Expert Council
Physician/Panel Q&A
Click here to download Q&A Transcript pdf or see below.
The results of the first-ever, multi-national attitudinal survey concerning the performance of CPR by healthcare professionals showed that a mere 25% of healthcare professionals actually perform CPR according to the AHA guidelines.
The results were presented concurrently with the American Heart Association’s (AHA) 2009 Scientific Sessions by a panel of CPR experts, including Robert O’Connor, M.D., University of Virginia Medical Center, Dana Edelson, M.D., The University of Chicago Hospital, and Vinay Nadkarni, M.D., University of Pennsylvania Hospital.
During the panel discussion, these experts discussed the current state of CPR, the discrepancies uncovered by the survey when it comes to perception and reality of how healthcare professionals perform CPR, and ways to improve the quality of CPR performance through training, debriefings and feedback devices.
Q: Are we making progress when it comes to improving CPR performance among healthcare professionals?
Dr. Edelson: Over the past four years, we’ve implemented multiple programs in my institution to try to improve CPR quality. We instituted instantaneous feedback, along with debriefing, and saw improvement in CPR quality. Now, CPR quality, in terms of compression depth and rate and ventilation rate, is significantly better. We get a pulse back in almost 60 percent of cases, which is a 50 percent improvement in pulse rate, compared to 40 percent prior to implementing these programs.
Q: Can training result in chest compressions that are closer to the ideal rate?
Dr. Edelson: Yes, if you train people to deliver the proper rate of compressions it can be done. Almost 100 percent of people deliver the proper depth post training.
There were a couple of scientific papers that came out a few years ago which stated that EMS chest compressions were not being delivered about 50 percent of the time, even when they accounted for legitimate reasons to have the responder’s hands off of the chest. The assumption was that CPR performance is better in the hospital; however, in a mannequin simulation, when the providers tried to adhere to the guidelines, they spent more time off the chest than on the chest.
As important as CPR is to survival, defibrillation is also important because longer interruptions between CPR and defibrillation decrease survival rates. The good thing is that the survey showed that 93 percent of the respondents understood that the amount of hands off time is something that should be minimized.
Q: Let’s talk about the survey findings. Is it the reality that a lot of centers are not using feedback, and if so, what can you suggest in terms of trainings - training on the unit or debriefing?
Dr. O’Connor: I think you’re shedding light on the gap between perception and performance, which is a very common phenomenon. This is another example of where, when one has a tool to measure what one is doing, when one becomes aware of the importance and the ability to change that.
Therefore, perception meeting performance and those two fitting together I think is what I’m reading from the results. In my own experience, in my own hospital, we have the same phenomenon: When we first measured and used several measuring devices to track depth rate interruptions of chest compressions and follow these up on the chest by the four components that you just talked about, we thought we were doing a very good job.
However, what we found was that even people who did it well, who had about a 77 percent compliance with guidelines, when they turned on the feedback and listened to the debriefings, the performance improved to 88 percent compliance. So I believe there is hope that we can improve, but it seems that we need some help to be able to figure out just how to comply with the guidelines.
Q: How do you handle debriefing and ongoing training with your team in the hospital?
Dr. Edelson: Resuscitation is surprisingly complicated. There are so many moving pieces, so many things that need to happen at the same time. All of these things have to happen quickly and at the same time, somebody’s life depends on it.
We know for example with chest compressions, that if they do CPR for a while and if you ask them at what point they got tired and that compression has got shallow, they say about seven minutes into the simulation. However, we can tell – in terms of their actual compressions - that after one minute, there is decay already.
We can’t be expected to be reliable in a setting like that to objectively evaluate our own performance.
Q: Have you found that your staff is very willing to learn, that they seem to welcome the additional training?
Dr. Nadkarni: When we first set out to track and debrief, we were very concerned that the practitioners would feel like Big Brother was watching them and that they wouldn’t want that. They have been doing this for 15 or 20 years and they know how to do it. And why is somebody now coming and trying to criticize what they are doing?
