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Resuscitation

High-quality chest compressions are possible during intra-hospital transport, but depend on provider position

A manikin study

Jansen, Gerrit; Kipker, Kristin; Latka, Eugen; Borgstedt, Rainer; Rehberg, Sebastian

Author Information
European Journal of Anaesthesiology: April 2020 - Volume 37 - Issue 4 - p 286-293
doi: 10.1097/EJA.0000000000001154

Abstract

Introduction

Previous research in emergency medicine identified high-quality chest compression and the reduction of no-flow time as key outcome measures for cardiopulmonary resuscitation (CPR).1–7 In this context, a shortening of the compression-free interval, early defibrillation and rapid and adequate treatment of reversible causes of cardiac arrest are important.1,5–7

As a consequence, transport of the patient with ongoing chest compression is often necessary. While substantial evidence has been published in respect to out-of-hospital cardiac arrest (OHCA), the quality of chest compression during in-hospital transportation, for example following an in-hospital cardiac arrest, has not been investigated.8–14

In contrast to OHCA, in the case of in-hospital cardiac arrest, advanced diagnostic and/or therapeutic options (e.g. catheter intervention in acute myocardial infarction (MI), fragmentation therapy in pulmonary embolism, etc.) are available within minutes, making it possible to treat the cause of an arrest in a timely manner.15,16 With this in mind, emergency care providers need to decide whether to continue CPR until return of spontaneous circulation is achieved at the initial resuscitation site, potentially squandering the benefits of treating the underlying cause or transport the patient for a potentially life-saving intervention to some other hospital site – with ongoing CPR.

The latter option only becomes reasonable, if a deterioration of chest compression quality during transport is avoided, as this may be detrimental to a patient's outcome. Using a manikin, the current study investigated different positions for chest compression providers during in-hospital transport. Quality indicators of chest compression as recommended by the current guidelines, transport time and the provider's perception as regards safety, comfort and compression sustainability were evaluated.

Methods

Ethical approval for this study (Ethical Committee No. 2019–397-f-S) was provided by the Ethical Committee of the university hospital of Muenster, Muenster, Germany (Chairperson Univ.-Prof. Dr med. W.E. Berdel) on 22 July 2019. The study was undertaken at the ‘Studieninstitut für kommunale Verwaltung Westfalen-Lippe, Fachbereich Medizin und Rettungswesen’, Bielefeld, Germany. After giving informed consent, 20 volunteers, all professional paramedics trained in Basic-Life-Support, were asked to perform chest compression in four simulated resuscitation scenarios. The order of the scenarios for each participant was random. The Laerdal Resusci Anne QCPR manikin (with legs) (Laerdal Medical GmbH, Lilienthalstr.5, 82178 Puchheim, Germany, http://www.laerdal.com/) was used. The control group performed one cycle of chest compression on the manikin on the floor in a static position – 2 min. In study groups 1 to 3 chest compressions were performed under, dynamic transport conditions: In group 1, the providers walked alongside the hospital bed. In group 2, the providers knelt on the bed beside the manikin (the choice of side was the provider's decision). In group 3 the providers knelt astride the manikin in the hospital bed. An overview of the classification of the groups is shown in Table 1. The provider positions are illustrated in Figs. 1–3.

T1
Table 1:
Classification of study groups
F1
Fig. 1:
Group 1, walking beside the bed.
F2
Fig. 2:
Group 2, kneeling beside the manikin.
F3
Fig. 3:
Group 3, kneeling astride the manikin.

During the transport simulation, a hydraulic hospital bed (model 4379–1430–71–01, series 9734–00135, Stiegelmeyer GmbH & Co. KG, Ackerstrasse 42, 32051 Herford, Germany, https://www.stiegelmeyer.com/) with a commercial hospital mattress was pushed a predefined distance of 100 m. Two people moved the bed while the third (the ‘active’ participant) performed chest compression in the assigned provider position. The adjustment of the height of the bed, the position of the manikin, and the transport speed were chosen by the participants and could be individually adjusted before and during the scenarios. The primary goal was the achievement of the highest possible chest compression quality as stated by the European Resuscitation Councils (ERC) 2015 guidelines.16

Data were transmitted via WLAN to the SimPad PLUS (SimPad PLUS, Laerdal Medical 2016, www.laerdal.com) with SkillReporter (Session Viewer, Laerdal Medical 2016, www.laerdal.com), already preinstalled on the tablet. The individual datasets were saved and evaluated using the Debriefing Software Session Viewer 6.2.6400 by Laerdal. The indicators of chest compression quality were measured according to current ERC guidelines (depth of compression, compression frequency, proportion of compressions with adequate frequency, correct hand position, complete unloading of the chest, sufficient compression depth), as well as the time required for the distance travelled, and the overall quality of resuscitation.16

Following the four scenarios, the participants were asked to complete a questionnaire, anonymously, which included their age, weight and experience and training in prehospital care. Using a Likert scale (choices: totally disagree, disagree, agree, totally agree), providers assessed each transport position as regards safety, fatigue and comfort. Finally, the providers were asked to recommend one of the positions that would allow optimal chest compression (refer to Supplement, https://links.lww.com/EJA/A271).

