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CPR: How Good Is Good?

Gaps in performance occur even among highly trained physicians.

Investigators sought to determine the quality of cardiopulmonary resuscitation at a university hospital in Austria where emergency department physicians not only were certified according to European standards but also were instructors in several courses per year and participants in yearly educator master classes.

CPR performance was measured against international guidelines (compression rate, 100 per minute; compression depth, 40–50 mm; ventilation rate, 12 per minute). The primary outcome was a novel measure termed the "hands-off ratio," defined as "hands-off time" (total cardiac arrest time minus time with chest compressions or spontaneous circulation) divided by cardiac arrest time. Thus, hands-off ratio represents the fraction of resuscitation time without cerebral or myocardial circulation.

Of 213 patients requiring CPR during a 39-month period, 80 met criteria and were included in the study. The mean hands-off time was 7.6 seconds per minute (and thus the mean hands-off ratio was 12.7%). Compressions were delivered at a mean rate of 114 per minute. The median ventilation rate was 18 per minute. Ventilation was performed at the recommended rate only 18% of the time.

During defibrillation, hands-off time was 11 seconds before and 6 seconds after shock delivery. Four episodes of ventricular fibrillation were unrecognized for periods ranging from 2 to 7 minutes.

Although acknowledging the excess ventilations, the authors conclude that "overall performance quality was higher than that reported by previous investigators." They note that hands-off time can be reduced by using defibrillators in the manual mode and by relying on physicians to interpret tracings and decide whether to deliver electrical therapy.

Comment: That recall of information and skills learned in an advanced cardiac life support course trails off abruptly after several months is well known. This study shows that even experts miss rhythms and overventilate. The challenge for EDs lies in ensuring that all necessary staff are properly trained as experts in the delivery of effective CPR and defibrillation. If we can’t get this right, who can?

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine January 12, 2007

Citation(s):

Losert H et al. Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Arch Intern Med 2006 Nov 27; 166:2375-80.

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