But in some ways it was a wake-up-call for us, for those who make the guidelines, to listen to the perceptions that are out there, and to be careful not to overload with too many instructions, but to try to hone in on those most key things.
Once those principles are sort of recognized and embraced, then you convince the staff. In our hospital my personal experience has been that once you are amongst them and have convinced them, that you really are after those principles of resuscitation and you are not there to just test them on the specific number of compressions.
Q: How do you employ feedback and debriefing and make the distinctions between the two?
Dr Edelson: We make that distinction that feedback is given in real-time, and debriefing is post-event. In our institution, we don’t do it immediately after an event. We think about it as a “Monday morning quarterback session”. One of the nice things that these monitoring devices allow you to do is to actually extract that data later.
Q: Could you talk about stationary CPR versus movement, for example in stairs, to the ambulance, etc.?
Dr. O’Connor: We have started to run the entire resuscitation on site until we get the pulse back or not. It’s been well documented that you can’t do CPR in the back of an ambulance. You are also exposing the providers to potential harm. It’s an unstable environment for instance if you crash or take a turn too fast.
I think that leads to that perception and some of the additional recognition that some tools, feedback and debriefing can help with identifying those times when they are at the highest risk to be “dropping the ball.” Maybe there is an opportunity in the future to use automated devices etc. to somehow alert you when you are over-breathing or under-breathing/over-compressing or under-compressing.
Q: Let’s talk some more about the survey and any potential biases.
Dr. Edelson: This survey offers the best case scenario for bias. People who are more apt to respond are the people who are more passionate about CPR, so with for example the statistic that 15 percent of people use instantaneous feedback, the percentage is likely to be higher than in reality.
Q: What about the country comparisons the survey makes?
Dr. Nadkarni: When looking at the results of the survey, it was tempting to draw comparisons, but in reality there were more similarities across the globe than expected. This underscores the fact that it’s a global issue at least in the countries that were surveyed.
Q: How would you evaluate the role of feedback on patient safety?
Dr. Nadkarni: Particularly in communities where survival rates are low and very few systems are in place, implementing the systematic approach and using the tools that are available to improve the quality of the process of care of CPR can make for the very dramatic doubling and quadrupling of survival. Where systems are already in place and working well, it is difficult to implement small changes and make a difference. Perhaps we have to be more artful at understanding the physiology of the patient and guiding the resuscitation to that.
Dr. Edelson: I think the future is bright, and I think we can use these tools to personalize our care, to improve it. It will be global improvements just by the process of implementing a quality improvement process; it’s a global problem, but a local solution. I think in almost every case, I’m sure that the solutions that seem to have worked in your hospital are the same principles that are working in my hospital, but the individual interventions have been very different. I don’t think there’s a simple “one size fits all solution” that’s likely to solve the problem.
Q: How can we create an improvement plan for the local hospital?
Dr. Edelson: Every system is different and you need to understand how it’s different to create the best plan. First you need to measure where you are at, know that you have a problem, design a plan that fits your system, institute that plan and then continue to measure for feedback and tweak the plan.
We are fortunate now to be in a position where we have the tools to be able to measure where we are so that we are able to tweak and find the best system for the individual hospitals. The key to aiding practitioners implement the guidelines is to use measurement/feedback tools and to keep it simple. The key to really being able to aid CPR practitioners do their job better is learning exactly who they are and what their current perceptions of good CPR are.
The science of resuscitation itself is very crude and in the early stages of development; the science of implementation is even younger. It’s important to realize that it takes a long time from when the guidelines are issued to them actually being implemented and embraced. We can accelerate the take-up and implementation of the guidelines by encouraging the use of quality measurement/feedback tools to coach and train people to do a better job.
Keeping it simple and reminding practitioners frequently and routinely of the key guidelines is also vital. Simplicity is key as it’s too difficult to think about lots of complicated actions when in the midst of performing CPR.
Click here to download detailed survey results.
