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

Article (PDF Available)inArchives of internal medicine 168(10):1063-9 · May 2008with82 Reads
DOI: 10.1001/archinte.168.10.1063 · Source: PubMed
Abstract
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.
ORIGINAL INVESTIGATION
Improving In-Hospital Cardiac Arrest Process
and Outcomes With Performance Debriefing
Dana P. Edelson, MD, MS; Barbara Litzinger, BS; Vineet Arora, MD, MAPP; Deborah Walsh, MS, RN; Salem Kim, BA;
Diane S. Lauderdale, PhD; Terry L. Vanden Hoek, MD; Lance B. Becker, MD, FAHA; Benjamin S. Abella, MD, MPhil
Background: Recent investigations have documented
poor cardiopulmonary resuscitation (CPR) perfor-
mance in clinical practice. We hypothesized that a de-
briefing intervention using CPR quality data from ac-
tual in-hospital cardiac arrests (resuscitation with actual
performance integrated debriefing [RAPID]) would im-
prove CPR performance and initial patient survival.
Methods: Internal medicine residents at a university hos-
pital attended weekly debriefing sessions of the prior
week’s resuscitations, between March 2006 and Febru-
ary 2007, reviewing CPR performance transcripts ob-
tained from a CPR-sensing and feedback-enabled defib-
rillator. 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.
Results: Cardiopulmonary resuscitation quality and out-
come data from 123 patients resuscitated during the in-
tervention 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 im-
provements. 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).
Conclusions: The combination of RAPID and real-
time audiovisual feedback improved CPR quality com-
pared with the use of feedback alone and was associ-
ated 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.
Trial Registration: clinicaltrials.gov Identifier:
NCT00228293
Arch Intern Med. 2008;168(10):1063-1069
C
ARDIOPULMONARY RESUSCI-
tation (CPR) is one of the
few therapies known to im-
prove survival from sudden
cardiac arrest.
1,2
While in-
struction in CPR is required for the major-
ity of health care professionals, the optimal
methods to teach and ensure correct perfor-
mance of the complex, time-critical actions
of CPR are unknown. The need for novel
CPR training and quality improvement ef-
forts is underscored by recent investigations
that document poor CPR performance dur-
ing actual cardiac arrests, despite rescuer
training in advanced cardiovascular life sup-
port (ACLS) or basic life support (BLS).
3-5
A number of studies have demon-
strated that initial survival is often corre-
lated with the quality of CPR that is deliv-
ered.
6,7
Specifically, improved outcomes
have been correlated with faster and deeper
chest compressions, decreased pauses in
chest compressions, and decreased venti-
lation rates.
8-12
These studies have prompted
the International Liaison Committee on
Resuscitation to call for renewed empha-
sis on CPR training and education in their
2005 revision of consensus resuscitation
guidelines.
2
Initial efforts to improve CPR perfor-
mance, via the use of either mechanical de-
vices to automate CPR delivery or feed-
back-enabled defibrillators, have yielded
variable or modest results during actual re-
suscitation events.
11,13-15
Our prior work
with a real-time audiovisual CPR feed-
back defibrillator demonstrated improve-
ments in CPR quality but did not yield im-
CME available online at
www.jamaarchivescme.com
and questions on page 1025
Author Affiliations: Section of
General Internal Medicine
(Drs Edelson and Arora),
Emergency Resuscitation
Center (Drs Edelson and
Vanden Hoek and Mss Litzinger
and Walsh), Department of
Health Studies (Dr Lauderdale),
and Section of Emergency
Medicine (Dr Vanden Hoek),
University of Chicago, Chicago,
Illinois; and Department of
Emergency Medicine and
Center for Resuscitation
Science, University of
Pennsylvania, Philadelphia
(Ms Kim and Drs Becker and
Abella).
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1063
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
provements in clinical outcomes.
15
Postevent debriefing
based on actual performance data represents an innova-
tive educational technique that has the potential to im-
prove CPR quality. This general method, which has been
widely integrated into both military and aviation prac-
tices, has demonstrated great success in the evaluation
of stressful and infrequent events for future perfor-
mance improvement.
16,17
Performance debriefing has been
combined with mannequin simulation in a variety of medi-
cal education settings, including resuscitation.
18,19
How-
ever, the impact of simulation training or debriefing tech-
niques on actual resuscitation performance remains
unknown.
Novel technology capable of collecting detailed tran-
scripts of CPR quality from actual resuscitations has re-
cently become available.
3,4,20
Using this technology, we
developed a unique debriefing program (resuscitation with
actual performance integrated debriefing [RAPID]) for
rescuers following in-hospital resuscitation attempts in
an academic teaching hospital. We hypothesized that the
RAPID educational intervention, using objective perfor-
mance data from the rescuers’ own recent resuscitation
efforts, would improve CPR quality metrics as well as ini-
tial clinical outcomes from cardiac arrest.
METHODS
STUDY SETTING AND POPULATION
The study hospital is an academic, tertiary care facility with ap-
proximately 600 in-patient beds. Cardiac arrests occurring in
the hospital are treated by the cardiac arrest resuscitation team,
which is led by the on-call cardiology resident physician and
includes 1 to 2 intern physicians and 0 to 2 medical students.
