control group. Course participants deemed the feedback method feasible and reported positive instructional effects. In order to make use of the potential of this promising feedback tool, we conclude that it is not sufficient to show the videos without didactical assistance.
Effects of real-time feedback on cardiopulmonary resuscitation quality on outcomes in adult patients with cardiac arrest: A systematic review and meta-analysis
2020, Resuscitation
To investigate the relationship between the implementation of real-time audiovisual cardiopulmonary resuscitation (CPR) feedback devices with cardiac arrest patient outcomes, such as return of spontaneous circulation (ROSC), short-term survival, and neurological outcome.
We systematically searched PubMed, Embase, and the Cochrane CENTRAL from inception date until April 30, 2020, for eligible randomized and nonrandomized studies. Pooled odds ratio (OR) for each binary outcome was calculated using R system. The primary patient outcome was ROSC. The secondary outcomes were short-term survival and favorable neurological outcomes (cerebral performance category scores: 1 or 2).
We identified 11 studies (8 nonrandomized and 3 randomized studies) including 4851 patients. Seven studies documented patients with out-of-hospital cardiac arrest and four studies documented patients with in-hospital cardiac arrest. The pooled results did not confirm the effectiveness of CPR feedback device, possibly because of the high heterogeneity in ROSC (OR: 1.42, 95% CI: 1.03–1.94, I²: 80%, tau²: 0.1875, heterogeneity test p <  0.01) and survival-to-discharge (OR: 1.27, 95% CI: 0.74–2.18, I²: 86%, tau²: 0.4048, heterogeneity test p <  0.01). The subgroup analysis results revealed that heterogeneity was due to the types of devices used. Patient outcomes were more favorable in studies investigating portable devices than in studies investigating automated external defibrillator (AED)-associated devices.
Whether real-time CPR feedback devices can improve patient outcomes (ROSC and short-term survival) depend on the type of device used. Portable devices led to better outcomes than did AED-associated devices. Future studies comparing different types of devices are required to reach robust conclusion.
Prospero registration ID CRD42020155388.
External Cardiac Massage Training of Medical Students: A Randomized Comparison of Two Feedback Methods to Standard Training
2020, Journal of Emergency Medicine
Citation Excerpt :
When looking specifically at data obtained with the Pocket CPR App, studies are sparse and controversial. A recent study reported that the Pocket CPR device had an overall lower performance than standard training while Park et al. showed that the Resusci Anne with the Skill Reporter software and the Pocket CPR App cannot be used interchangeably (5). These authors were unable to define which system performs better than standard training method in laypersons (16).
The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices.
The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students.
This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention.
Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p < 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups.
The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.
Using a Mobile Phone Application Versus Telephone Assistance During Cardiopulmonary Resuscitation: A Randomized Comparative Study
2020, Journal of Emergency Nursing
In recent years, the way CPR instructions are given has changed because of the development of new technology that allows bystanders who witness a cardiac arrest to be guided in performing CPR. This study aimed to compare the effectiveness of using a mobile phone application (app) versus telephone operator assistance in performing cardiopulmonary resuscitation (CPR) techniques in simulated settings.
A comparative study was performed with 2 intervention groups: (1) mobile phone app and (2) telephone assistance. A total of 128 students participated and were distributed randomly into each intervention group. A CPR observation checklist and standard CPR quality parameter measurements were used for data collection.
The group that used the app obtained better results than the group that had telephone assistance on 5 items during CPR observation: checking if the area is secure (X²(1) = 26.81; P < 0.05), asking for help (X²(1) = 66.07; P < 0.05), opening of airways (X²(1) = 12.03; P < 0.05), checking for breathing (X²(1) = 6.10; P < 0.05), and contacting emergency services (X²(1) = 12.41; P < 0.05). Regarding the skill level of CPR, no statistically significant differences were found when comparing the 2 intervention groups (X²(1) = 0.91; P = 0.33). As for the parameters measured, there were only statistically significant differences found in the item compression fraction (U = 1,593.00; Z = −2.16; P < 0.05), with the group that used the app obtaining better results.
Better outcomes were observed in recognizing if the area was safe, asking for help, opening up the airways, checking for breathing, and calling emergency services in the mobile phone app group. However, the results indicated that there were no differences in the CPR parameters, except compression fraction, when the app was used as opposed to being guided by telephone.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.10.028.

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Simulation and educationComparing three CPR feedback devices and standard BLS in a single rescuer scenario: A randomised simulation study☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study protocol

Results

Discussion

Conclusion

Conflict of interest statement

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Trends Anaest Crit Care

Resuscitation

Simulation and education
Comparing three CPR feedback devices and standard BLS in a single rescuer scenario: A randomised simulation study☆