Real-time Audiovisual Feedback Research Articles

Don't Be So Quick to Use CPR Feedback Devices!

Devices that provide real-time audiovisual feedback during cardiopulmonary resuscitation (CPR) are becoming more commonplace, but do they improve CPR quality measures? In an open randomized, controlled parallel group study, 240 medical students performed an 8-minute simulated single-rescuer basic life support (BLS) resuscitation without feedback or …

Abstract 268: Improvements in Emergency Department CPR Quality Utilizing Real-Time Audiovisual CPR Feedback

Background: CPR quality is closely linked to outcome in cardiac arrest. The AHA 2010 Guidelines recommend monitoring CPR quality performed by healthcare providers both inside and outside the hospital. However, most EDs currently do not monitor CPR quality. The goal of the present investigation was to assess the quality of CPR performed in an urban ED and determine the influence of training and real-time audiovisual feedback (RTAVF) on CPR quality and patient outcome. Methods: CPR quality was monitored using an R Series defibrillator (ZOLL Medical) during the treatment of adult cardiac resuscitation attempts. During phase 1 (P1; 11/2010-11/2012), real-time audiovisual chest compression feedback was disabled. During phase 2 (P2; 11/2012-3/2013), clinicians underwent a 60 minute didactic/hands-on CPR training session after which the RTAVF and the ECG artifact filtering feature were enabled. CPR quality data (fraction, depth, rate, release, peri-shock pause) were reviewed using Code Review software (ZOLL Medical). Student’s t-test and Wilcoxon-signed rank test were employed. Results: A total of 44 OHCA patients were treated in P1 (mean age 57±18 yrs, 59% male) and 24 in Phase 2 (mean age 63±15 yrs, 88% male). The majority of patients (89% P1; 96% P2) suffered prehospital arrest and were transported to the ED. Chest compression (CC) depth increased from 1.8±0.5 inches in P1 to 2.3±0.4 in P2 (p<0.001), with the percentage of compressions exceeding 2 inches more than doubling from 36% in P1 to 79% in P2 (p<0.001). CC release velocity increased from 1.25±0.36 inch/sec in P1 to 1.69±0.28 in P2 (p<0.001). No significant differences were identified in CC rate (125±12 cpm P1 vs. 121±15 cpm P2, p=0.3) or CC fraction (82% P1 vs. 87% P2, p=0.1). Pre-shock pause (11.5±10.4 sec P1 vs. 8.0±6.2 P2, p=0.4) and post-shock pause (5.2±3.4 sec vs. 3.8±0.6, p=0.9) were statistically similar in P1 and P2. Conclusion: The bundle of real time audiovisual CPR feedback and training were associated with an improvement in chest compression depth and recoil and closer adherence to guidelines for CPR quality in this large urban ED.

Abstract 306: Use of Real-Time Audiovisual CPR Feedback is Associated With Improved CPR Quality During Patient Transfer From the Scene to the Ambulance in Out-of-Hospital Cardiac Arrest

Background: In the simulation setting, chest compression (CC) quality is reduced when out-of-hospital cardiac arrest “patients” are prepared for transport (i.e. packaged and moved to ambulance). It is unknown whether use of real-time audiovisual CPR feedback (RTAVF) affects manual CC quality when the patient is prepared for transport during actual out-of-hospital resuscitations. We tested the hypothesis that CC quality during patient transfer would be better when using RTAVF. Methods: CC quality was monitored at two EMS agencies using an E Series monitor/defibrillator with CC sensing capability (ZOLL Medical) during the treatment of consecutive out-of-hospital cardiac arrest patients who received CC on scene and were transported with ongoing CC. Data were collected during study phases; P1: RTAVF disabled, P2: RTAVF enabled following scenario-based training. Student’s t-test and Wilcoxon-Mann Whitney tests were used to compare CC quality in P1 vs. P2 during early scene and late scene treatment. Late scene was defined as the 3 minutes prior to transport (when packaging and transfer to the ambulance occurs) and early scene was all prior minutes at the scene. Results: 211 cardiac arrest cases were included: mean age 64±15 yrs, 67% male, 8% survival to hospital discharge. The Table shows that CC quality was superior during both early scene and late scene treatment in P2, when RTAVF was enabled, vs. P1, when RTAVF was disabled. Conclusion: CC quality, particularly the CC fraction, declines when a patient is packaged for transport and moved to the ambulance. While this decline is not prevented by RTAVF, CC quality during the late scene period is significantly better when using RTAVF. Further study is required to determine the impact of this improvement on outcomes.