The team is joined by a critical care nurse, respiratory thera-
pist, anesthesiologist, and pharmacist at the cardiac arrest lo-
cation. While on the cardiology rotation, resident teams took
calls every fourth night and participated in approximately 3 to
4 cardiac resuscitations per month. All physician rescuers were
ACLS certified and received a 45-minute orientation to the study
defibrillator and review of resuscitation protocols on or imme-
diately before their first call day of the month.
Resuscitation attempts for consecutive hospitalized adult pa-
tients who had a cardiac arrest during the study periods (de-
fined by the loss of a pulse, requiring the delivery of chest com-
pressions) were included for analysis. Resuscitation attempts
were excluded if the patient was younger than 18 years, the pa-
tient had a do-not-resuscitate order, or if the arrest took place
in the emergency department or operating room environ-
ment. In addition, a small number of patients during the study
periods did not receive treatment with a CPR-sensing defib-
rillator and were therefore excluded from analysis. If a patient
had multiple cardiac arrests, only the initial event was in-
cluded to minimize confounding of the results.
DESIGN
A prospective interventional trial using a historical control group
was used to evaluate the combined effects of audiovisual feed-
back and performance debriefing on CPR quality and patient
outcomes. Resuscitations in our RAPID cohort were included
from March 2006 to February 2007. Arrest event, patient, and
rescuer data were compared with that from a previously pub-
lished cohort (collected between December 2004 and Decem-
ber 2005) that served as a control in the present study.
15
In both
the intervention and control groups, a CPR-sensing defibrilla-
tor provided real-time audiovisual feedback on CPR quality dur-
ing resuscitation attempts. However, during the intervention
period, rescuers participated in a debriefing intervention using
data obtained from that defibrillator following the resuscita-
tion attempt. Both cohorts received care under the same resus-
citation team structure, and no notable changes to hospital re-
suscitation policy were made during either period. However,
new international resuscitation guidelines were released just
before the start of the intervention period.
2
The study protocols, consents, and data collection mecha-
nisms were approved by the institutional review board of the
University of Chicago Medical Center, Chicago, Illinois. Waiver
of consent provisions were used for patients (on the basis of
minimal harm and general impracticability), while an oral con-
sent process was used for rescuers. Collection of patient infor-
mation was designed to comply with the Health Insurance Port-
ability and Accountability Act of 1996 regulations.
CPR-SENSING MONITOR AND DEFIBRILLATOR
A commercially available monitor and defibrillator (MRx with
Q-CPR; Philips Medical Systems, Andover, Massachusetts) with
the capability to detect and record chest compressions and ven-
tilations was used during resuscitation attempts in the RAPID
cohort. This device relies on the same technology as the inves-
tigational device (US Investigational Device Exemption
G020121) used in our baseline cohort. Chest compression mea-
surements were obtained via a chest compression pad, outfit-
ted with both an accelerometer and force detector, which was
adhered to the patient’s sternum. Ventilations were measured
by changes in thoracic impedance obtained through standard
defibrillation pads. Technical aspects of these measurements
have been described and validated elsewhere.
4,20-22
These data
were then analyzed using customized software (Q-CPR Re-
view; Philips Medical Systems). The technical specifications for
CPR detection and algorithms for audiovisual feedback re-
mained the same between the 2 defibrillator models used in the
different cohorts.
EDUCATIONAL INTERVENTION
During the intervention period, members from all resuscita-
tion teams attended weekly debriefing sessions, led by study
investigators (D.P.E., T.L.V.H., L.B.B., and B.S.A.) and other
attending physicians from the fields of cardiology, anesthesi-
ology, and emergency medicine, in which transcripts from the
prior week’s cardiac arrest resuscitation events were reviewed.
These transcripts included electrocardiograhy, ventilation, chest
compression, and end-tidal carbon dioxide waveforms as well
as notations for audio feedback received during the resuscita-
tions. Approximately 2 to 4 cases were chosen by study per-
sonnel (D.P.E. and B.S.A.) for presentation. Key sections in the
arrest transcript detailing aspects of CPR quality deficiency or
therapeutic interventions, such as defibrillation, were rou-
tinely converted into presentation slides (PowerPoint; Micro-
soft Corp, Redmond, Washington) by study investigators (D.P.E.,
B.L., and S.K.) and served as the basis for discussion (
Figure 1).
Recent publications highlighting resuscitation techniques spe-
cific to each session were briefly reviewed as appropriate. These
sessions were approximately 45 minutes in duration each week
and included approximately 30 minutes for review of specific
cases and 15 minutes for general discussion and brief didactic
instruction. An internal medicine chief resident helped to fa-
cilitate discussion. Attendance was strongly encouraged, and
approximately 6 to 10 trainees attended each week. Rescuers
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1064
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
who delivered care during the control cohort period did not
participate in debriefing sessions, but at the start of the monthly
rotation they received a similar orientation to the defibrillator
and protocols as used for the rescuers in the RAPID cohort. In
both the baseline and RAPID cohorts, trainees received auto-
mated real-time audiovisual prompts regarding CPR quality dur-
ing resuscitations and received the same training in the use of
this feedback during monthly orientations.
