Article, Emergency Medicine

Chest compressions performed by ED staff: a randomized cross-over simulation study on the floor and on a stretcher

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1928-1934

Original Contribution

Chest compressions performed by ED staff: a randomized cross-over simulation study on the floor and on a stretcher

Mustapha Sebbane MD, PhD a,?, Megan Hayter MD, Med b, Joaquim Romero BSN a, Sophie Lefebvre PhD a, Colette Chabrot BSN a, Gregoire Mercier MD c,

Jean-Jacques Eledjam MD, PhD a, Richard Dumont MD a,

Patricia L. Houston MD, Med, FRCPC b, Sylvain Boet MD, MEd d

aDepartement des urgences, Centre Hospitalier Regional Universitaire Lapeyronie – 371, avenue du doyen Gaston Giraud -34295 –

MONTPELLIER Cedex 5

bResearch into Teaching (SMART) Simulation Group, St. Michael’s Hospital, and Department of Anesthesia,

University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B1W8

cDepartement d’information medicale, Centre Hospitalier Regional Universitaire Lapeyronie – 371, avenue du doyen Gaston Giraud -34295 – MONTPELLIER Cedex 5

dDepartment of Anesthesiology, General Campus, The Ottawa Hospital and University of Ottawa Skills and Simulation Centre (uOSSC) University of Ottawa, 501 Smyth Road, Ottawa, K1H 8L6, Ontario, Canada

Received 23 February 2012; revised 12 April 2012; accepted 12 April 2012

Abstract

Background: Multiple factors may contribute to the observed survival variability following in-hospital cardiopulmonary resuscitation (CPR). While in-hospital CPR is most often performed on patients lying on a bed or stretcher, CPR training uses primarily manikins placed on the floor. We analyzed the quality of external chest compressions (ECC) in simulated Cardiac arrest scenarios occurring both on a stretcher and on the floor.

Methods: Prospective cross-over simulation study enrolling ED nurses and nurse’s aides as part of an annual evaluation. Simulated CPR was performed in the 2 rescuer-mode for 2 min, both kneeling on the floor, and standing beside a knee high stretcher. The order of position was randomized. ECC parameters were compared.

Results: ED nurses (n= 48) and nurse’s aides (n= 26) performed 128 scenarios. Mean ECC depth was 32 +- 13 mm on the floor and 27 +- 11 mm on a stretcher (?: 5 mm, 95%CI [3-7], P b.001). Participants last trained within a year (n= 17) developed deeper ECCs than their colleagues (n= 47) in both positions (floor: 39 +- 12 mm vs stretcher: 34 +- 11 mm (p= 0.016) for those trained within the year, and floor: 29 +- 12 mm vs stretcher: 24 +- 10 mm (P b.001) for those trained over a year ago).

Conclusions: The Quality of chest compressions performed by ED staff was below 2005 guideline standards, with decreased ECC depth during CPR on a stretcher. Annual refresher courses should be implemented in the ED, with a focus on obtaining required ECC depth while standing next to a stretcher.

(C) 2012

* Corresponding author. Departement des urgences, Centre Hospitalier Regional Universitaire Lapeyronie, 371, avenue du doyen Gaston Giraud -34295 – MONTPELLIER Cedex 5.

E-mail address: [email protected] (M. Sebbane).

0735-6757/$ – see front matter (C) 2012 http://dx.doi.org/10.1016/j.ajem.2012.04.013

Introduction

Background

Numerous experimental and clinical studies have dem- onstrated the benefit of high quality cardiopulmonary resuscitation (CPR) on the success of resuscitation [1-3]. Effective CPR depends on multiple factors including rescuer-related and Environmental factors, all contributing to the observed survival variability following in-hospital CPR. The support on which the patient is positioned, an hospital bed or stretcher, or the ftoor in out of hospital conditions, may be a key factor [4].

It is now accepted that the major determinant of effective CPR is represented by the quality of external chest compressions (ECCs), correlated with cardiac output and time without cerebral ftow. Despite the efforts made to improve CPR procedures and training, the quality of in hospital CPR remains insufficient, even with trained medical or paramedical personnel, often exposed to cardiac arrests [5,6]. The 2005 European Resuscitation Council (ERC) and International Liaison Committee for Resuscitation recommended positioning cardiac arrest victims in the supine position on a firm surface (backboard or ftoor) during ECCs to optimize the effectiveness of compressions. Rescuer’s arms should be straight, their shoulders positioned over the thorax, so that the thrust of each ECC is straight down onto the chest [7].

