Date Published: February 13, 2019
Publisher: Public Library of Science
Author(s): Kuan-Yu Chen, Ying-Chih Ko, Ming-Ju Hsieh, Wen-Chu Chiang, Matthew Huei-Ming Ma, Steve Lin.
Performing high-quality bystander cardiopulmonary resuscitation (CPR) improves the clinical outcomes of victims with sudden cardiac arrest. Thus far, no systematic review has been performed to identify interventions associated with improved bystander CPR quality.
We searched Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Ovid PsycInfo, Thomson Reuters SCI-EXPANDED, and the Cochrane Central Register of Controlled Trials to retrieve studies published from 1 January 1966 to 5 October 2018 associated with interventions that could improve the quality of bystander CPR. Data regarding participant characteristics, interventions, and design and outcomes of included studies were extracted.
Of the initially identified 2,703 studies, 42 were included. Of these, 32 were randomized controlled trials. Participants included adults, high school students, and university students with non-medical professional majors. Interventions improving bystander CPR quality included telephone dispatcher-assisted CPR (DA-CPR) with simplified or more concrete instructions, compression-only CPR, and other on-scene interventions, such as four-hand CPR for elderly rescuers, kneel on opposite sides for two-person CPR, and CPR with heels for a tired rescuer. Devices providing real-time feedback and mobile devices containing CPR applications or software were also found to be beneficial in improving the quality of bystander CPR. However, using mobile devices for improving CPR quality or for assisting DA-CPR might cause rescuers to delay starting CPR.
To further improve the clinical outcomes of victims with cardiac arrest, these effective interventions may be included in the guidelines for bystander CPR.
Sudden cardiac arrest (SCA) poses a significant threat to our community in the industrialized world and is responsible for 420,000 and 275,000 deaths per year in the US and Europe, respectively [1,2]. It has been proved that bystander cardiopulmonary resuscitation (CPR) improves the survival rate of victims with SCA . Therefore, numerous strategies have been implemented to increase the rate of bystander CPR. For example, many CPR training courses have been held to enable more laypersons to perform CPR because wider dissemination of CPR training might ultimately increase the rate of bystander CPR. Additionally, dispatcher-assisted CPR programs had also been shown to increase bystander CPR rates and the clinical outcomes of victims with SCA [4,5], and were recommended to be integrated into the system of care for prehospital cardiac arrest [6–8]. In addition to improving the rate of performing bystander CPR, the quality of CPR is also vital for the outcome of victims with SCA. High-quality CPR is associated with survival to emergency department arrival , survival to hospital admission , survival to hospital discharge [11,12], and favourable functional outcome . To further improve the outcomes of victims with SCA, it is necessary to explore which interventions can improve the quality of bystander CPR. Therefore, the aim of our study was to perform a systematic review to identify interventions that could improve the quality of bystander CPR.
Our review showed that telephone DA-CPR seemed to improve the overall quality of bystander CPR. Further studies revealed that telephone DA-CPR with simplified or more concrete instructional protocols might further improve the quality of bystander CPR. It suggested that more efforts might be needed in the future not only for dispatchers to identify patients with cardiac arrest and instruct the bystander to perform CPR, but also to build up an effective instructional protocol to let bystanders perform high-quality CPR. Including effective on-scene interventions into instructional protocols, such as four-hand CPR for elderly rescuers, kneel on opposite sides for two-person CPR, and CPR with heels for a tired rescuer, could improve the overall quality of CPR. In addition, it had been shown that, among participants who received the same telephone instruction, the participants receiving CPR training before had better CPR performance than those without receiving any CPR training . It seemed that prior CPR education and telephone DA-CPR had a synergistic effect on the quality of bystander CPR. Therefore, to improve the survival of victims with SCA by improving the quality of bystander CPR, the importance of CPR education and the effective strategy of telephone DA-CPR should be emphasized to the community. More people who receive CPR training would improve the overall quality of bystander CPR. It could translate into better outcomes for patients with out-of-hospital cardiac arrest if an effective, evidence-based protocol of telephone DA-CPR is implemented in the community.
There were some limitations in our study. First, during our search for studies on interventions which could improve the quality of bystander CPR, we could not find a study performed in a real-life resuscitation situation. Whether such interventions associated with higher quality of bystander CPR could be translated to better victims’ outcomes remained unknown. However, several studies have already shown that high-quality CPR could be translated to good outcomes for the victims [9–12]. Second, the inconsistencies in CPR quality measurement among studies were high. There were different parameters that were recorded in studies included, and how the researchers measured CPR quality was also different. In addition, there were inherent biases when the instructors assessed CPR performance when using video recordings or checklists by visual assessment . Yet, we extracted the most commonly recognized parameters in CPR quality measurement . Finally, we found that all of studies included had a high risk of bias in the blinding of participants and personnel while performing risk of bias assessment. Because the participants knew the interventions they were performing during evaluation, it might have affected their self-confidence somewhat, influencing CPR performance. This might be another cause for some bias.
In our systematic review, telephone DA-CPR with simplified or more concrete instructional protocols was shown to improve the quality of bystander CPR. Compression-only CPR and other on-scene interventions also seemed to improve CPR quality. Devices providing real-time feedback and mobile devices containing a CPR app or software were also found to be beneficial to CPR quality. However, using mobile devices for improving CPR quality or for assisting DA-CPR might cause rescuers to spend more time starting CPR. Additional efforts are needed to build up an effective protocol to organize these interventions to improve bystander CPR quality, further improving the clinical outcomes of cardiac arrest victims.