During the second half of the intervention cohort period (be-
tween September 2006 and February 2007), trainees were sur-
veyed at the start and conclusion of their month on the cardi-
ology service regarding their knowledge of ACLS guidelines and
confidence in their role as rescuer. Matched, written surveys
composed of 24 preintervention and 30 postintervention open-
and close-coded questions were administered by study person-
nel (B.L. and D.W.). Surveys were analyzed for answers to CPR
guideline questions based on the 2005 ACLS target range of
100/min for compression rate, 8/min to 10/min for ventilation
rate, and 1.5 to 2.0 inches (38-51 mm) for compression depth.
2
DATA ANALYSIS
Objective CPR performance and electrocardiographic data were
downloaded from the study defibrillators after resuscitation
events. All arrest transcripts were manually annotated by study
personnel for the start (defined as the first chest compression)
and end (defined as 5 minutes after the start or at the return of
spontaneous circulation [ROSC], if occurring within 5 min-
utes) of an episode. Preshock and postshock pauses, defined
as the duration of time between chest compressions and defi-
brillation, were calculated manually. Cardiac rhythm at the start
of the resuscitation, as well as before and after defibrillation,
were noted. Patient demographic and outcome data were ab-
stracted via subsequent review of medical records.
Return of spontaneous circulation was defined as the onset
of an organized rhythm with a palpable pulse and measurable
blood pressure for at least 20 minutes. Cardiopulmonary re-
suscitation quality parameters such as chest compression rate
and depth, ventilation rate, and no-flow fraction, which rep-
resents the fraction of time, within a given period, that a pulse-
less patient went without chest compressions, were calculated
in 30-second segments of CPR and as aggregate mean values
over the first 5 minutes of resuscitation. Criteria for the calcu-
lation of these parameters have been previously pub-
lished.
4,10,15
Cardiopulmonary resuscitation quality was deemed
within the target range for each 30-second segment if the com-
pression rate was between 90/min and 120/min, compression
depth was 38 mm or greater, and the ventilation rate was 15/
min or less, as recommended by expert consensus for the mea-
suring and reporting of CPR quality.
23
The duration for CPR
quality assessment was chosen to be consistent with our prior
work evaluating CPR quality in 30-second segments.
3,4,8,10
The
first 5 minutes of CPR was used for consistency in both co-
horts, as well as to minimize the potential confounding asso-
ciated with CPR provided near the end of a cardiac arrest (which
may have been deemed futile by rescuers).
ECG/FeedbackVentilationsCompressions
Compress deeper
Compress a little
deeper
Compress deeper
5 Seconds
Figure 1. Sample performance debriefing presentation slide. A 20-second defibrillator tracing used in a postevent debriefing illustrates shallow chest
compressions, failure to respond to audio prompts to “compress deeper,” and hyperventilation. Each ventilation is marked with an arrow, and each audio prompt
is marked with an asterisk. ECG indicates electrocardiograph.
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1065
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
All calculations were performed using a statistical software
application (Stata version 9.0; StataCorp, College Station, Texas).
Skewed data, such as time intervals, were reported as medians
with interquartile ranges and compared using a Wilcoxon rank
sum test. Means were compared using a 2-sided t test, and bi-
nary variables were compared using the
2
test. A logistic re-
gression analysis was undertaken to adjust for the effects of pa-
tient age, sex, initial rhythm, and time and location of arrest
on ROSC. P .05 was considered statistically significant.
RESULTS
During the RAPID period, 112 trainees attempted resus-
citation on 123 distinct patients. These events were com-
pared with resuscitations from 101 patients, performed by
142 trainees, in the baseline period (
Table 1 and Table 2).
There were no significant differences between the groups
in age, sex, presence of a shockable initial rhythm, or lo-
cation or timing of cardiac arrest. In addition, there was
no significant difference in rescuer level of training be-
tween the 2 groups. There was, however, a significant dif-
ference between the 2 groups in terms of when during the
academic cycle the arrests occurred, with the baseline ar-
rests less likely to occur in July, August, or September and
more likely to occur in January, February, and March.
During the second half of the debriefing intervention
period, 48 of 67 eligible trainees completed baseline sur-
veys before starting their month-long rotation as resus-
citation team members. Of those trainees, 40 (83%) com-
pleted final surveys at the conclusion of the month
(
Table 3). The training level distribution in respon-
dents was similar to that in the entire intervention co-
hort. Of the 48 respondents, 20 (42%) had been certi-
fied in ACLS within 6 months of baseline survey
administration; 33 (69%), within 1 year; and 43 (90%),
within 2 years. Before RAPID, only 36 (75%) knew the
correct ACLS recommended rate of chest compres-
sions; 19 (40%) knew the recommended compression
depth; 17 (35%) knew the recommended ventilation rate,
and 18 (38%) knew that stacked shocks of escalating en-
ergy were no longer indicated. Following the interven-
tion, there was a nonsignificant increase in the percent-
age of rescuers answering correctly for compression rate
(P=.07) and depth (P= .23) as well as a significant im-
provement in those answering correctly for ventilation
(P=.04) and defibrillation (P .001). Most respondents
Table 1. Patient Demographics and Resuscitation
Characteristics by Cohort
a
Variable
Baseline
(n=101)
RAPID
(n=123) P Value
Sex
Female 51 (51) 63 (52)
b
.87
Male 50 (50) 59 (48)
b
Age, mean (SD), y 62.3 (17) 60.7 (16) .48
Initial rhythm
VF or VT 18 (18) 19 (16)
.63
PEA or asystole 83 (82) 104 (85)
Location
ICU 56 (56) 77 (63)
.53Hospital ward 40 (40) 40 (33)
Other 5 (5) 6 (5)
Daytime event
c
44 (44) 60 (49) .44
Academic quarter
July-September 18 (18) 47 (38)
.001
October-December 25 (25) 25 (20)
January-March 26 (26) 13 (11)
April-June 32 (32) 38 (31)
Abbreviations: ICU, intensive care unit; PEA, pulseless electrical activity;
RAPID, resuscitation with actual performance integrated debriefing; VF,
ventricular fibrillation; VT, ventricular tachycardia.