Most in-hospital cardiac arrests occur with patients lying on either a bed or stretcher. Nurses must be proficient in CPR, able to start resuscitation immediately in the two rescuer-mode. However, there are no specific CPR recom- mendations concerning rescuer positions, for in-hospital “patient on bed” conditions. In Emergency Departments (ED), CPR is more likely to be performed while standing next to a patient lying on a stretcher. Unlike beds, stretcher width is insufficient to accommodate a rescuer kneeling next to the patient. Nevertheless, CPR certification classically uses supine mannequins placed on the ftoor. Few studies have analyzed the inftuence of setting on CPR efficiency, including being positioned on the ftoor or a bed, with controversial findings [8-12]. We hypothesized that ECCs administrated by ED staff while standing beside a stretcher would be less effective than ECC’s performed with the patient lying on the ftoor.

Goals of this investigation

The primary objective of this study is to compare the quality of ECCs performed by the emergency nurses and nurse’s aides on a stretcher to those performed on the ftoor, in a BLS resuscitation scenario. The secondary objective was to determine the inftuence of ED staff-related variables, including profession and effect of time since last CPR training, on the Quality of CPR.

Methods

Study design and setting

This is a prospective randomized cross-over simulation study conducted in the Emergency Department of an urban university hospital counting approximately 50,000 annual visits.

Participants

Participants were emergency department staff, including nurses and nurse’s aides. All were active ED staff members and had previously received CPR training and certification. The study was part of a systematic annual re-training. Participants received written information about the study and consented to participate. Because of the educational nature of the study, the Institutional Review Board waived written informed consent.

Study protocol

All participants previously validated a 3hr instructor-led BLS training course, including hands-on practice. At the onset of the study, participants received a short refresher course combining a brief theoretical review by an instructor and a video highlighting the core elements of BLS, according to the 2005 ERC and ILCOR guidelines. Cardiac arrest scenari were then run using the Rescusci’Anne Laerdal Skill Reporter Modular system (SkillReporter Resusci Anne, Laerdal Medical, France), either positioned on the ftoor or on a stretcher. Simulated CPR was performed in the ED ward, to approach as close as possible to the everyday clinical setting.

CPR was administered in the two-rescuer mode, in accordance with the 2005 BLS guidelines. Ventilations were given by one investigator with a standardized airway kit, (Bag-mask ventilation, mask #4, Laerdal Medical, France). Compression to ventilation ratio was 30:2. Participants performed CPR in two different positions: kneeling beside the manikin on the ftoor (F); or standing beside the manikin installed on a stretcher, adjusted to the height of the rescuer’s knee. The order of position was randomized. ECC were performed for 2 min, with a 30 min rest period in between two positions.

The manikin was laid supine, either on the ftoor or ontoa

stretcher (Promotal armeo hydraulic biplane) equipped with a transfer ambulance mattress 5 cm thick, using a backboard. The use of a stretcher rather than a bed, with the rescuer standing beside the stretcher, was chosen to replicate as closely as possible ED conditions. No difference in ECC quality has been reported in the literature when standing beside or kneeling on a bed during in- hospital resuscitation [10]. We did not use a metronome to control ECC frequency. The manikin weighed 21 kg, and no extra weights were added.

Data collection and processing

The manikin was connected to a computer with a PC Skillreporter software, allowing real time recording of CPR parameters. The equipment was installed so that no feedback on CPR performance could be given to the participant from the monitor. The instructor did not provide immediate feedback to the participant. ECC parameters, including the mean compression depth, rate, complete release, Duty cycle and the percentage of correct compressions (depth= 38-51 mm), too shallow (depthb 38 mm) and too deep compres- sions (depth N 51 mm) were analyzed for each minute. Ventilations parameters were not assessed. Before executing the scenarios, all participants completed a questionnaire, indicating their gender, height, training and experience of CPR, including time since last CPR training and time since last experience of CPR.

Outcome measures

Outcome was depth of ECC, as performed by nurses and nurse’s aides, both on the ftoor and on the stretcher in a simulated BLS scenario in the ED ward.

Primary data analysis

Sample size calculations indicated that 20 participants would be required to detect a 10% change in ECC depth at a significance level of 0.05 and 80% power.

When data was normally distributed, description of quantitative variables was presented as means and standard deviations or percentage (%) with the values range. Median and interquartile range were given for non-normally distributed data. Comparisons between positions were performed for each quantitative ECC parameter using the paired Student’s test or the paired Wilcoxon test, in order to take into account the non-independence of observations. Comparisons between groups were performed using the Student or Wilcoxon tests. Comparisons between groups defined by the time since last training were tested using Bonferroni’s correction in order to control the type 1 error rate. The significance level was set at 0.05 for all tests used. Statistical analysis was performed with SAS software version 9 (SAS Institute, Cary, NC).

