Cardiopulmonary resuscitation (CPR) can help to reduce fatality risks from heart attacks (Masters et al. 2017; Nishiyama et al. 2010). Botha et al. ((2012) advised that the spontaneous blood circulation to the vital organs can be improved by optimum pressure utilising chest compressions and can, therefore, be restored in the case of cardiac arrest. Nichol et al. (2015) also added that interruption during the chest compression for ventilation or defibrillation processes can reduce blood flow and, thus, CPR’s efficiency. Furthermore, continuous chest compression (CCC) application has been shown to improve neurogenic outcomes, compared to interrupted compassions (Bobrow et al. 2010). However, it must be kept in mind that CCC can cause the rescuer fatigue and, thus, can reduce the compression quality, which might require the rescuer to be replaced (Gianotto-Oliveira et al. 2015).
This study analyses the effect of compression rates on chest compression quality variables. It uses a randomised controlled crossover manikin study, examining the effect of different compression rates (80, 100, 120, 140 and 160 per minute) for 2 minutes on a manikin, on the number of compressions delivered, the compression duty cycle, compression depth and decay in compression quality. This highlights the fact that good strategy to avoid CCC quality degradation is to prevent rescuer fatigue and such findings can be potentially vital in clinical application.
Access to the study papers was availed through the PubMed database, via the Cardiff University Online Database System. The keywords used for the search were chest compressions AND basic life support AND quality AND CPR AND cardiac arrest. The search for relevant articles was limited to manikin studies published in English between2007 and2017 in order to compare the results within the new guidelines’ framework. Two articles were found in the PubMed Database, one of which was chosen because of its relevance to the assignment.
The sampling strategy selected was primary sampling; the method was randomised controlled crossover research, with automated data recording and analysis using a computer and software and double-blind methods to remove bias. The sampling strategy used manikins to study changes in compression quality with different chest compression rates during CCC, recorded by a computer and subjected to statistical evaluation. The study also investigated effective teamwork’s role in the CPR team’s performance.
Field et al.’s (2012) study was a randomised controlled manikin crossover study into different continuous compression rates ‘effects on the quality and total number of compressions and, thus, the CPR procedure’s efficiency. 5 different CPR rates were measured: 80, 100, 120, 140 and 160 compressions per minute for 2 minutes. Lee et al. (2016) identified that a chest compression rate of 120 per minute provided the highest quality of CPR in their comparison of CPR rates of 100, 120, 140 and 160 compressions per minute. They found that incomplete chest recoils were significantly fewer when the compressions were given at 100 to 120 per minute.
The study was based upon certain important reviews. Studies by Edelson et al. (2006) and Nolan et al. (2005) showed that, for successful resuscitation, high quality compressions must be applied with fewest interruptions. Perkins et al. (2008) identified that, during both training and actual attempts, CPR and compression quality is low. This was also supported by Feneley et al.’s (1988) animal studies, which showed that chest compression at 120 and 160 per minute demonstrated improved CPR survival rates. Quicker compression rates have also shown similar results in human studies. Field et al.’s (2012) study used a Randomised Control Trial (RCT) method, which Parahoo (2014) has quoted as being the best study techniques it allows the evaluation of experiments ‘outcomes and reduces bias, if performed correctly. Moule, Aveyard and Goodman ((2016) supported this, adding that results ‘strong validity and reliability are due to the ability to analyse the differences between experiment relationships.
Dyson and Norrie (2013) stated the necessity of ethical approval, which ensures the participants’ protection, as well as ethical standards’ maintenance in the study’s practice. However, since the study was performed on manikins, the participants were from the healthcare profession background and have all undergone CPR training. The study was approved by the Trust Research and Development Department of the Heart of England National Health Service (NHS) Foundation.
Houser (2016) stated the necessity of estimating the population sample size before conducting research. Field et al.’s (2012) study involved 20 participants from the healthcare profession, including one doctor, two resuscitation officers, six medical students, eight student nurses and three controls, and the male to female ratio was 8:12. All had received a prior CPR training. The sample size of 20 was selected based on previous studies by Perkins et al. (2005), whose calculations showed that a difference of 10% in the compression quality can be calculated using 20 participants.
As per Bowling (2014), having a prior estimation is important to ensure the results’ validity. The study divided the participants into two pairs for alternate testing. Each participant was instructed to perform CPR for 2 minutes and provided with a 3-minute break between the compressions. A metronome was used to guide the compressions. Each group was assigned to provide compression at a specific rate, which was randomly allocated to them. This eliminates the chance of bias to a significant degree and improves validity (Parahoo 2014).
The study used a Workflow Diagram, which can be an effective problem-solving tool, as proposed by Shukla et al. (2014), to outline the CPR stages to support the participants in following the correct steps and movements through the stages. The inclusion and exclusion criteria used to describe the target population are not highlighted in the study, although the authors did mention the different professional areas from which the participants were selected and how many were from each profession. However, the basis of selecting the professional from each profession is also not clear. According to Aveyard (2014), this can influence the result’s validity.