a
Data are shown as number (percentage) unless otherwise specified.
b
Demographic data were missing from 1 patient in the RAPID phase.
c
Daytime is defined as 7:00 AM to 6:59 PM.
Table 2. Trainee Level by Cohort
Level of
Training
Baseline,
No. (%)
(n=142)
RAPID,
No (%)
(n=112) P Value
PGY3-4 19 (13) 12 (11)
.88
PGY2 23 (16) 21 (19)
PGY1 84 (59) 65 (58)
MS4 16 (11) 14 (13)
Abbreviations: PGY, postgraduate year; MS4, fourth-year medical student
(subintern); RAPID, resuscitation with actual performance integrated
debriefing.
Table 3. Rescuer Knowledge and Attitudes
Before and After RAPID
Variable
Before
RAPID,
No. (%)
(n=48)
After
RAPID,
No. (%)
(n=40)
P
Value
Knowledge of 2005 ACLS
recommendations
Compression depth 19 (40) 21 (53) .23
Compression rate 36 (75) 36 (90) .07
Ventilation rate 17 (35) 23 (58) .04
Defibrillation algorithm 18 (38) 37 (93) .001
Attitudes regarding role of intervention
Improved guideline understanding NA 33 (83)
Improved comfort level NA 33 (83)
Improved leadership skills NA 28 (70)
Was a valuable addition to curriculum NA 33 (83)
Missing 1 (3)
Level of training
PGY3-4 7 (15) 10 (25)
.96
PGY2 11 (23) 7 (18)
PGY1 25 (52) 19 (48)
MS4 4 (8) 4 (10)
Missing 1 (2) 0
ACLS certification before intervention, mo
6 20 (42) NA
7-12 13 (27) NA
13-24 10 (21) NA
24 5 (10) NA
Debriefing sessions attended
1 NA 12 (30)
2-3 NA 24 (60)
4-5 NA 4 (10)
Abbreviations: ACLS, Advanced Cardiovascular Life Support; NA, not
applicable; MS4, fourth-year medical student (subintern); PGY, postgraduate
year; RAPID, resuscitation with actual performance integrated debriefing.
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1066
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
believed that the debriefing sessions improved their un-
derstanding of the guidelines, comfort level with resus-
citations, and leadership skills. In addition, a majority
believed that the RAPID program was a valuable addi-
tion to their curriculum.
A number of CPR quality metrics improved in the RAPID
cohort (
Table 4). With the implementation of RAPID,
mean (SD) compression depth increased (50 [10] vs 44 [10]
mm; P.001), mean (SD) compression rate increased (105
[10]/min vs 100 [13]/min; P=.003), mean (SD) ventila-
tion rate decreased (13 [7] vs 18 [8]/min; P.001), and
mean (SD) no-flow fraction decreased (0.13 [0.10] vs 0.20
[0.13]; P.001). These were associated with a significant
decrease in the percentage of 30-second segments during
the first 5 minutes that were outside of target range for com-
pression rate and depth as well as ventilation rate (P.001
for each parameter) (
Figure 2). In addition, preshock and
postshock pause times decreased significantly (P.001 for
each), and the proportion of appropriate shocks (shocks
for ventricular fibrillation and ventricular tachycardia, as
opposed to pulseless electrical activity and asystole) in-
creased in the RAPID cohort (Table 4).
These improvements were associated with a signifi-
cant improvement in the rate of ROSC between the groups
(59% vs 45%; P= .03) (
Figure 3). Survival to discharge
was indistinguishable between the groups (7% vs 9%;
P=.69). After adjusting for shockable vs nonshockable ini-
tial rhythm, time and location of arrest, and patient de-
mographics, RAPID was associated with a significant in-
crease in the odds of ROSC (median [interquartile range]
OR, 1.83 [1.06-3.16]; P=.03). To account for the poten-
tial bias introduced by including resuscitations during the
intervention that occurred before the first debriefing of each
month, all the analyses were repeated without including
the 31 resuscitations meeting that criteria, and the results
were not significantly altered (data not shown).