Table 1 Characteristics of participants (N= 64)

Results

Characteristics of study participants

A total of 65 members, including ED nurses (n= 38, 54%) and nurse’s aides (n= 26, 41%) participated in the study. One participant was excluded for misrecording of CPR data. Forty four participants were female (69%). Mean height was 170 +- 10 cm. Mean age was 35 +- 10 years. Mean experience

in the ED was 4.4 +- 4.8 years. About half of participants had administered CPR on a patient in the preceding year. All participants had received BLS training, as part of their professional education (Table 1).

Effect of rescuer’s position on the quality of chest compressions

128 CPR scenarios were analyzed. A total of 10212 and 9783 ECCs were performed on the ftoor and on a stretcher, respectively. Mean compression depth was significantly higher on the ftoor (32 +- 13 mm) than on a stretcher (27 +- 11 mm; mean difference: 5 mm, 95%CI [3-7], P b.001) (Fig. 2). Percent of too-shallow ECCs (depthb 38mm) was significantly lower on the ftoor (65 +- 43 %) than on a stretcher (80 +- 36 %, mean difference: 15 %, 95%CI [7-24], P b.001) (Table 1) (Fig. 1). No significant difference in compression rate, or correctly released compression was found (Table 1).

Effect of time since last BLS training on CPR quality

The effect of time since last BLS training was analyzed in all 128 scenarios, regardless of the position. Out of the 64 participants, 17 (27%) had received their last BLS training within the year, while 14 had received their last training over a year ago but within the last 2 years, 14 within the last 4 years and 19 within the last 5 years.

There were significant differences in ECC depth between participants who had received their last training within the year and those of the other groups: within the last 2 years depth (? depth: 10 mm, 95% CI [3-16]), within the last 3 and 4 years (? ECC depth: 9 mm, 95%CI [2-16] or within the last 5 years and beyond (? ECC depth: 10 mm, 95%CI [5-15] (Fig. 1).

In contrast, no significant difference in ECC depth was found between all participants last trained over a year ago

Variables

Median Age (y) 32 (IQ: 26; 41) Gender

Female 44 (69%)

Male 20 (31%)

Mean Height (cm) 170 +- 10 (154-178) Qualification

Nurses 38 (60 %)

Nurses ‘s aides 26 (41%)

No of working years 2.6 (IQ: 1.2; 5.7)

No of years since last training 3.0 (IQ: 1.0; 5.0) Experienced ECC on a patient

Yes 33 (52%)

No 31 (48%)

Value are given as numbers (%), mean +-SD, or median (interquartile range).

Fig. 1 Compression depth according to time since last CPR training. Participants last trained within the year, within the last 2 years, within the last 3-4 years, or within the last 5 years and beyond were compared. Compression depth is shown as mean and SD (error bars). The asterisk indicates significant difference (P b.05).

and beyond. They developed a mean ECC depth of 27 +- 12 mm, 95% CI [24-29], across both scenarios, with a mean difference in ECC depth of 9 mm, 95% CI [5-14] (P b.001) with participants who had received their last training within the year.

When considering participants last trained within the year (n = 17), mean ECC depth was 39 +- 13 mm on the ftoor and 34 +- 11 mm on the stretcher (? depth ftoor vs stretcher: 5 mm, 95%CI [3-7], P b .001) (Fig. 2). A significant difference in the percent of too shallow ECCs was also observed (? % of shallow ECC ftoor vs strectcher: 15 %, 95% CI [5-25], P b .001).

There was no difference in the ECC rate or compression- decompression ratio between ftoor and stretcher (Table 2).

Participants last trained over a year ago (n= 47) carried out ECCs with less depth, in both positions.

Mean ECC depth was 29 +- 12 mm on the ftoor and 24 +- 10 mm on the stretcher (? depth ftoor vs stretcher: 5 mm, 95%CI [1-9] p= 0.02)) (Fig. 2), and a significant difference in the % of ECC with correct depth (? % of correct ECC ftoor vs strectcher: 17%, 95%CI [3-31] (p= 0.002)). There was no difference in the ECC rate.

The effect of profession on CPR quality: nurses versus nurse’s aides

The impact of profession (nurses (n= 38) versus nurse’s aides (n= 26)) on CPR quality, was studied.