Promoting smoke-free homes: a novel behavioral intervention using real-time audio-visual feedback on airborne particle levels.

Interventions are needed to protect the health of children who live with smokers. We pilot-tested a real-time intervention for promoting behavior change in homes that reduces second hand tobacco smoke (SHS) levels. The intervention uses a monitor and feedback system to provide immediate auditory and visual signals triggered at defined thresholds of fine particle concentration. Dynamic graphs of real-time particle levels are also shown on a computer screen. We experimentally evaluated the system, field-tested it in homes with smokers, and conducted focus groups to obtain general opinions. Laboratory tests of the monitor demonstrated SHS sensitivity, stability, precision equivalent to at least 1 µg/m3, and low noise. A linear relationship (R2 = 0.98) was observed between the monitor and average SHS mass concentrations up to 150 µg/m3. Focus groups and interviews with intervention participants showed in-home use to be acceptable and feasible. The intervention was evaluated in 3 homes with combined baseline and intervention periods lasting 9 to 15 full days. Two families modified their behavior by opening windows or doors, smoking outdoors, or smoking less. We observed evidence of lower SHS levels in these homes. The remaining household voiced reluctance to changing their smoking activity and did not exhibit lower SHS levels in main smoking areas or clear behavior change; however, family members expressed receptivity to smoking outdoors. This study established the feasibility of the real-time intervention, laying the groundwork for controlled trials with larger sample sizes. Visual and auditory cues may prompt family members to take immediate action to reduce SHS levels. Dynamic graphs of SHS levels may help families make decisions about specific mitigation approaches.

Real-time audiovisual feedback system in a physician-staffed helicopter emergency medical service in Finland: the quality results and barriers to implementation

ObjectivesTo evaluate the quality of cardiopulmonary resuscitation (CPR) in a physician staffed helicopter emergency medical service (HEMS) using a monitor-defibrillator with a quality analysis feature. As a post hoc analysis, the potential barriers to implementation were surveyed.MethodsThe quality of CPR performed by the HEMS from November 2008 to April 2010 was analysed. To evaluate the implementation rate of quality analysis, the HEMS database was screened for all cardiac arrest missions during the study period. As a consequence of the observed low implementation rate, a survey was sent to physicians working in the HEMS to evaluate the possible reasons for not utilizing the automated quality analysis feature.ResultsDuring the study period, the quality analysis was used for 52 out of 187 patients (28%). In these cases the mean compression depth was < 40 mm in 46% and < 50 mm in 96% of the 1-min analysis intervals, but otherwise CPR quality corresponded with the 2005 resuscitation guidelines. In particular, the no-flow fraction was remarkably low 0.10 (0.07, 0.16). The most common reasons for not using quality-controlled CPR were that the device itself was not taken to the scene, or not applied to the patient, because another EMS unit was already treating the patient with another defibrillator.ConclusionsWhen quality-controlled CPR technology was used, the indicators of good quality CPR as described in the 2005 resuscitation guidelines were mostly achieved albeit with sufficient compression depth. The use of the well-described technology in improving patient care was low. Wider implementation of the automated quality control and feedback feature in defibrillators could further improve the quality of CPR on the field.Trial registrationClinicalTrials.gov (NCT00951704)

The Influence of Scenario-Based Training and Real-Time Audiovisual Feedback on Out-of-Hospital Cardiopulmonary Resuscitation Quality and Survival From Out-of-Hospital Cardiac Arrest

