Measured Progress in Cardiopulmonary Resuscitation
- automated extermal defibrillator
- cardiac arrest
- cardiopulmonary resusciation
- emergency medical services
- sudden cardiac arrest
“…inspiration is easy. Implementation is the hard part.”
–Bob Taylor, Taylor Guitars
Eight months after Kouwenhoven et al1 published their 1960 landmark report of successful closed chest cardiac compressions for 2 children and 2 adults who developed perioperative cardiac arrest,1 a cardiologist provided that same closed chest cardiopulmonary resuscitation (CPR) in the operating suite after my 4-year-old brother experienced cardiac arrest during induction of anesthesia. My brother is alive today because of published resuscitation science applied to practice.
In 1961, Peter Safar proposed combining mouth-to-mouth ventilation with closed chest compressions in a poster for the Pennsylvania chapter of the American Heart Association (AHA), and the ABCs of CPR were born. In 1966, the National Academy of Sciences–National Research Council conference on CPR charged the AHA with teaching CPR to healthcare providers. In 1973, the second conference on CPR and Emergency Cardiovascular Care recommended expanding teaching of CPR to the lay public. This conference also recommended that the AHA establish resuscitation guidelines based on scientific data and develop standards for basic and advanced life support training. The American Red Cross and other organizations, such as the Citizen CPR Foundation, soon supported the lay rescuer CPR training effort. Great enthusiasm existed for the potential of CPR, but little scientific data on which to base recommendations, with more emphasis on teaching CPR skills than on measuring CPR outcomes.
By 1991, the chain of survival provided a metaphor for the priorities of resuscitation and training, emphasizing early bystander recognition of cardiac arrest and access to the emergency medical services system, early CPR, early defibrillation, and early advanced care. Although the 1992 AHA guidelines recommended evaluation of cardiac arrest survival and regular assessment of in-hospital provider resuscitation skills, resuscitation courses still focused on training rather than evaluation of actual resuscitation performance or outcomes.
In the late 1980s and through the 1990s, a few resuscitation centers of excellence (eg, Seattle King County Emergency Medical Services, Pittsburgh Safar Center) provided community outreach, and measured and improved resuscitation outcomes; however, other communities reported low survival and low CPR quality. At the same time, education researchers documented wide variability in training quality and course content, with students often unable to perform CPR skills immediately after course completion. In 2000, concerns about course quality led to widespread adoption of video-based courses to standardize course content and format, quality of skill demonstration, and skill practice time. New emphasis was placed on instructor preparation to improve course quality. The goal was to optimize training to save more lives.
In the 1990s, automated external defibrillators became widely available in communities, adding a powerful resuscitation tool for providers, instructors, students, and researchers. Automated external defibrillators prompt rescuers through the steps of use and enable defibrillation before arrival of emergency medical services providers. The automated external defibrillator recorders document details of resuscitation events, facilitating evaluation of CPR quality. Although some wondered whether automated external defibrillators would render CPR obsolete, it soon became clear that CPR is needed until a shock is delivered (if indicated) and even after defibrillation until return of spontaneous circulation.
The 1990s saw the formation of the International Liaison Committee on Resuscitation (ILCOR), a resuscitation council of councils. ILCOR (http://www.ilcor.org/about-ilcor/about-ilcor/) provides the framework for the world’s resuscitation scientists, clinicians, and educators to meet, share information, reach consensus about published science, and make treatment recommendations.2 ILCOR also develops Utstein templates to standardize reporting of resuscitation outcomes. ILCOR now coordinates an international continuous evidence evaluation process, including an online systematic review website, the Systematic Evaluation and Review System (https://volunteer.heart.org/apps/pico/pages/default.aspx).