When both ftoor and stretcher positions were considered, compression rate was higher in all of the 76 CPR’s performed by nurses as compared to all of the 52 CPR’s performed by nurses’s aides, regardless of the position. Median compression rate was 110 min, IQ range [90-121] and 82 min [68-112] for nurses and nurse’s aides respectively (P b.001) (Fig. 4).

No difference in compression depth nor compression- decompression ratio was recorded. Mean (SD) compression depth was 30 (13) mm, 95% CI [27-33] and 29 (12) mm, 95% CI [25-32] for the nurses and nurse’s aides respectively (P =.643) (Table 2).

Fig. 2 Compression depth according to time since last BLS training and to position. Participants last trained within the year (n= 17) or over a year ago (n= 47) administered CPR both on ftoor and on the stretcher, order of position was randomized. Compres- sion depth is shown as mean and SD (error bars). Asterisks indicate significant difference (P b.05).

When distinguishing between the ftoor and stretcher positions, differences in ECC depth were observed between ftoor and stretcher, for both the nurses and nurse’s aides (Fig. 3). In contrast, no difference in the ECC rate was recorded, for either the nurses or nurses’ aides (Fig. 4).

Discussion

We compared the quality of ECC’s performed on the ftoor to those carried out on an emergency stretcher, by ED nurses and nurse’s aides, during simulated cardiac arrest.

The study participants represented 60% of an actual ED workforce.

Chest compressions parameters, including the ECC rate and duty cycle were often respected throughout the Resuscitation procedure. However, the average ECC depth developed by all participants was suboptimal in both positions, according to the 2005 international guidelines that applied to the study period. ECC depth of 32 +- 13 mm and 27 +- 11 mm were recorded on the ftoor and stretcher respectively, with a significant 15% decrease in ECC depth on the stretcher (? depth: 5mm, P b.001).

The overall poor BLS skills demonstrated by our ED staff are in line with previous findings reported for 296 nurses from non critical-care wards [6].

Despite their ED experience, our study participants did not get frequent exposure to real life resuscitation throughout the year. Indeed 48% acknowledged no prior experience of resuscitation on a patient. Our participants may have faced the simulated resuscitation with high stress levels, which may have impeded their ability to confront and handle the

Variables

All subjects (n= 64)

trained within a year (n= 17)

trained over a year ago (n= 47)

All subjects (n = 64)

trained within a year (n= 17)

trained over ago (n= 47)

a

year

Total ECCs (2 min)

10212

3204

7008

9783

3145

6638

NS

Rate (n/min)

101 +- 30

119 +- 17

99 +- 3

99 +- 27

118 +- 15

93 +- 27

NS

Depth (mm)

32 +- 13

39 +- 13+

29 +- 12*

27 +- 11

34 +- 11+

24 +- 10*

b.001

Compression

0.64 +- 0.21

0.57 +- 0.16

0.67 +- 0.21*

0.59 +- 0.20

0.59 +- 0.15

0.59 +- 0. 21*

.015

decompression ratio

Correct Depth

6 (0-51)

38 (0-84)

0 (0-44) *

0 (0-9)

11 (0-68)

0 (0-4) *

.002

(38 – 51 mm) %

Values are given as mean+-SD, or median (interquartile range).

P value b.05 is considered significant. P b.05 between parameters recorded on ftoor vs. stretcher in the +group trained within the year or * in group trained over a year ago. NS: not significant, ECCs: External Chest Compressions.

N= 128 scenarios executed by 64 nurses and nurse’s aides. Rescuers performed CPR both kneeling on the ftoor or standing beside the stretcher. Order of

position was randomized.

situation. A gender effect, which may be related to body weight or muscle strength, could also be advocated, as more than 68% of our participants were female.

Table 2 Chest compression parameters according to the position and time since last CPR training

Position Floor Stretcher

P

In this manikin study, the rescuer’s position “standing next to a stretcher” affects the quality of chest compressions in a simulated in-hospital cardiac arrest setting.

A 15% decrease in mean ECC depth was recorded on the stretcher versus on the ftoor (? depth ftoor-stretcher: 5mm, P b.001).

According to animal and clinical studies evaluating the effect of CPR quality on clinical outcome, a 10 to 20% (0.5- 1cm) change in ECC depth might have a clinical impact, as described on cardiac output, blood ftow or successful defibrillation associated with CPR [3,13-17].