We assess whether an initiative to optimize out-of-hospital provider cardiopulmonary resuscitation (CPR) quality is associated with improved CPR quality and increased survival from out-of-hospital cardiac arrest. This was a before-after study of consecutive adult out-of-hospital cardiac arrest. Data were obtained from out-of-hospital forms and defibrillators. Phase 1 included 18 months with real-time audiovisual feedback disabled (October 2008 to March 2010). Phase 2 included 16 months (May 2010 to September 2011) after scenario-based training of 373 professional rescuers and real-time audiovisual feedback enabled. The effect of interventions on survival to hospital discharge was assessed with multivariable logistic regression. Multiple imputation of missing data was used to analyze the effect of interventions on CPR quality. Analysis included 484 out-of-hospital cardiac arrest patients (phase 1 232; phase 2 252). Median age was 68 years (interquartile range 56-79); 66.5% were men. CPR quality measures improved significantly from phase 1 to phase 2: Mean chest compression rate decreased from 128 to 106 chest compressions per minute (difference -23 chest compressions; 95% confidence interval [CI] -26 to -19 chest compressions); mean chest compression depth increased from 1.78 to 2.15 inches (difference 0.38 inches; 95% CI 0.28 to 0.47 inches); median chest compression fraction increased from 66.2% to 83.7% (difference 17.6%; 95% CI 15.0% to 20.1%); median preshock pause decreased from 26.9 to 15.5 seconds (difference -11.4 seconds; 95% CI -15.7 to -7.2 seconds), and mean ventilation rate decreased from 11.7 to 9.5/minute (difference -2.2/minute; 95% CI -3.9 to -0.5/minute). All-rhythms survival increased from phase 1 to phase 2 (20/231, 8.7% versus 35/252, 13.9%; difference 5.2%; 95% CI -0.4% to 10.8%), with an adjusted odds ratio of 2.72 (95% CI 1.15 to 6.41), controlling for initial rhythm, witnessed arrest, age, minimally interrupted cardiac resuscitation protocol compliance, and provision of therapeutic hypothermia. Witnessed arrests/shockable rhythms survival was 26.3% (15/57) for phase 1 and 55.6% (20/36) for phase 2 (difference 29.2%; 95% CI 9.4% to 49.1%). Implementation of resuscitation training combined with real-time audiovisual feedback was independently associated with improved CPR quality, an increase in survival, and favorable functional outcomes after out-of-hospital cardiac arrest.

Abstract 208: Achieving the 2010 AHA Guideline Metrics for CPR Quality Is Associated with Improved Survival from Out-of-Hospital Cardiac Arrest

Objective: The 2010 AHA Guidelines stress the need for minimally interrupted, high quality CPR. We performed a prospective, before/after trial to determine if real-time audiovisual feedback (RTAVF) along with scenario-based training (SBT) would 1) achieve the 2010 CPR targets and 2) improve survival from OHCA. Methods: Data obtained from EMS care forms and defibrillators (E Series, ZOLL) from 2 EMS agencies (population base-500,000). Phase 1 (P1, before): 18 months of baseline data with the RTAVF mode disabled (9/08-3/10). Interventions: 1) Guideline-based SBT of ~450 EMTs, 2) RTAVF enabled, 3) EMT post-code debriefings. Phase 2 (P2, after): 8 months following implementation of interventions (5/10-12/10). For univariate analyses we used Fisher's exact test (proportions), t-test (means) or Kruskal-Wallis test (medians). To estimate odds ratios for survival to hospital discharge we used multivariable logistic regression and assessed final model diagnostics, fit, and discrimination. Results: The final analysis included 284 adult OHCAs (P1-176, P2-108). Mean age 65.4 years (SD ± 15.3) with 66.6% males. Quality measures improved significantly from P1 to P2: Median (Interquartile range) chest compression (CC) rate-121 CC/min (109-135) to 101 CC/min (100-106), p &lt;0.001; CC depth-1.73 in. (1.42-1.97) to 2.09 in. (1.92-2.3), p &lt;0.001; CC fraction-66.5% (59.3-75.9%) to 84.0% (77.8-88.7%), p &lt;0.001. All-rhythms survival increased significantly (p=0.034) from P1 to P2 (18/176, 10.2% vs. 23/108, 19.4%), an absolute survival increase of 9.2% (95% CI: 0.5%-17.9%). Crude odds ratio for survival for P2 vs. P1 was 2.1 (95% CI: 1.1-4.2) and adjusted odds ratio was 5.8 (95% CI: 1.8-18.9), after controlling for confounders including age, sex, location, witnessed arrest, initial rhythm, and therapeutic hypothermia. Survival for arrests with a shockable rhythm was 27.7% (18/65) for P1 and 53.9% (14/26) for P2 (p=0.028). Conclusion: RTAVF combined with SBT was associated with a significant improvement in the proportion of compressions meeting the 2010 AHA Guidelines. This intervention was associated with a 90% relative increase in overall survival. We believe this is the first report to show an improvement in OHCA survival by achieving the 2010 AHA CPR Guidelines.

Abstract 218: CPR Quality in an Urban Teaching Hospital Emergency Department: Are 2010 AHA Guidelines Being Implemented?