Data were entered into Microsoft Excel Version 2016 and Microsoft Word Version 2016 (Microsoft, Germany) for statistical evaluation. SPSS V.20.0 (SPSS V.20.0, IBM, New York, New York, United States of America) was used for statistical analysis. The sample size was calculated with a standardised tolerance limit of one standard deviation and no difference, 20 participants were required for a power = 0.8 with a significance level of 0.05. To check for variance homogeneity, the Levene test was performed. In case of variance homogeneity, one-factor analysis of variance (ANOVA) was used to detect significant differences; in all other cases, the Welch test was used. With regard to significant differences between the groups, the Tukey test was performed as a post hoc test following ANOVA, and by the Games Howell test after the Welch test. The statistical evaluation of the provider survey was performed with the Wilcoxon–Mann–Whitney test. The significance level was set at P of 0.05 or less. Resuscitation data were presented as mean ± SD. The results of the provider survey are presented as a percentage.

Results

A total of 20 participants (eight female, 12 male) with an average professional experience since enrolment for training of 4.8 ± 3.1 years and an average age of 25.1 ± 4.0 years were included in the study and performed all four scenarios. The results of the measured parameters for the individual study groups are listed in Table 2. As high-quality chest compression could be performed in the control group, it was suitable as a comparison group. Compared with group 1 (139 ± 20 s), transport time for the predefined distance was significantly shorter in groups 2 and 3 (92 ± 16 s, P < 0.001 and 85 ± 13 s, P < 0.001, respectively). The average compression depth in the control group and in groups 2 and 3 was in the range specified by the ERC guidelines with no statistically significant differences between the individual groups. In group 1 the compression depth was less than in all 3 of the other groups (P = 0.004 vs. control, P = 0.035 vs. group 2, P = 0.006 vs. group 3) and lower than recommended by the guidelines. A sufficient compression depth was achieved in the control group and in groups 2 and 3 in more than 75% of cases, but in group 1, only 40% of cases achieved an adequate compression depth 1 (P = 0.04 vs. control; P = 0.028 vs. group 2; P = 0.002 vs. group 3).

T2
Table 2:
Quality parameters of chest compressions

In all groups, the mean compression frequencies were guideline-compliant, in the range between 100 and 120 min−1 with no statistically significant differences between the groups. The proportion of compressions with adequate frequency was 81% in the control group. In all transport scenarios this value was lower, but without statistical significance.

There was no statistically significant difference between the control group and groups 2 and 3 in terms of the correct hands position (Table 2). In group 1, the correct hands position was achieved in only 80% of cases (P = 0.044 vs. control). Regarding ‘complete chest rebound’ there were no statistical differences between study groups (Table 2).

Both, the compression ratio and the quality of resuscitation were above 90% in the control group. In all 3 other groups, lower values were observed. The comparison of the control group and groups 2 and 3 showed no significant differences, while the compression ratio and quality of resuscitation in group 1 differed significantly from the control group and groups 2 and 3 (compression ratio: P < 0.001 vs. control; P = 0.019 vs. group 2; P = 0.01 vs. group 3; quality of resuscitation: P < 0.001 vs. control; P = 0.019 vs. group 2; P = 0.009 vs. group 3).

The results of the survey are shown in Fig. 4. 70% of the participants recommended position 3 for carrying out resuscitation during ‘patient’ transport, 30% recommended position 2. Position 1 was not recommended.

F4
Fig. 4:
Results of the participant survey (red numbers show disagreement with the statement and black numbers show agreement with the statement).

Discussion

The current study shows that high-quality chest compression according to current guidelines is possible during in-hospital transport on a regular hospital bed, if the provider is kneeling beside or astride the manikin. Furthermore, compared with walking next to the bed, these kneeling positions not only allow faster transportation, but also were perceived as more comfortable and less tiring by the providers.

According to the ERC guidelines, patients with OHCA should be considered for transport if treatment options exist in the target hospital (e.g. percutaneous coronary intervention) which cannot be performed out of hospital.16 While numerous studies shed light on the implementation and quality of prehospital resuscitation under transport conditions,9,13,14 research on in-hospital transport during CPR has largely been neglected.3,14 As a consequence, there are numerous recomendations, but no evidence how to implement optimal chest compression during in-hospital transport.17 This is astonishing as, in the in-hospital setting, there are multiple treatment resources in close proximity for reversible causes of cardiac arrest.

While concerns have been raised regarding the negative effects of interruptions of chest compression, leading to increasing no-flow times, it is claimed that the quality of manual chest compression is often inadequate during transport.11–13,18 The present data does not support the hypothesis that resuscitation while moving a patient inevitably leads to an increased no-flow time. To the contrary, our results demonstrate that during in-hospital transport guideline compliant manual chest compression is possible and is as efficient as normal static chest compression, if the provider is kneeling beside or astride the patient. In addition, no time is wasted transferring the manikin to a stretcher. Based on this knowledge, provider changes with the shortest possible no-flow time can be assured and provider position can be adjusted to the individual situation (e.g. the ‘kneeling beside’ position if the femoral vessels need to be assessed or ‘kneeling astride’ position if chest drainage is required). Walking beside the bed did not allow chest compression with sufficient quality and was associated with a longer transport time.