Our results are in contrast with a previous study reporting that kneeling on the ftoor or standing beside the manikin on the table did not affect the compression force and depth of CPR performed by experienced rescuers [12]. The selection

Fig. 3 Compression depth according to the profession. Nurses (n= 38) and nurse’s aides (n= 26) were compared, using data from CPR scenarios performed both on the ftoor or standing beside the strecher. Compression depth is shown as mean and SD (error bars). Asterisks indicate significant differences (P b.05).

of participants may explain the difference with our study. Chi’s study enrolled healthcare providers, experienced in CPR, and probably very well trained as their performance was high, reaching that of other study participants who were members of a cardiac arrest resuscitation team. Moreover, the participants were volunteers, and may not be representative of all healthcare professionals, including emergency professionals.

Our results support other evidence suggesting that the efficacy of ECCs may be affected by the rescuer’s position [8,9,18]. The difference in mean depth between “kneeling on the ftoor” and “standing besides the bed” positions was similar in all three manikin studies, including ours, reaching about 5 mm in depth, P b.05. This difference seems to be observed regardless of the rescuer level of experience or training, or the effectiveness of ECC, as shown in our study for the group of participants who had benefited from an ACLS/BLS course

Fig. 4 Compression rate according to the profession. Nurses (n= 38) and nurse’s aides (n= 26) were compared, using data from CPR scenarios performed both on the ftoor or standing beside the strecher. Compression rate is shown as median and interquartile range and expressed as %.

within the year, and who demonstrated better ECC depth than their colleagues.

Other studies have investigated the impact of kneeling beside the manikin placed either on the ftoor or on a bed, showing no alteration of the ECC parameters (depth, rate and duty cycle) in either settings [10,11].

The significant difference in the efficiency of ECCs administered when kneeling on the ftoor or standing beside the manikin positioned on a stretcher may be related to the type of training. All ED participants in this study had received training in BLS, using manikins placed on the ftoor. The initial ftoor training is probably more adapted to out of hospital CPR, than to in-hospital CPR. Our results suggest that simulator training for resuscitation should be adapted to the different clinical settings in which CPR might be performed.

Only those rescuers who had last been trained within the year developed an average ECC depth compliant to the 2005 international Resuscitation guidelines, regardless of the position adopted, as compared to participants who had received their last training more than one year beforehand.

Our study clearly demonstrates the deleterious effect of time on the technical skills of ED professionals in our department, despite educational training for CPR and emergency experience, thus confirming previous findings [19]. Literature data suggest that training for resuscitation should be performed at least every 3-6 months to avoid deterioration of both skills and knowledge [20,21]. Our data suggest that ACLS/BLS refreshers should be proposed no less than once a year, which is more feasible, given the staffing turnover, and time constraints of many EDs.

Our results also show poorer performance of ED nurses aides compared to nurses. However, 85% of the nurse’s aides had not been trained within the year. This could be the determining factor for this difference.

The performance of training in CPR by conventional methods of learning remains poor despite many efforts. Specific learning methods have been advocated to improve efficacy of BLS training, including speech feedback during workouts, or automatic verbal and visual feedback [22-25]. These positive results encourage us to further develop and optimize these methods to improve the quality of chest compressions, during training and clinical practice.

Study limitations

Our emergency staff demonstrated poor BLS skills.

However they are representative of our ED workforce.

This study focused on the quality of ECC parameters. Other important BLS parameters such as hand position, hands-off time or Ventilation parameters were not investigated.

We used a resuscitation manikin model. Though simulation training has proved to be a relevant approach in education and assessment of competencies in emergency medicine, especially in crisis situations, CPR performance

data on resuscitation manikin may not be directly extrapo- lated to patients. In particular, whether a 5 mm difference in the ECC depth delivered to a resuscitation manikin would translate to a clinically relevant difference in patients remains to be evaluated. Furthermore, because of the large N for the number of chest compressions, the possibility of commiting a type I error cannot be excluded.

Conclusion

In the present study, the quality of chest compression demonstrated by ED Nurses and Nurse’s aides during simulated resuscitation was poor, suggesting that current professional training for emergency professionals is insuffi- cient to insure proper BLS skills retention, with compliance to international standards.

Performing CPR while standing next to a stretcher may lead to deterioration in the quality of ECCs when rescuers are trained in CPR on the ftoor. Improving CPR skills is likely to require optimizing of the quality of training, including adapting to different clinical settings, increasing frequency of training and the use of appropriate pedagogical methods.

The clinical impact of our results, as well as the need for refresher training courses, with a specific emphasis on the effect of rescuer position on CPR performances and immediate outcome remain to be confirmed in further studies.

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