Background: CPR quality is closely linked to outcome in cardiac arrest. AHA 2010 Guidelines recommend monitoring CPR quality performed by healthcare providers both inside and outside the hospital. We recently reported that CPR quality varies significantly during the transition from the prehospital to emergency department (ED) setting in cases of out-of-hospital cardiac arrest (OHCA). While many EMS systems are now monitoring CPR quality, most EDs do not. We began an ongoing ED CPR quality improvement program based upon the 2010 AHA Guidelines. This two-phase study will measure the baseline quality of ED CPR, followed by measurement of CPR quality with the initiation of real-time CPR feedback technology. Here we report preliminary data showing the baseline CPR quality from Phase I. Methods: Prospective, IRB-approved study at an urban, teaching hospital ED. Chest compression (CC) quality was measured using accelerometer-equipped monitor/defibrillators (ZOLL R-Series, Chelmsford, MA). These baseline data were collected with the real-time audiovisual CPR feedback feature disabled. Results: CC data were captured over 7 months from 31 adult patients in cardiac arrest resulting in 6.5 hours of CPR and 37,348 individual CCs. CC fraction was 76.2%. Mean CC depth was 1.89 ± 0.61 inches and average rate was 122.4 ± 16.5 compressions/min. Using the 2010 AHA Guideline-recommended CC depth &gt;2 inches, 61.0% of compressions were too shallow. The rate of compressions was below 100/min in 6.3%. The mean pre-shock and post-shock pauses in CC were 7.8 and 7.4 sec, respectively (n=24 defibrillations/cardioversions). Conclusions: We describe the quality of CPR in a large urban teaching hospital ED. At the beginning of our ED CPR QI program, a large proportion of chest compression depth was less than the 2010 AHA Guideline of 2 inches. These data will be used for resuscitation training during the next phase of the program which will include real-time audiovisual CPR feedback and debriefing sessions for the ED providers.

Abstract 75: Body Weight-Related Adjustments to Chest Compression Depth by EMS Providers During Out-of-Hospital Cardiac Arrest

Background: The 2010 AHA Guidelines state rescuers should perform chest compressions (CCs) of at least 2 inches in depth for adult cardiac arrest patients. Although the pediatric guidelines recommend adjustment of CC depth based upon anteroposterior chest dimension, there is no such recommendation for adults. Purpose: To determine 1) whether prehospital providers intuitively vary CC depth in adults according to patient size and 2) whether implementation of real-time audiovisual CPR feedback (RTAVF) impacts weight/CC depth variation. Methods: CC quality data were prospectively collected prior to (9/08-4/10; Pre-feedback) and after (5/10-12/10; Post-feedback) implementation of an RTAVF system (ZOLL Medical, Chelmsford MA) from 3 EMS agencies. The RTAVF includes a visual display of absolute CC depth and gives audio prompts when depth is outside of the Guideline-recommended range. Among 363 cases of adult, non-traumatic out-of-hospital cardiac arrest (OHCA), body weight was estimated by EMS in 249 patients (study group; 66%). CPR quality data were available for all cases via code review software. Results: 168 Pre-feedback and 81 Post-feedback study group cases (mean 64±16 years, 68% male). Mean estimated body weight was 201 lbs (quartiles 161, 231; range 70-451) and was not different between groups. CC depth increased significantly with RTAVF use (Pre-feedback = 1.77, 95% confidence interval [CI]:1.71-1.83 in.; Post-feedback = 2.10, CI: 2.04-2.15 in.; p&lt;0.001). CC depth did not vary significantly by patient gender or age (p&gt;0.4). Multivariate linear regression (r 2 =0.23, p&lt;0.001 for model) revealed a significant increase in CC depth with estimated weight in both periods (0.07in/50lbs, p&lt;0.001) after controlling for the presence of RTAVF. RTAVF was not an effect-modifier of the relationship between estimated weight and CC depth (p-value for interaction term=0.4). Conclusion: Although not specifically recommended in the 2010 AHA Guidelines for adults, rescuers may instinctively and/or intentionally adjust CC depth according to patient size. In this setting, weight/CC depth adjustments occurred both without and with real-time feedback. Follow-up studies are needed to determine the potential effect of size-adjusted CC depth on patient outcome.