COMMENT
We have demonstrated that an integrated debriefing pro-
gram based on actual resuscitation performance (RAPID)
is effective in improving objective measurements of CPR
quality and initial patient survival from in-hospital car-
diac arrest. Specifically, we have shown that detailed “play-
back” of actual resuscitation events with targeted dis-
cussion is both feasible and effective in improving rescuer
knowledge and performance of cardiac resuscitation as
well as patient outcomes. This work has broad applica-
bility for improving resuscitation training in both in-
hospital and out-of-hospital settings.
Cardiac resuscitation in clinical practice requires a com-
plex set of actions to be carried out by multiple rescuers
under considerable stress. Given this reality, it is perhaps
not surprising that conventional resuscitation education and
training has had limited success.
24
Simulation training has
been used in an attempt to address some of these issues by
mimicking the complexities found in actual events.
25
In a
randomized, crossover design study of internal medicine
residents, Wayne et al
26
demonstrated that simulator train-
ing sessions significantly improved ACLS skills, while trainee
experience alone had no significant effect. Another simu-
lation-based study combined high-fidelity simulation with
team training and intensive debriefing and demonstrated
an improvement in simulated survival from 0% to 90% over
the course of 1 day of training.
19
However, simulation training has practical limitations
and requires infrastructure that may not be accessible to
Table 4. Cardiopulmonary Resuscitation Quality by Cohort
Quality Metric Baseline RAPID
P
Value
5-Minute mean (SD) (n=101) (n=123)
Compression depth, mm 44 (10) 50 (10) .001
Compression rate, No./min 100 (13) 105 (10) .003
Ventilation rate, No./min 18 (8) 13 (7) .001
No-flow fraction 0.20 (0.13) 0.13 (0.10) .001
Preshock pause,
median (IQR), seconds
16.0 (8.5-24.1)
(n=108)
7.5 (2.8-13.1)
(n=108)
.001
Postshock pause,
median (IQR), secomds
7.1 (2.7-14.8)
(n=124)
2.4 (1.9-3.6)
(n=106)
.001
Appropriate shocks,
No./total No. (%)
110/151 (73)
(n=151)
104/117 (89)
(n=117)
.001
Abbreviations: IQR, interquartile range; RAPID, resuscitation with actual
performance integrated debriefing.
90
50
60
70
80
40
20
10
30
0
Ventilation Rate
38
49
Compression Rate
65
82
Compression Depth
70
86
Segments in Target Range, %
Baseline
RAPID
Figure 2. Cardiopulmonary resuscitation (CPR) quality as a percentage of
time within target range. Data are given as percentage of 30-second
segments during the first 5 minutes of CPR that are 15/min or less for
ventilations, 38 mm or greater for compression depth, and 90/min to
120/min for compression rate. P .001 for each parameter. RAPID indicates
resuscitation with actual performance integrated debriefing.
70
50
60
40
20
10
30
0
Baseline (n
=
101)
45%
RAPID (n
=
123)
59%
ROSC, %
P = .03
Figure 3. Return of spontaneous circulation (ROSC) by cohort. RAPID
indicates resuscitation with actual performance integrated debriefing.
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1067
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
all institutions. In addition, the applicability of simulated
scenarios to actual clinical events remains poorly under-
stood. For example, the effects of audiovisual feedback in
a simulated study of resuscitation were considerably more
promising than during actual cardiac arrest.
11,15,27
There-
fore, the possibility of combining the educational strate-
gies of feedback and debriefing with actual clinical events
is both appealing and potentially accessible to a wider au-
dience. Historically, this has not been feasible, given the
lack of objective data available during and following car-
diac arrest resuscitation attempts. However, new technol-
ogy, capable of accurately measuring and potentially re-
cording CPR quality in real time, is now available in both
defibrillators and free-standing lower cost devices, allow-
ing rescuers to learn from their actual performance by ap-
plying these educational techniques.
The differential effect of real-time audiovisual feed-
back between simulated and clinical scenarios suggests that
human factors during actual resuscitation (such as noise
at the scene, stress, and competing clinical priorities for
the attention of team members) may have prevented the
real-time feedback from having maximal benefit. We pos-
tulate that one of the ways RAPID worked was through
sensitizing rescuers to the real-time audiovisual prompts
they received during subsequent resuscitations.
Another potential mechanism that may have ac-
counted for the improved resuscitation performance by
the house staff was the knowledge that their perfor-
mance was going to be reviewed in an open forum with
faculty and colleagues. In both study groups, the train-
ees consented to have their CPR quality measured. How-
ever, in the intervention period, the trainees knew that
their performance was going to be analyzed openly. This
heightened awareness may have motivated increased at-
tention to detail during resuscitation care. This is sup-
ported by the lack of a difference in results when the re-
suscitations preceding the first debriefing of the month
were omitted from analysis.
This study has several limitations. First and foremost,
we cannot exclude improvements in CPR quality due to
secular trend, particularly in light of the release of the 2005
ACLS guidelines in November 2005,
2
which decreased the
recommended ventilation rate and increased the “quan-
tity” of CPR to be delivered between pulse checks. How-
ever, we also observed improvements in compression rate
and depth, which were not the subject of any changes in
the CPR guidelines. In addition, the poor baseline knowl-
edge the house staff had of these changes and the signifi-
cant improvement in that knowledge following the inter-
vention suggests that part of the benefit of RAPID was an
increase in rescuer awareness of the 2005 ACLS guide-
lines. Finally, our prior published work, comparing au-
diovisual feedback with an earlier historical control co-
hort, which showed only modest improvements in CPR
quality and no change in outcomes,
15
argues against a sig-
nificant effect of time and experience or Hawthorne effect.