Polit and Hungler (1994) indicated that proper processing of data after its collection can improve the validity, as well as the reliability, of an experiment’s results. Field et al. (2012) stated that CPR at different rates (80, 100, 120, 140, and 160) was performed by each group and each participant was instructed to follow the metronome to continue CPR for 2 minutes, uninterrupted, followed by a 3-minute break. Data about the CPR quality was recorded by a computer via sensors fitted in the manikin and Skill Reporting software version 2.2.1 was used to collect it. This software allowed the recording of the sessions ‘duration, the total number of compressions applied, the compression rate, the duty cycle and depth, incomplete releases and shallow compressions with respect to the standard CPR qualities (Kramer-Johansen et al. 2007). The importance of using carefully selected tool for data recording and to prevent observer bias was identified by Hunt et al. (2015). The data calculations were automatic and the researchers collecting the data were double blinded, which decreased the detection bias risk..
Kramer-Johansen et al. (2007) proposed that the chest compression rate could be a significant indicator of the compression quality. Keeping this in mind, it becomes necessary to study how the chest compression rate can have an effect on other compression variables. This study measured those variables, such as compression depth, leaning and impact of compression duration and duty cycle by each participant on the decay in compression quality. The data was analysed using the analytical software PASW for Windows 18 (SPS Inc. Chicago, IL) (Cronk 2017). The data outputs on the compression variables were evaluated using analysis of variance (ANOVA) and the decay point analysis was carried out by Friedman’s Test, while a Q test was used to analyse performance decay, leaning and lower compression rates.
ANOVA allows analysis between each group’s means to determine any significant differences and, thus, is an analysis of variance. The SPSS tool utilised by Field et al. (2012) to analyse the statistical information is considered an accurate measure and means of explaining the results, according to Moule, Aveyard and Goodman (2014). Additionally, the use of multiple tests has been suggested by Houser (2016). A p value less than 0.05 has-been used to represent probability, where the p value is the statistical significance that is the probability that the given results are a product of chance ( (Polit and Hungler 1994).
Answering the study’s objectives ought to be the primary focus of an analysis. Field et al. (2012) provided a proper explanation of their research findings in a way that was both meaningful and relevant and provided justification for the study’s objectives. The results were also well explained and logically presented, using graphs and tables. Moule (2015) highlights the necessity of linear graphs, figures and tables as effective ways to enable the reader to understand the results by making them more meaningful.
Parahoo (2014) discussed how knowledge can be progressed through a study’s results. Additionally, as recommended by LoBiondo-Wood and LoBiondo-Wood and Haber (2005), the study’s limitations were mentioned, addressing the research model’s weakness, which can help in understanding the extent to which the findings can be generalised. This forms a solid foundation of Evidence Based Practice, as identified by Rees (2011).
The conclusion is short, precise, and easy to understand, addresses the study’s main objective, is thoroughly based on the study’s results and is in alignment with Parahoo’s recommendations (2014).
Field et al. (2012) showed that a compression rate of between 100 and120 per minute for two minutes is feasible to maintain proper chest compression quality in regard to the compression variables, such as depth, duty cycle, leaning and decay in performance. Their work also leaves scope for further studies on deeper and quicker compression rates. The findings were in alignment with European Resuscitation Council (ERC) guidelines ,which recommend an optimal chest compression depth of 5cm, but less than 6cm, with a compression rate of between 100 and 120 compressions per minute (Perkins et al. 2015). Thus, chest compression rates can have significant effect on the quality of the compressions. This justifies the authors ‘recommendations to maintain the stated compression rate to ensure that the compression quality, as outlined by CPR regulations, is maintained.
Oh et al. (2014) showed that chest compression quality can decrease significantly over a prolonged CPR process during a heart attack and this reduction in quality can be due to the rescuer experiencing fatigue. The decision to alternate between two rescuers providing CPR for 2 minutes each was in line with Manders and Geijsel’s (2009) studies, which showed a decrease in fatigue experienced by the rescuers. Ashton et al.’s studies (2002) also showed that fatigue can lower the quality of chest compressions and can be caused by at least three minutes of uninterrupted chest compressions. The ERC guidelines 2010 (Nolan et al. 2010) have also supported such recommendations, adding that the rescuer experiences fatigue in two minutes of continuous CPR and, hence, should be replaced, while ensuring minimum interruption between the compressions. Nolan et al. (2010) stated that this can be achieved by rotating the rescuers.
There are negative effects of long interruptions in CPR on its efficiency, affectivity, myocardial blood circulation and coronary perfusion (Yu et al. 2002). Guidelines set by the ERC and the American Heart Association (AHA) also recommend minimal interruptions during chest compressions to ensure spontaneous blood circulation, as stated by Miller and Flaherty (2014). With this in mind, the AHA (2010) recommendations stipulate that interruptions in CPR should be less than 8-10 seconds, which was considered during the study.
