Keys to Boosting CPR Quality

Dr. Bentley J. Bobrow discusses the lessons for employers in a study that involved resuscitation training and AEDs that provide real-time CPR feedback.

A recent study that tested a method for improving EMTs' performance of cardiopulmonary resuscitation has important lessons for how trained responders in the workplace can be taught to perform it better, said Dr. Bentley J. Bobrow, M.D., FACEP, medical director for the Arizona Department of Health Services' Bureau of EMS and Trauma System. He is the study's lead author.

"We're learning more and more just how important CPR quality is. To not just do CPR, but to do CPR well, and what exactly does that mean," Bobrow said. "There is mounting evidence that there is an enormous difference between outcomes for cardiac arrest victims when they have good-quality CPR and bad-quality CPR. It's also really challenging to do high-quality CPR, we think especially without the assistance of some technology that can help people do high-quality CPR."

CPR is a complex series of motor skills that is challenging even for those who are expert at it, let alone for someone who takes courses every few years and never has the opportunity to practice and receive feedback, he said.

The study, published online recently by Annals of Emergency Medicine, involved scenario-based resuscitation training and a "pit crew" model, with specified roles for those on the responder team, utilized by the Mesa Fire and Medical Department in Mesa, Ariz. The EMTs used AEDs that provided real-time audio and visual feedback on their performance, and they participated in debriefing sessions. Bobrow described these as "a very teachable moment" when those who have performed CPR are motivated to improve their performance the next time. The Mesa EMTs received one-page, graphical depictions of how well they had done it.

The combination was stunningly successful, Bobrow and his colleagues found. "We more than doubled survival, and this is remarkable, especially because the survival rate in this city was already significantly higher than the national average. And their survival rate in the post period, after they implemented, was 56 percent. More than one out of two people who had a sudden cardiac arrest, and their heart was in ventricular fibrillation when the EMS providers got there, more than one out of two of those patients survived and went home with their families."

While it tested this method for only a brief period, the study sheds light on how companies can keep people proficient in recognizing cardiac arrest and knowing how to do high-quality CPR and how to use a public access defibrillator. "It's not a complex problem. It's really just an implementation and training issue," Bobrow said. "You really want people to understand what to do. You can learn bystander CPR very briefly, but you're unlikely to use it for a long, long, long time, sometimes years later."

Another important element is training dispatchers to do what he called "just-in-time training." They're trained to question callers accurately to determine whether someone is in cardiac arrest and to engage callers to get them to perform CPR.

"I personally think that CPR quality needs improvement everywhere. I've seen enough real-life CPR to know it's really, really difficult to do. I'm not saying everyone will achieve these results; some might achieve better results. But I think that we can dramatically improve our CPR quality, and that will lead to a significant improvement in survival," Bobrow said. "Across the country, if we did this, we would likely have thousands -- if not tens of thousands -- of survivors a year from cardiac arrest if we implemented this type of CPR quality improvement program everywhere. It's very doable."

Just doubling the current national rate of sudden cardiac arrest survival, which is only about 8 percent, could save 50,000 people per year, he said.

To read the study, "The Influence of Scenario-Based Training and Real-Time Audiovisual Feedback on Pre-hospital Cardiopulmonary Resuscitation Quality and Survival from Out-of-Hospital Cardiac Arrest," visit http://tinyurl.com/a6455n6.

Improving Lay Rescuers' CPR
The 2010 American Heart Association guidelines stress high-quality CPR, and a new AHA guideline statement explaining how to measure and achieve high-quality CPR is imminent, Bobrow said.

Achieving it with lay rescuers is a challenge, but AEDs are available that provide real-time feedback. Asked whether the training that worked so well for the EMTs could somehow be given to members of the general public, Bobrow mentioned lay rescuers who are trained in teams to respond on site. "They should do simulations, and they should do them frequently. The model is really to do frequent, small simulations." He said he knows of one hospital that placed a manikin on a cart and moved it around so employees could perform a few minutes of CPR practice each month. "That's really what needs to happen," he said.

SHARE, Save Hearts in Arizona Registry and Education, is a statewide program the bureau started in 2004 with the goal of having Arizona achieve the world’s best survival rate from cardiac emergencies. SHARE's website (www.azshare.gov) is a trove of CPR and AED information and resources for schools, businesses, the public, emergency medical services, and hospitals, including an invitation for businesses to be recognized as "Heart Safe."

Also on the site are stories from some of the more than 1,000 sudden cardiac arrest survivors in Arizona.

'It's the Difference Between Life and Death'
One of the stories recounts Kathy Sekardi's sudden cardiac arrest episode on Aug. 1, 2012. Sekardi, 53 at the time, works in downtown Phoenix for a state agency. Stricken during the lunch hour, she was saved by co-workers who performed CPR and a facility manager who quickly arrived with an AED, along with Phoenix Fire Department EMTs and medical personnel at St. Joseph's Hospital and Medical Center. Sekardi said she'd had no health issues before that day.

She returned to work six weeks later. "When this whole thing happened, I didn't realize until I actually came back to work how traumatizing this was to a lot of my co-workers who not only witnessed this but worked on me and were in the office, and they were aware of everything that was going on," she said during an April 18 interview. "I'm really grateful that my agency even brought in some counselors for people to speak with them, which I thought was a great idea.

"I know that some of my co-workers went and visited their doctors afterward to make sure that they were okay. We've taken CPR classes. Our agency is also making sure that a couple of times a year, these classes are available for anybody who wants to take them, and it's hands on," she continued. "When you go to work, you never think you may never come back home. That's something I'm very, very aware of these days. And any time I go anywhere, I think, 'Where are the AED units? Do they have them? How can I position myself?' And I'm always looking for the opportunity in case this should happen to somebody else.... I'm glad that my family knows what to do now, a lot of my friends know what to do now. I've posted on Facebook different training videos and what people should be looking for."

Speaking about AEDs, Sekardi said, "I would think, if I were an employer, 'I want my people to go home at the end of the day.' And if costs $1,200 for a machine to give you the peace of mind to know that if this kind of an event is going to happen on your floor, for goodness sakes ... this simple, little machine could be the difference in them going home at night, or going to the hospital. It's the difference between life and death, and that is everything."

This article originally appeared in the June 2013 issue of Occupational Health & Safety.

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