28
Nonetheless, since both cohorts in the present study re-
ceived audiovisual feedback, the baseline CPR quality in
this study is possibly better than in other institutions. This
study design therefore tests only the added effect of the
debriefing intervention to audiovisual feedback. How-
ever, this effect would have been slightly larger had we used
our original historical control group that received no feed-
back. Another limitation of this study is that it was con-
ducted at a single institution; the applicability of our find-
ings to other institutions with different resuscitation team
structures or paramedics remains unknown. In addition,
to protect the confidentiality of the trainees, we did not
maintain identifying data to link them with specific pa-
tients and therefore only have aggregate monthly data. It
is therefore not possible to test the effects of the interven-
tion on specific residents over time.
In the aggregate analysis of rescuer level of training, we
found no difference between the 2 groups. However, there
was a significant difference between the 2 groups in terms
of when the arrests took place during the academic cycle,
with the baseline arrests less likely to occur in July, Au-
gust, or September and more likely to occur in January,
February, and March. We postulate that this discrepancy
would be more likely to bias toward the null, since train-
ees are less experienced in the late summer and early fall
and gain experience throughout the year. However, when
ROSC was assessed as a function of the time of year and
quarter was included in the regression analysis, no sig-
nificant differences were found (data not shown).
It is interesting to note that while we achieved a 33%
improvement in the rate of ROSC, there was no signifi-
cant difference in survival to discharge. One possibility for
this discrepancy is that while ROSC is necessary for sur-
vival to discharge, many postresuscitation factors play a
notable role as well, such as therapeutic hypothermia, tight
glycemic control, and early revascularization, which are
likely underused in clinical practice.
29-31
Return of spon-
taneous circulation was chosen as the main patient out-
come variable because of power considerations and be-
cause it is most affected by resuscitation performance, the
process variable targeted by our intervention.
In conclusion, an educational intervention of postresus-
citation team debriefing using new CPR-sensing technol-
ogy during actual cardiac arrest may improve objective mea-
sures of rescuer performance of CPR as well as initial patient
outcomes from cardiac arrest. This relatively simple in-
tervention could be implemented using a variety of CPR-
sensing tools currently available or using recordings of elec-
trocardiographic data from most defibrillators, since chest
compression rate and pause times can often be inferred
from an electrocardiographic artifact caused by the com-
pressions. The recording of CPR data provides a number
of opportunities for further improvement and optimiza-
tion of both education and actual care, and future work
will be required to identify the most effective methods of
using these new tools in a wider variety of settings to im-
prove resuscitation clinical skills and patient survival.
Accepted for Publication: November 18, 2007.
Correspondence: Benjamin S. Abella, MD, MPhil, Uni-
versity of Pennsylvania, Department of Emergency Medi-
cine, 3400 Spruce St, Ground Ravdin, Philadelphia, PA
19104 (benjamin.abella@uphs.upenn.edu).
Author Contributions: Drs Edelson and Abella had full
access to all the data in the study and take responsibility
for the integrity of the data and the accuracy of the data
analysis. Study concept and design: Edelson, Becker, and
Abella. Acquisition of data: Edelson, Litzinger, Walsh, Kim,
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1068
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
Vanden Hoek, Becker, and Abella. Analysis and interpre-
tation of data: Edelson, Litzinger, Arora, Lauderdale, and
Abella. Drafting of the manuscript: Edelson, Litzinger,
Kim, and Abella. Critical revision of the manuscript for
important intellectual content: Edelson, Arora, Walsh,
Lauderdale, Vanden Hoek, Becker, and Abella. Statistical
analysis: Edelson, Litzinger, and Lauderdale. Obtained fund-
ing: Edelson, Becker, and Abella. Administrative, techni-
cal, and material support: Kim, Vanden Hoek, and Becker.
Study supervision: Becker and Abella.
Financial Disclosure: None reported.
Funding/Support: This work was supported by a grant from
Philips Medical Systems, Andover, Massachusetts. Dr Edel-
son is supported by a career development award from the
American Heart Association, and Dr Abella also received
support for this work from the National Heart, Lung, and
Blood Institute (NHLBI 1 K23 HL 83082-01).
Role of the Sponsors: The sponsor had no role in any
other aspect of this work, including the design and con-
duct of the study; the collection, management, analysis,
and interpretation of the data; and the preparation, re-
view, or approval of the manuscript.
Previous Presentations: Preliminary versions of these data
were presented as posters at the 2007 annual meetings
of the Society of General Internal Medicine (April 27,
2007; Toronto, Ontario, Canada) and the Society for Hos-
pital Medicine (May 24, 2007; Dallas, Texas). In addi-
tion, an abstract of these data was presented at the Re-
suscitation Science Symposium of the American Heart
Association Scientific Sessions; November 4, 2007; Or-
lando, Florida.