The effect of real-time CPR feedback and post event debriefing on patient and processes focused outcomes: A cohort study: trial protocol

BackgroundCardiac arrest affects 30-35, 000 hospitalised patients in the UK every year. For these patients to be given the best chance of survival, high quality cardiopulmonary resuscitation (CPR) must be delivered, however the quality of CPR in real-life is often suboptimal. CPR feedback devices have been shown to improve CPR quality in the pre-hospital setting and post-event debriefing can improve adherence to guidelines and CPR quality. However, the evidence for use of these improvement methods in hospital remains unclear. The CPR quality improvement initiative is a prospective cohort study of the Q-CPR real-time feedback device combined with post-event debriefing in hospitalised adult patients who sustain a cardiac arrest.Methods/designThe primary objective of this trial is to assess whether a CPR quality improvement initiative will improve rate of return of sustained spontaneous circulation in in-hospital-cardiac-arrest patients. The study is set in one NHS trust operating three hospital sites. Secondary objectives will evaluate: any return of spontaneous circulation; survival to hospital discharge and patient cerebral performance category at discharge; quality of CPR variables and cardiac arrest team factors. Methods: All three sites will have an initial control phase before any improvements are implemented; site 1 will implement audiovisual feedback combined with post event debriefing, site 2 will implement audiovisual feedback only and site 3 will remain as a control site to measure any changes in outcome due to any other trust-wide changes in resuscitation practice. All adult patients sustaining a cardiac arrest and receiving resuscitation from the hospital cardiac arrest team will be included. Patients will be excluded if; they have a Do-not-attempt resuscitation order written and documented in their medical records, the cardiac arrest is not attended by a resuscitation team, the arrest occurs out-of-hospital or the patient has previously participated in this study. The trial will recruit a total of 912 patients from the three hospital sites.ConclusionThis trial will evaluate patient and process focussed outcomes following the implementation of a CPR quality improvement initiative using real-time audiovisual feedback and post event debriefing.Trial registrationISRCTN56583860

Characterization of spasticity in cerebral palsy: dependence of catch angle on velocity

To evaluate spasticity under controlled velocities and torques in children with cerebral palsy (CP) using a manual spasticity evaluator. The study involved 10 children with spastic CP (six males, four females; mean age 10 y 1 mo, SD 2 y 9 mo, range 7-16 y; one with quadriplegia, six with right hemiplegia, three with left hemiplegia; Gross Motor Function Classification System levels I [n=2], II [n=3], III [n=2], IV [n=2], and V [n=1]; Manual Ability Classification System levels II [n=5], III [n=4], and V [n=1]) and 10 typically developing participants (four males, six females; mean age 10 y 3 mo, SD 2 y 7 mo, range 7-15 y). Spasticity and catch angle were evaluated using joint position, resistance torque, and torque rate at velocities of 90 degrees, 180 degrees, and 270 degrees per second, controlled using real-time audio-visual feedback. Biomechanically, elbow range of motion (ROM), stiffness, and energy loss were determined during slow movement (30 degrees/s) and under controlled terminal torque. Compared with typically developing children, children with CP showed higher reflex-mediated torque (p<0.001) and the torque increased more rapidly with increasing velocity (p<0.001). Catch angle was dependent on velocity and occurred later with increasing velocity (p=0.005). Children with CP showed smaller ROM (p<0.05), greater stiffness (p<0.001), and more energy loss (p=0.003). Spasticity with velocity dependence may also be position-dependent. The delayed catch angle at higher velocities indicates that the greater resistance felt by the examiner at higher velocities was also due to position change, because the joint was moved further to a stiffer position at higher velocities.

Effect of caregiver gender, age, and feedback prompts on chest compression rate and depth

Background Quality of chest compressions (CC) is an important determinant of resuscitation outcome for cardiac arrest patients. Purpose To characterize the quality of CC performed by hospital personnel, evaluate for predictors of CC performance, and determine the effects of audiovisual feedback on CC performance. Methods Seven hundred and fifty four individuals participated in a CPR quality improvement challenge at 30 US hospitals. Participants performed 2 min of CC on a manikin with an accelerometer-based system for measuring both rate (CC/min) and depth (in.) of CC (AED Plus:ZOLL Medical). Real-time audiovisual feedback was disabled. A subset of participants performed a second trial of CC with the audiovisual feedback prompts activated. Results Mean depth of CC was below AHA minimum guidelines (<1.5 in.) for 34% (1.30 ± 0.14 in.) and above maximum guidelines (>2.0 in.) for 12% of participants (2.20 ± 0.22 in.). Depth of CC was greater for male vs. female ( p < 0.001) and younger vs. older ( p = 0.009) but did not differ between ACLS, BCLS, and non-certified participants ( p = 0.6). Predictors of CC depth included CC rate ( r part = −0.34, p < 0.0001), gender ( r part = 0.13, p = 0.001), and age ( r part = −0.09, p = 0.02). Mean depth of CC increased, mean rate decreased, and variance in CC depth and rate declined when feedback was used ( p ≤ 0.0001 vs. without feedback). The percentage of CC performed within AHA guidelines (1.5–2 in.) improved from 15 to 78% with feedback. Conclusions The quality of CC performed by personnel at US hospitals as judged by their performance on a manikin is often suboptimal. Quality of CC can be improved with use of CPR feedback technologies.