In the first years of the new century, national and international out-of-hospital and in-hospital registries were established. They provide a wealth of information characterizing cardiac arrest and outcomes and stimulating additional research. Examples now include out-of-hospital arrest registries such as the Cardiac Arrest Registry to Enhance Survival (https://mycares.net/), the Resuscitation Outcomes Consortium epistry (https://roc.uwctc.org), the European Registry of Cardiac Arrest (https://www.erc.edu/projects/eureka-one), and the All-Japan Utstein Registry (http://circ.ebm-library.jp/trial/doc/c2003232.html). In-hospital resuscitation registries include the Get with the Guidelines-Resuscitation registry (formerly the National Registry of Cardiopulmonary Resuscitation [http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines-Resuscitation/Get-With-The-Guidelines-Resuscitation_UCM_314496_SubHomePage.jsp]) and the Pan-Asian Resuscitation Outcomes Study (https://eparos.org/).
In 2005, publications from the out-of-hospital3 and in-hospital4 settings provided irrefutable evidence that CPR performance by healthcare providers was often poor, with inadequate compression rate and depth and frequent and prolonged interruptions in compressions for rhythm check, defibrillation, and other interventions. These sobering reports spurred emphasis on the provision of high-quality CPR and measuring and debriefing resuscitation performance and outcomes to improve them. In addition, healthcare providers increased focus on preventing cardiac arrest with early warning systems.
In 2007 came documentation of the need for meticulous, protocol-driven postcardiac arrest care to ensure that those who develop return of spontaneous circulation after cardiac arrest can survive neurologically intact to hospital discharge.5 Recognition of the importance of this resuscitation phase led to international adoption of a new link in the chain of survival, post-cardiac arrest care. Specific elements of this postcardiac care supported by recent clinical trials include targeted temperature management and emergency percutaneous coronary intervention.
In 2013, the AHA reformed its three Emergency Cardiovascular Care Subcommittees, creating the Science, the Educational Science and Programs, and the Systems of Care Subcommittees to better align efforts to review the science and develop the guidelines, processes, and programs needed to prevent and optimally treat cardiac arrest. In 2015, the tasks ahead were delineated when the Institute of Medicine published “Strategies to Improve Cardiac Arrest Survival: A Time to Act” (http://www.nationalacademies.org/hmd/Reports/2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx).
The chain of survival remains a useful framework for examining and improving cardiac arrest survival. To increase bystander CPR in the out-of-hospital setting, emergency dispatchers must use protocols to ensure rapid identification of cardiac arrest and rapid initiation of dispatcher-guided CPR. However, dispatchers require training, and their performance must be monitored. If every high school student learns CPR before graduation, then future generations of rescuers will be available to act. If no trained bystanders are present at an arrest, then some communities can also summon nearby volunteer rescuers via mobile phone text messaging.
CPR classroom education is important, but we must leverage technology to enable CPR training to reach well beyond classrooms. On-demand educational opportunities and innovations such as the Hands-Only CPR® airport kiosks, CPR Anytime®, online and virtual learning environments, and realistic simulation can make training available whenever and wherever the lay rescuer or healthcare provider is able to learn and can tailor refresher instruction to meet rescuer need.
More research is needed. We must learn from the “best practices” of centers of resuscitation excellence. Programs with successful community outreach, training, quality improvement, and practice can provide templates for saving lives.
With the current availability of mobile applications at our fingertips, it is unnecessary for every rescuer to recall every resuscitation step in an emergency. Performance support tools, available by smartphone, defibrillators, and other devices, can guide lay rescuers and healthcare providers in critical resuscitation skills, providing feedback and recording CPR quality indicators. Ideally, these devices should be able to upload essential information to a registry.
Survival from cardiac arrest is improving—not by leaps and bounds but by careful attention to detail. Every resuscitation system must establish a process of continuous quality improvement—we cannot improve what we do not measure.
Ms Hazinski receives significant compensation from the AHA to serve as a Senior Science Editor of AHA Guidelines (and Guidelines Updates) for CPR and Emergency Cardiovascular Care and AHA training materials in basic and advanced life support, and Co-Editor of the ILCOR Consensus on CPR and Emergency Cardiovascular Care Science Statements.
Circulation is available at http://circ.ahajournals.org.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
- © 2016 American Heart Association, Inc.
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