Elsevier

Resuscitation

Volume 142, September 2019, Pages 91-96
Resuscitation

Simulation and education
The impact of resuscitation guideline terminology on quality of dispatcher-assisted cardiopulmonary resuscitation: A randomised controlled manikin study

https://doi.org/10.1016/j.resuscitation.2019.07.016Get rights and content

Abstract

Background

Cardiopulmonary resuscitation (CPR) guidelines vary in the terminology used to describe target chest compression depth, which may impact CPR quality. We investigated the impact of using different chest compression depth instruction terminologies on CPR quality.

Methods

We conducted a parallel group, three-arm, randomised controlled manikin trial in which individuals without recent CPR training were instructed to deliver compression-only CPR for 2-min based on a standardised dispatcher-assisted CPR script. Participants were randomised in a 1:1:1 ratio to receive CPR delivery instructions that instructed them to deliver chest compressions based on the following terminologies: ‘press at least 5 cm’, ‘press approximately 5 cm’ or ‘press hard and fast.’ The primary outcome was compression depth, measured in millimetres.

Results

Between October 2017 and June 2018, 330 participants were randomised to ‘at least 5 cm’ (n = 109), ‘approximately 5 cm’ (n = 110) and ‘hard and fast’ (n = 111), in which mean chest compression depth was 40.9 mm (SD 13.8), 35.4 mm (SD 14.1), and 46.8 mm (SD 15.0) respectively. Mean difference in chest compression depth between ‘at least 5 cm’ and ‘approximately 5 cm’ was 5.45 (95% confidence interval (95% CI) 0.78–10.12), between ‘hard and fast’ and ‘approximately 5 cm’ was 11.32 (95% CI 6.65–15.99), and between ‘hard and fast’ and ‘at least 5 cm’ was 5.87 (95% CI 1.21–10.53). Chest compression rate and count were both highest in the ‘hard and fast’ group.

Conclusions

The use of ‘hard and fast’ terminology was superior to both ‘at least 5 cm’ and ‘approximately 5 cm’ terminologies.

Trial registration: ISRCTN15128211.

Introduction

International survival following adult out-of-hospital cardiac arrest (OHCA) is poor with only approximately 10% of patients surviving to hospital discharge.1, 2 Following cardiac arrest, immediate treatment with high-quality cardiopulmonary resuscitation (CPR) is essential to increase the likelihood of survival.3 A key component of high-quality CPR is chest compression depth.4, 5, 6

In 2015, the International Liaison Committee on Resuscitation, based on its evaluation of scientific literature, made a treatment recommendation that chest compressions should be delivered at a depth of “approximately 5 cm.”7 The translation of this treatment recommendation in to clinical guidelines has produced variability in guideline language, both between and within guidelines. For example, Resuscitation Council of Asia guidelines recommend a depth of approximately 5 cm, whilst American Heart Association guidelines recommend a depth of at least 5 cm.8, 9 Within the European Resuscitation Council guidelines, the main text recommends a depth of at least 5 cm, whilst the step-by-step basic life support sequence of action figure instructs rescuers to “press down on the sternum approximately 5 cm.”10

Previous studies have highlighted the potential impact of CPR instruction terminology on CPR delivery.11, 12, 13, 14, 15, 16, 17 Driven by these data and current variability in guideline terminology, we designed a randomised controlled manikin trial to compare the effect of these terminologies when used in the context of dispatcher-assisted CPR delivered to an adult. We incorporated a third arm of ‘hard and fast’ based on the terminology's use in high-profile media campaigns by the American Heart Association and the British Heart Foundation.18, 19

Section snippets

Methods

We conducted a three-armed, parallel group, single-centre, randomised controlled manikin trial to evaluate the effect of CPR delivery instruction terminology on CPR quality delivered by people without recent practical CPR training.

The protocol was approved by the West Midlands Edgbaston Research Ethics Committee and Health Research Authority. The study was funded by Resuscitation Council (UK). The trial sponsor was Heart of England NHS Foundation Trust. The trial protocol was registered with

Results

Between October 2017 and June 2018, we screened 573 individuals of which 330 were randomised in the trial. Main reasons for exclusion included declination (n = 131), receipt of CPR training in preceding 2 years (n = 50), and disability preventing CPR delivery for 2-min (n = 30). A study CONSORT flow diagram is shown in Fig. 1.

Of the 330 randomised participants, 109 were randomised to ‘at least 5 cm’, 110 were randomised to ‘approximately 5 cm’ and 111 were randomised to ‘hard and fast.’

Discussion

In this randomised controlled manikin trial of 330 participants without recent CPR training, we found that participants who were instructed to press ‘hard and fast’ delivered the highest quality chest compressions, in terms of chest compressions depth, chest compression rate and delivery of high-quality compressions. The instructions to deliver compressions to a depth of ‘approximately 5 cm’ and ‘at least 5 cm’ resulted in chest compressions that were markedly below target depth and target rate.

Conclusions

The findings from this study demonstrate that resuscitation terminology has an important effect on delivery of CPR by untrained bystanders in simulated OHCA. Further research is required to evaluate the role of this simplified terminology and its possible effect on CPR delivery in real-life OHCA.

Authors’ contributions

KC conceived and designed the study, participated in acquisition of data, analysis and interpretation of data, revised the article and gave final approval of the version submitted. MH, SE, TM and GDP participated in study conception and design, revised the article and gave final approval of the version submitted. SPT and HV participated in acquisition of data, analysis and interpretation of data, revised the article and gave final approval of the version submitted. SPT and HV are joint first

Funding

This study was supported by a research grant awarded by Resuscitation Council (UK). KC is supported by an NIHR post-doctoral fellowship award.

Conflicts of interest

Professor Perkins is an Editor of Resuscitation, co-chair of the International Liasion Committee on Resuscitation, European Resuscitation Council director of guidelines, and chair of the Resuscitation Council (UK) Community Ambulance Committee. The remaining authors have no conflicts of interest to declare.

Acknowledgements

We would like to thank the critical care research team at Birmingham Heartlands Hospital for their contribution to acquisition of data. We also thank Dr Ryan Laloo for his support in extracting outcome data.

References (24)

Cited by (7)

  • Effects of resuscitation guideline terminology on pediatric cardiopulmonary resuscitation

    2022, American Journal of Emergency Medicine
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    Trainees could not achieve effective CCD when the target depth was presented as a range regardless of the depth of the range. After this report, the effect of guideline terminology was evaluated for adult and infant CPR [5,9]. In both cases, the CCD was significantly decreased when the adverb ‘approximately’ was presented as a target depth compared with target depth of ‘at least’.

  • Sustaining improvement of dispatcher-assisted cardiopulmonary resuscitation for out-of-hospital cardiac arrest patients in Japan: An observational study

    2020, Resuscitation Plus
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    In dispatcher-assistance by phone, it can accurately instruct only auditory information. The rate conveyed is a rhythm, using a metronome, can be accurately instructed via telephone, but depth of compression, position, or recoil can not be instructed if using the guideline recommendations.29–33 This study has several limitations.

  • Relief alternatives during resuscitation: Instructions to teach bystanders. a randomized control trial

    2020, International Journal of Environmental Research and Public Health
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1

Drs Trethewey and Vyas are joint first authors.

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