Concerns have been raised that transport with continuation of manual chest compression in OHCA may lead to deviations from the correct hands position, with deterioration in chest compression quality due to transport-induced centrifugal forces.11–13,18–20 However, in our study, the only significant deviations from the correct hands position occurred in the case of the ‘walking’ provider. Furthermore, concerns that continuing chest compression while performing in-hospital transport may result in reduced chest rebound (e.g. by having to support the chest compression provider to maintain their balance during transport) cannot be confirmed by our data.11–13,18

Rapid therapy of reversible causes of cardiac arrest (e.g. reperfusion therapy for MI) is important in improving outcomes.15,16 Accordingly, the transport of patients with cardiac arrest to other in-hospital sites where such interventions are performed is considered as time-critical. Therefore, transport times during dynamic resuscitation conditions are of high clinical relevance. Although the distance defined in this investigation was short, the results in both ‘kneeling’ positions show that an in-hospital transport can be performed quickly and without negative effects on chest compression quality. This raises the question, as to whether the return of spontaneous circulation is a necessary requirement before transport, or if the patients should be transported as early as possible to a site for effective treatment, even if this requires transport with ongoing chest compression.13,15,16

Manual chest compression is immediately available and can be performed with high-quality following appropriate training. Therefore, manual chest compression represent the gold standard. The role of mechanical resuscitation devices is controversial,4,21 and positive effects on the outcome could not be confirmed.4,16,17,21 The use of mechanical resuscitation devices is recommended in selected cases of OHCA, to enable patient transfer with minimal risk for the providers and to ensure high-quality chest compression during transport.21–23 The availability of mechanical resuscitation devices could be useful in the catheter-laboratory, by reducing chest compression provider exposure to radiation during coronary angiography, or in the ICU. But based on the present results it is not an absolute requirement as part of the standard equipment for medical emergency teams.

Providers need to be assured of safety in order to perform adequate resuscitation.24–28 In addition, fatigue may reduce chest compression quality or lead to premature cessation of resuscitation efforts.16,29 Our study shows that chest compression in the ‘kneeling’ positions is particularly suitable for enabling in-hospital transport with on-going resuscitation: these positions allow high-quality chest compression and faster transport than chest compression while the provider walks alongside the bed. In addition, these kneeling positions are perceived as safe, comfortable and less tiring by the providers. Our results are supported by the participants’ recommendation to perform chest compression in a ‘kneeling astride’ position. Thus, use of this position may increase the likelihood of implementation in practice.

The current study has some limitations that need to be acknowledged. Taking part in the study may have influenced the participants and thus altered the results (Hawthorne effect). Furthermore, manikin-based investigations provide only a limited reproduction of reality. Factors influencing resuscitation, such as stress or fatigue during a longer resuscitation period, should be investigated in the future.

Contrary to the manikin with standardised body measurements (pelvic circumference 86 cm), a patient's body habitus may limit the space available on the bed for the chest compression provider to take a kneeling position beside the patient, or the width of the legs may make kneeling astride uncomfortable or impossible. Interindividual variations of the thoracic resistance of patients may also be considered a bias of a simulation-based examination.

It is known that the quality of the chest compression decreases over time. Thus, for longer in-hospital transport times the quality of chest compression may deteriorate over time. Furthermore, chest compression was performed by trained emergency medical personnel (see quality indicators of the control group), but not by members of in-hospital emergency teams. Participants were not specifically trained to carry out CPR while transporting patients in bed before conducting the study. Targeted training may further improve resuscitation quality.

Conclusion

High-quality chest compression is possible during in-hospital transport of patients. The providers should kneel beside or astride the patient on the bed. Not only do these positions allow faster transport and higher quality chest compression than performing chest compression while walking next to the patient's bed, but they are also perceived as safer, more effective and less tiring by the participants. In the future, clinical studies are needed to investigate the potential benefits of early transport of patients for effective curative treatment while CPR is ongoing.

Acknowledgements relating to this article

Assistance with the study: we are grateful for all participating paramedics. We would like to thank Mr Daniel Marx for the creation of the graphics, Mr Marvin Deslandes for revision, Arne Thies for statistical and Mr Oliver Ashworth for the technical support.

Financial support and sponsorship: the work was financed from the study centre's own resources.

Conflicts of interest: EL is the headmaster of the Studieninstitut Westfalen-Lippe training school for paramedics. SR is a medical advisor for Fresenius Kabi Germany, has received honoraria and travel expenses from Amomed Pharma and Orion Pharma.

Presentation: preliminary data of the presented study have in part been presented in abstract form at the 39th International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium, 19 March 2019; the 10th German Interdisciplinary Emergency Medicine Congress, Koblenz, Germany, 21 March 2019; and the German Anesthesia Congress, Leipzig, Germany, 11 May 2019.

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