Decreases in basic life support chest compression fraction after advanced life support arrival

Abstract

Chest compression continuity is an essential component of out-of-hospital cardiopulmonary resuscitation (CPR). Using data from the Resuscitation Outcomes Consortium, Christenson et al. and Vaillancourt et al. have verified that higher chest compression fraction (CCF) is associated with increased rates of return of spontaneous circulation and survival to hospital discharge.1Christenson J. Andrusiek D. Everson-Stewart S. et al.Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.Circulation. 2009; 120: 1241-1247Crossref PubMed Scopus (568) Google Scholar, 2Vaillancourt C. Everson-Stewart S. Christenson J. et al.The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation.Resuscitation. 2011; 82: 1501-1507Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar However, the reasons for CPR interruptions or CCF impairment remain unclear. We have observed that basic life support (BLS) fire fighters often decrease the intensity of resuscitative efforts after the arrival of advanced life support (ALS) paramedics, resulting in interruptions of CPR chest compressions and reductions in CCF. To illustrate this phenomenon, we examined out-of-hospital cardiac arrests (OHCAs) treated by Birmingham Fire Department (Birmingham, Alabama, United States), an urban, tiered fire-based EMS system responding to over 65,000 EMS incidents annually. In this agency, first responding BLS fire fighter and ALS paramedic units jointly provide care for OHCA. From September 1, 2009 to July 30, 2011, we identified 9 adult OHCA (from a total of 355 treated cases) where (1) BLS rescuers arrived on scene before ALS personnel, (2) BLS personnel provided at least 2 min of CPR before and after ALS arrival, and (3) CPR process data were continuously recorded by both BLS automated external defibrillators (Lifepak 500 or Lifepak 1000, Physio Control, Inc., Redmond, Washington) and ALS cardiac monitors (Lifepak 12, Physio Control, Inc., Redmond, Washington). Using commercial software (CodeStat 8.0, Physio Control, Inc., Redmond, Washington), we calculated the change in chest compression fraction (CCF) before ALS arrival (BLS phase) and after ALS arrival (ALS phase), defining CCF as the proportion of each minute with active chest compressions. Mean CPR times were: BLS phase 5 min 48 s, ALS phase 14 min 18 s. Mean chest compression fractions were: BLS phase 0.75 (95% CI: 0.68–0.82), ALS phase 0.58 (0.44–0.73) (Fig. 1). The mean reduction in CCF was 0.17 (95% CI: 0.01–0.32). Limiting our analysis to the last 5-min of the BLS phase and the first 5-min of the ALS phase, we observed a similar reduction in CCF. Our observations highlight that CPR CCF may decrease during the transition from BLS to ALS care. While the reasons for this decrease in BLS intensity are not clear, potential explanations include distractions from ALS interventions (for example, endotracheal intubation), the complication of scene management from the presence of additional personnel, and the perception of hierarchy between BLS and ALS personnel, which may hinder team coordination and execution of resuscitative efforts.3Wang H.E. Simeone S.J. Weaver M.D. Callaway C.W. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.Ann Emerg Med. 2009; 54: 645 e1-652 e1Abstract Full Text Full Text PDF Scopus (204) Google Scholar, 4Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB. The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival. Prehospital Emergency 2010;14:71–7.Google Scholar Potential aids to improve the BLS–ALS transition of care may include metronomes and active feedback monitors as well as mannequin or simulator-based training emphasizing coordinated teamwork during BLS/ALS care transitions.5Andersen P.O. Jensen M.K. Lippert A. Ostergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams.Resuscitation. 2010; 81: 695-702Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar EMS medical directors and personnel must devise strategies to optimize and maintain CPR continuity during transitions of OHCA care. The authors declare no conflicts of interest.