Field et al.’s (2012) results are well supported by the AHA and ERC criteria that highlight the necessity of rescuer changeover to minimise fatigue during CPR administration and to ensure minimal interruptions and, therefore, to maintain compression quality. Such considerations, such as fatigue’s effect on the variables in compression quality, ought to be identified by CPR providers. To ensure adherence to said guidelines, Resuscitation Council United Kingdom (UK) guidelines (2015) stipulate the requirement for a team leader, who will monitor the CPR quality and promptly change the rescuer if signs of fatigue are observed. Abella et al. (2005) also added that CPR qualities in hospitals are often poorer as a result of frequent interruptions due to rhythm checks, defibrillation or ventilation. To address such concerns, the guidelines set by the Resuscitation Council UK recommend chest compressions should be uninterrupted except for pauses for specific interventions and that certain interventions can also be carried out while chest compressions are performed, to further reduce interruptions.
Boaden et al. (2008) identified the need for a change in the guidelines and policies in hospitals to incorporate the obligation to deliver quality CPR and to ensure optimum effectiveness, and utilised the evidence from several works of research that suggested rotation of the rescuers to minimise their fatigue. CPR providers, especially in surgical theatres, ought to utilise such practices in order to maximise survival chances. Additionally, using flowcharts and a metronome can ensure maintenance of the rhythm, as well as preventing deviation from the steps required. Similarly, it is vital to have good team dynamics, to ensure optimum performance, though effective communication and coordination between members. Team work’s importance has also been supported by Yeung et al. (2014), who stated its role in ensuring high quality CPR, which is vital in determining the success of the resuscitation process, alongside other factors such as technical skills (chest compression quality and proper defibrillator use) and non-technical skills (situational awareness, decisiveness and leadership).
Resuscitation Council UK (2011) also highlights the importance of technical skills in the effectiveness of the resuscitation process after a heart attack. .Therefore, healthcare professionals need to be aware of the latest guidelines and should undergo training sessions in developing their technical abilities. Joshi (2015) also supported the recommendation of training sessions to ensure awareness of the guidelines.
On the other hand, on-technical skills can play a key role in making the right leadership decisions and utilising the human factors to manage challenging circumstances and to maintain CPR quality. To ensure this, the CPR teams’ leaders should possess competencies in leadership, decisiveness and guiding the team, having sufficient knowledge and experience of the practice (Norris and Lockey 2012). Similarly, bad leadership can result in diminished CPR success (Yeung et al. 2012). This shows the necessity of effective and quality leadership in the maintenance of the optimum effectiveness of CPR.
The two primary considerations for a healthcare professional in an emergency heart attack situation are to know when to begin and when to cease. It is strongly suggested that current protocols, guidelines and legal obligations are adhered to, as stated by the Health and Care Professions Council (HCPC) (2012). Hazinski and Field (2010) advised that CPR providers should have awareness of all the factors, such as legal, ethical and cultural, related to patients. Medical Ethics, such as beneficence, non-malfeasance, individuals’ autonomy, justice and non-discrimination, can be utilised in the current scenario. Hence, to maintain such standards, it is important for the CPR teams to know not to have interruptions during chest compressions and to avoid fatigue, apart from having a solid aversion towards any action that can directly or indirectly be maleficent to the patient, while attaining the balance between risk and benefit (Bossaert et al. 2015). Lippert et al. (2010) explained beneficence as providing benefits that are in the best interest of the patient in order to have the best result. This shows the importance of maintaining high quality CPR. Additionally, all patients should be treated equally and with respect, regardless of gender, race, ethnicity or religion. The HCPC also recommends that healthcare professionals respect patients ‘right to privacy and maintain honesty and clarity in conversation during the treatment.
Conclusion:
CCC is a vital strategy to restore blood circulation and the efficiency of the resuscitation process increases with minimal interruptions and maintaining a high quality of chest compressions, in terms of variables like compression depth, duty cycle, leaning and performance decay over time. Additionally, rapid compression rates or prolonged compression can lower the quality of the compressions, among the variables mentioned, as well as the total number of compressions delivered. Furthermore, compression quality is further compromised by frequent interruptions due to interventions or switching between CPR providers, thus reducing the CPR procedure’s overall chance of success. It has been suggested that optimum CPR efficiency can be maintained by the provision of adequate support for the CPR providers, such as flow diagrams and metronomes, as well as a strong leadership approach. Inclusion of training sessions can also be effective strategy in ensuring the development of both the technical and non-technical skills needed to deliver efficient CPR. Quick rotation of the CPR providers every 2 minutes, pausing only for interventions such as defibrillation or ventilation, and conducting other interventions (wherever possible) while still administering CCC, effective leadership skills, constant team performance monitoring, checking CPR providers ‘fatigue levels, strong communication and motivational abilities are needed for a successful CPR team. Furthermore, the patients’ ethical, legal and cultural factors and patient care must also be ensured to prevent any harm to them during the treatment and to maintain the care provision with their best interests.
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