Abstract P150: Chest Compression Depth is Influenced by Compression Rate and Gender

Purpose: Quality of chest compressions (CC) is an important determinant of resuscitation outcome for cardiac arrest patients. The purpose of this study was to characterize the quality of CC performed by hospital personnel and to evaluate for predictors of CC performance. Methods: A total of 754 individuals (488 nurses, 178 other healthcare professionals, 36 nursing students, and 52 non-healthcare professionals) participated in a CPR quality improvement challenge at 31 U.S. hospitals. Participants performed 2 minutes of CC on a manikin with an accelerometer-based system for measuring both rate (CC/min, cpm) and depth (in) of CC using the AED Plus (ZOLL Medical). Real-time audiovisual feedback normally available on the AED was disabled. Results: The mean depth of compressions was below AHA minimum guidelines (&lt;1.5 in) for 34% of participants (1.30±0.14 in, n=255) and above maximum guidelines (&gt;2.0 in) for 12% of participants (2.20±0.22 in, n=93). CC depth related inversely to CC rate (r=−0.37, p&lt;0.0001), suggesting that excessive CC rate can contribute to insufficient CC depth. Male participants performed CC of greater depth compared with female participants [1.72±0.33 in (n=187) vs.1.60±0.31 (n=534), p&lt;0.0001]. There were no differences in CC depth between ACLS, BCLS, and non-CPR certified participants [1.64±0.33 in (n=392) vs. 1.63±0.31 (n=278) vs. 1.58±0.23 (n=34); p=0.6]. However, depth of CC was greater for non-healthcare professionals compared with healthcare professionals [1.74±0.33 in (n=52) vs. 1.63±0.32 (n=702)]. CC depth varied slightly with rescuer age [&lt;20yr= 1.82±0.27 in (n=8); 21–30 yr= 1.66±0.31 (n=177); 31–40 yr= 1.65±0.31 (n=204); 41–50 yr= 1.62±0.32 (n=196); 51–60yr= 1.54±0.29 (n=109); 61–70 yr= 1.63±0.47 (n=13), p=0.009]. Multivariate linear regression revealed that CC rate (r part =−0.37, p&lt;0.001) and gender (r part = 0.15, p=0.001) were predictors of CC depth. Conclusions: Many hospital personnel do not perform CC within AHA guideline recommendations for depth. Depth of CC may be compromised when rescuers provide CC of excessive rate. Males provide CC of greater depth compared with females.

Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing*

Delivery of high-quality cardiopulmonary resuscitation increases survival from cardiac arrest, yet studies have shown that cardiopulmonary resuscitation quality is often poor during actual in-hospital resuscitation. Furthermore, recent work has shown that audiovisual feedback alone during cardiopulmonary resuscitation modestly improves performance. We hypothesized that a multimodal training method comprising audiovisual feedback and immediate debriefing would improve cardiopulmonary resuscitation performance among care providers. Prospective randomized interventional study. Simulated cardiac arrests at an academic medical center. A total of 80 nurses were randomized to two groups. Each group underwent three trials of simulated cardiac arrest. The "feedback" group received real-time audiovisual feedback during the second and third trials, whereas the "debriefing-only" group performed cardiopulmonary resuscitation without feedback. Both groups received short individual debriefing after the second trial. Cardiopulmonary resuscitation quality was recorded using a cardiopulmonary resuscitation-sensing defibrillator that measures chest compression rate/depth and can deliver audiovisual feedback messages from both groups during the three trials. An adequate compression rate was defined as 90-110 compressions/min and an adequate depth as 38-51 mm. In the debriefing-only group, the percentage of participants providing compressions of adequate depth increased after debriefing, from 38% to 68% (p = 0.015). In the feedback group, depth compliance improved from 19% to 58% (p = 0.002). Compression rate did not improve significantly with either intervention alone. The combination of feedback and debriefing improved compression rate compliance from 45% to 84% (p = 0.001) and resulted in a doubling of participants providing compressions of both adequate rate and depth, 29% vs. 64% (p = 0.005). Significant cardiopulmonary resuscitation quality deficits exist among healthcare providers. Debriefing or feedback alone improved cardiopulmonary resuscitation quality, but the combination led to marked performance improvements. Cardiopulmonary resuscitation feedback and debriefing may serve as a powerful tool to improve rescuer training and care for cardiac arrest patients.