Additional Contributions: This study would not have
been possible without the support and dedication of the
residents and medical students at the University of Chi-
cago and the Internal Medicine Residency Program.
In addition, Joe G. N. “Skip” Garcia, MD, and James
Woodruff, MD, provided support in establishing the cur-
riculum; William Borden, MD, Jason Poston, MD, and
George Bell, MD, helped lead the discussions; and
David Beiser, MD, Martin Burke, DO, Anthony Kim,
MD, Bradley Knight, MD, and Avery Tung, MD, acted
as faculty discussants. Anne Barry, MBA, RN, Theodore
Karrison, PhD, Raina Merchant, MD, Vincent Retirado,
MD, Joel Teitelbaum, PhD, and Ronald A. Thisted,
PhD, provided constructive discussions during our
work. Lynne Harnish, Michael Retzer, and Ameena
Al-Amin provided expert administrative assistance, and
Elizabeth Weidman provided critical review and sub-
mission preparation.
REFERENCES
1. Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med. 2001;344(17):
1304-1313.
2. ECC Committee, Subcommittees and Task Forces of the American Heart Asso-
ciation. 2005 American Heart Association Guidelines for Cardiopulmonary Re-
suscitation and Emergency Cardiovascular Care. Circulation. 2005;112(24)
(suppl):IV1-IV203.
3. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resus-
citation during out-of-hospital cardiac arrest. JAMA. 2005;293(3):299-304.
4. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resusci-
tation during in-hospital cardiac arrest. JAMA. 2005;293(3):305-310.
5. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions of chest compressions dur-
ing emergency medical systems resuscitation. Circulation. 2005;112(9):1259-
1265.
6. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al; Belgian Cerebral Resuscita-
tion Study Group. Quality and efficiency of bystander CPR. Resuscitation. 1993;
26(1):47-52.
7. Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmo-
nary resuscitation and survival following out-of-hospital cardiac arrest. JAMA.
1995;274(24):1922-1925.
8. Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during car-
diopulmonary resuscitation are suboptimal: a prospective study during in-
hospital cardiac arrest. Circulation. 2005;111(4):428-434.
9. Rea TD, Helbock M, Perry S, et al. Increasing use of cardiopulmonary resusci-
tation during out-of-hospital ventricular fibrillation arrest: survival implications
of guideline changes. Circulation. 2006;114(25):2760-2765.
10. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth
and pre-shock pauses predict defibrillation failure during cardiac arrest.
Resuscitation. 2006;71(2):137-145.
11. Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out-of-hospital cardio-
pulmonary resuscitation with real time automated feedback: a prospective in-
terventional study. Resuscitation. 2006;71(3):283-292.
12. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hy-
potension during cardiopulmonary resuscitation. Circulation. 2004;109(16):
1960-1965.
13. Ong ME, Ornato JP, Edwards DP, et al. Use of an automated, load-distributing
band chest compression device for out-of-hospital cardiac arrest resuscitation.
JAMA. 2006;295(22):2629-2637.
14. Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs use of an
automated chest compression device during resuscitation following out-of-
hospital cardiac arrest: a randomized trial. JAMA. 2006;295(22):2620-2628.
15. Abella BS, Edelson DP, Kim S, et al. CPR quality improvement during in-hospital
cardiac arrest using a real-time audiovisual feedback system. Resuscitation. 2007;
73(1):54-61.
16. Troiani TA, Boland RT. Critical incident stress debriefing: keeping your flight crew
healthy. J Air Med Transp. 1992;11(10):21-24.
17. Samter J, Fitzgerald ML, Braudaway CA, et al. Debriefing: from military origin to
therapeutic application. J Psychosoc Nurs Ment Health Serv. 1993;31(2):23-27.
18. Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ. Value of debriefing
during simulated crisis management: oral versus video-assisted oral feedback.
Anesthesiology. 2006;105(2):279-285.
19. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving medical emer-
gency team (MET) performance using a novel curriculum and a computerized
human patient simulator. Qual Saf Health Care. 2005;14(5):326-331.
20. Aase SO, Myklebust H. Compression depth estimation for CPR quality assess-
ment using DSP on accelerometer signals. IEEE Trans Biomed Eng. 2002;49
(3):263-268.
21. Wik L, Myklebust H, Auestad BH, Steen PA. Retention of basic life support skills
6 months after training with an automated voice advisory manikin system with-
out instructor involvement. Resuscitation. 2002;52(3):273-279.
22. Handley AJ, Handley SA. Improving CPR performance using an audible feed-
back system suitable for incorporation into an automated external defibrillator.
Resuscitation. 2003;57(1):57-62.
23. Kramer-Johansen J, Edelson DP, Losert H, Kohler K, Abella BS. Uniform report-
ing of measured quality of cardiopulmonary resuscitation. Resuscitation. 2007;
74(3):406-417.
24. Baskett PJ, Nolan JP, Handley A, Soar J, Biarent D, Richmond S. European Re-
suscitation Council guidelines for resuscitation 2005: section 9: principles of train-
ing in resuscitation. Resuscitation. 2005;67(suppl 1):S181-S189.
25. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethi-
cal imperative. Acad Med. 2003;78(8):783-788.
26. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medi-
cine residents in advanced cardiac life support protocols: a randomized trial. Teach
Learn Med. 2005;17(3):210-216.
27. Wik L, Thowsen J, Steen PA. An automated voice advisory manikin system for
training in basic life support without an instructor: a novel approach to CPR training.
Resuscitation. 2001;50(2):167-172.
28. Campbell JP, Maxey VA, Watson WA. Hawthorne effect: implications for pre-
hospital research. Ann Emerg Med. 1995;26(5):590-594.
29. Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised treat-
ment protocol for post resuscitation care after out-of-hospital cardiac arrest.
Resuscitation. 2007;73(1):29-39.
30. Abella BS, Rhee JW, Huang KN, Vanden Hoek TL, Becker LB. Induced hypother-
mia is underused after resuscitation from cardiac arrest: a current practice survey.
Resuscitation. 2005;64(2):181-186.
31. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization
among physicians after resuscitation from cardiac arrest. Crit Care Med. 2006;
34(7):1935-1940.
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 10), MAY 26, 2008 WWW.ARCHINTERNMED.COM
1069
©2008 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ on 02/25/2013
    • "The ACLS guideline for using ETCO 2 monitoring during CPR provides the basis on which providers can have real-time feedback about the quality of chest compressions , thus offering patients a better chance of survival [18, 19] . To our knowledge, ours is the first study regarding possible survival benefits with ETCO 2 monitoring in real clinical situations. "
    [Show abstract] [Hide abstract] ABSTRACT: During cardiac arrest, end-tidal carbon dioxide (ETCO 2 ) monitoring is recommended as a chest compression performance indicator. However, its frequency of use during out-of-hospital cardiac arrest (OHCA) and its benefits have never been evaluated in real clinical situations. We investigated OHCA patients in Taiwan to evaluate the frequency of ETCO 2 monitoring and its effects on sustained return of spontaneous circulation (ROSC). We sampled the Taiwan National Health Insurance claims database, which contains 1 million beneficiaries. All adult beneficiaries older than 18 years who presented with OHCA and received chest compression between 1 January 2005 and 31 December 2012 were enrolled. We further identified patients with ETCO 2 monitoring and matched each 1 with 20 patients who did not receive ETCO 2 monitoring based on their propensity scores. A simple conditional logistic regression model was applied to compare the odds ratio (OR) for sustained ROSC in the matched cohorts. A total of 5041 OHCA patients were enrolled. The frequency of ETCO 2 monitoring has increased since 2010 but still is low. After matching, 53 patients with ETCO 2 monitoring and 1060 without ETCO 2 monitoring were selected. The OR of sustained ROSC in the ETCO 2 group was significantly increased (2.38, 95 % CI 1.28–4.42). Patients who received ETCO 2 monitoring during OHCA had a higher possibility of sustained ROSC, but the overall use of ETCO 2 monitoring is still low despite strong recommendations for its use.
    Full-text · Article · Dec 2015
    • "In the past decade, in the in-hospital setting, quality measures of CPR effectiveness have evolved from survival rate of individual CPR events, to survival to hospital discharge, to assessment of neurological disability at the time of hospital discharge [6,21222324 . Girotra et al, identified all adults (>18 years) who had treated IHCA at 374 hospitals that participated in the Get with the guidelines-Resuscitation registry in the past decade and showed that both survival and neurologic outcomes improved. "
    [Show abstract] [Hide abstract] ABSTRACT: Current prevalence estimates of gastrostomy tube (GT)/tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation (CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE.We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004-2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables.During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40-49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53-0.80, p
    Full-text · Article · Jul 2015
    • "In order to standardize the quality of cardiopulmonary resuscitation (CPR) and simultaneous monitoring, certain mechanical or physiological parameters are considered.1,2 Discovery of positive relationship between the cardiac output and end-tidal carbondioxide pressure (PetCO2) has led to use of capnography during cardiopulmonary resuscitation.3,4 "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To measure end-tidal carbon dioxide pressure (PetCO2) in preset interval in order to evaluate the efficiency of cardiopulmonary resuscitation (CPR) performed on patients in cardiopulmonary arrest, evaluate the validity of PetCO2 in predicting the mortality and finally assess the PetCO2 levels of the patients in cardiopulmonary arrest based on the initial presenting rhythm. Methods: This prospective study was conducted at the Ankara Training and Research Hospital on patients who presented with cardiopulmonary arrest. Standard ACLS (Advanced Cardiac Life Support) protocols were performed. Patients were categorized in two groups based on their rhythms as Ventricular Fibrillation and Asystole. Patients’ PetCO2 values were recorded. Results: PetCO2 levels of the Return of Spontaneous Circulation (ROSC) group in the 5th, 10th, 15th and 20th minutes were significantly higher compared to the exitus group (p<0.001). In distinguishing ROSC and exitus, PetCO2 measurements within 5-20 minute intervals showed highest performance on the 20th and lowest on the 5th minutes. Conclusion: PetCO2 values are higher in the ROSC group. During the CPR, the most reliable time for ROSC estimation according to PetCO2 values is 20th minute. None of the patients who had PetCO2 levels less than 14 mmHg survived.
    Full-text · Article · Feb 2014
Show more