Clinical paperImproving cardiopulmonary resuscitation in the emergency department by real-time video recording and regular feedback learning☆
Introduction
Cardiopulmonary resuscitation (CPR) was introduced more than 50 years ago, and the International Liasion Committee on Resuscitation (ILCOR) has established CPR guidelines which are renewed every 5 years.1, 2 Although healthcare professionals are expected to perform efficient resuscitation, studies have found that the skills in CPR are poorly acquired since CPR performance on scene did not always comply with these guidelines.3, 4, 5, 6, 7, 8 On the other hand, the survival rate from cardiac arrest remains poor. Only about 1–6% of patients with out-of hospital cardiac arrest survive hospital admission. Survival rate of in-hospital arrest is higher, but only 17% of these patients are discharged alive,9, 10, 11 and no significant progress has been observed in the past decade.12
Survival rate of cardiac arrest patients has been connected with the quality of delivered CPR and the timing of initiation.13 CPR quality has been demonstrated to be influenced by many factors both in animal experiments and in clinical studies,3, 4, 6, 7 such as delay in initiating CPR, too low a rate of chest compression, too rapid ventilation and too much hands-off time.14, 15, 16, 17 The guidelines have suggested increasing the ratio of chest compressions to ventilation, to benefit coronary artery perfusion. Wik et al.18 even showed that out-of hospital cardiac arrest patients receiving 3 min CPR before defibrillation had a better survival than those receiving immediate defibrillation. A high rate of lung inflations can influence outcome by reducing coronary artery perfusion. Interruptions in CPR or failure to provide compression during CPR is considered as “hands-off time”, which may have a negative impact on survival.19 Too much hands-off time can reduce the chances of success of subsequent defibrillation in out-of hospital CPR.20 The delayed initiation of CPR has been shown to correlate with poor survival in in-hospital cardiac arrest even if the delay was short.13
Therefore, several attempts have been made to improve CPR quality, including CPR education for Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certification, manikin training, mechanical CPR, electronic monitoring and feedback/prompt devices. Although ILCOR guidelines knowledge is well-acquired through certificated education, skill performance remains poor.21 Manikin studies have shown CPR improvement by video-recording evaluation, audio-feedback teaching or audio-feedback integrated into an automatic external defibrillator,15, 22, 23 but such research was carried out during manikin training rather than in actual CPR practice. Feedback/prompt devices for CPR performance have been confirmed to improve CPR quality in clinic human resuscitation.5, 6, 24
Given the proven survival benefit of high-quality CPR, we carried out a prospective study to evaluate CPR efforts in our emergency department (ED) by installing a video-recording system in the rescue room. We wanted to test the hypothesis that video recording associated with regular feedback learning can rapidly and efficiently improve CPR quality provided by an in-hospital emergency team.
Section snippets
Patient enrollment
Our study protocol was approved by the Institutional Review Board (IRB) of Zhongnan Hospital of Wuhan University (Wuhan, People's Republic of China). Waived informed consent was authorized because the study did not interfere with standard care provided to the patients. Nevertheless, information about video recording was provided to the patients and relatives in the ED. We conducted a prospective study of CPR resuscitation from March 2007 to July 2008 in the ED of Zhongnan Hospital in Wuhan
Results
During the study period, CPR was performed in 60 consecutive cases. Because of early device dysfunction or manual operation mistakes, we lost 15 cases of video recording. Therefore, 45 consecutive recordings were analyzed and divided into three sequential groups: the first 15 patients were allocated in group 1, the second 15 in group 2 and last 15 in group 3.
Main characteristics of patients with cardiac arrest are summarized in Table 1. There were no significant differences among the three
Discussion
There is an agreement that CPR is often of suboptimal quality in clinical settings,3, 4, 5, 6, 7 and changes are needed to improve cardiac arrest outcome.25 In this study, we attempted to evaluate CPR maneuvers performed in our ED by real-time video recording and to assess the effectiveness of video recording associated with regular feedback learning. There were two important findings in our study. First, simple regular video feedback learning helped to eliminate some errors, including
Conclusions
In this study, we attempted to evaluate our CPR quality by video-recording system and the effectiveness of video feedback learning. Our resuscitation quality was suboptimal, including high and unsteady chest compressions, unnecessary hands-off intervals, and prolonged intubation attempts. Regular video feedback learning could produce useful improvement, especially by reducing hands-off time, time to first compression/ventilation and controlling the compression rate to that recommended in the
Conflicts of interest statement
There is no conflict of interest declared. The study was supported only by institutional sources.
Acknowledgments
We would like to thank the medical staff and nurses in the Emergency Department of Zhongnan Hospital, Wuhan University. Their efforts made this study possible.
We also thank Professor Bruno Riou, M.D., Ph.D. (Dept. of Emergency Medicine and Surgery (Chairman) and Dept. of Anesthesiology and Critical Care, University Pierre and Marie Curie-Paris 6 and Groupe Hospitalier Pitié-Salpêtrière, Paris, France) and Dr. David Baker, DM, FRCA (Dept. of Anesthesiology, CHU Necker-Enfants Malades, Paris) for
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.06.023.
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Co-first author.