Improving In-Hospital Cardiac Arrest Process and Outcomes With Performance Debriefing

Recent investigations have documented poor cardiopulmonary resuscitation (CPR) performance in clinical practice. We hypothesized that a debriefing intervention using CPR quality data from actual in-hospital cardiac arrests (resuscitation with actual performance integrated debriefing [RAPID]) would improve CPR performance and initial patient survival. Internal medicine residents at a university hospital attended weekly debriefing sessions of the prior week's resuscitations, between March 2006 and February 2007, reviewing CPR performance transcripts obtained from a CPR-sensing and feedback-enabled defibrillator. Objective metrics of CPR performance and initial return of spontaneous circulation were compared with a historical cohort in which a similar feedback-delivering defibrillator was used but without RAPID. Cardiopulmonary resuscitation quality and outcome data from 123 patients resuscitated during the intervention period were compared with 101 patients in the baseline cohort. Compared with the control period, the mean (SD) ventilation rate decreased (13 [7]/min vs 18 [8]/min; P < .001) and compression depth increased (50 [10] vs 44 [10] mm; P = .001), among other CPR improvements. These changes correlated with an increase in the rate of return of spontaneous circulation in the RAPID group (59.4% vs 44.6%; P = .03) but no change in survival to discharge (7.4% vs 8.9%; P = .69). The combination of RAPID and real-time audiovisual feedback improved CPR quality compared with the use of feedback alone and was associated with an increased rate of return of spontaneous circulation. Cardiopulmonary resuscitation sensing and recording devices allow for methods of debriefing that were previously available only for simulation-based education; such methods have the potential to fundamentally alter resuscitation training and improve patient outcomes. clinicaltrials.gov Identifier: NCT00228293.

Abstract 62: Resuscitation with Actual Performance Integrated Debriefing (RAPID) Improves CPR Quality and Initial Patient Survival

Introduction Recent investigations have documented poor cardiopulmonary resuscitation (CPR) performance in clinical practice. We hypothesized that a debriefing intervention using CPR quality data from actual cardiac arrests (Resuscitation with Actual Performance Integrated Debriefing, or RAPID) would improve CPR performance and initial patient survival. Methods Rescuers at a university teaching hospital underwent weekly RAPID sessions between March, 2006 and February, 2007. During the intervention period, facilitators led debriefing discussions using actual performance data, obtained from a CPR-sensing defibrillator with audiovisual feedback capability, and highlighted deficiencies in CPR quality and defibrillation. These data were compared to an historical control in which a similar defibrillator was used. The main outcomes were objective metrics of CPR performance and initial return of spontaneous circulation (ROSC). Results CPR quality and outcome data from 123 patients resuscitated during the intervention period were compared to 101 patients in the baseline cohort. Compared to the control period, CPR quality parameters and defibrillation accuracy were improved (table ). These were associated with a significant improvement in the unadjusted rate of ROSC (table ). After adjusting for shockable vs. non-shockable rhythm, time and location of arrest, and patient demographics, the RAPID intervention was associated with a significant increase in the adjusted odds of ROSC (OR 1.84 [1.06 –3.20]; p=0.03). Conclusions The combination of RAPID and real-time audiovisual feedback improved CPR quality over the use of feedback alone, and was associated with an increased rate of ROSC. CPR sensing and recording devices allow for methods of debriefing that were previously available only for simulation based education; such methods have the potential to fundamentally alter resuscitation training and improve patient outcomes. Resuscitation Performance and Patient Outcomes by Cohort

CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system

Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest. An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5 min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004. Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104+/-18 to 100+/-13 min(-1); test of means, p=0.16; test of variance, p=0.003) and ventilation rate (20+/-10 to 18+/-8 min(-1); test of means, p=0.12; test of variance, p=0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge. Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival.