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Feedback for CPR quality

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest in any setting (P), does real-time feedback and prompt device regarding the mechanics of CPR quality (e.g. rate and depth of compressions and/or ventilations) (I), compared with no feedback (C), change survival with favorable neurologic outcome, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, bystander CPR rates, time to first compressions, time to first shock, CPR quality (O)?
Consensus on Science:
This review identified 12 studies, of which 2 studies were randomized studies(Bohn 2011, 257; Hostler 2011, d512) and 10 studies were observational of before-after design studies.(Kern 1992, 145; Berg 1994, 35; Chiang 2005, 297; Kramer-Johansen 2006, 283; Abella 2007, 54; Niles 2009, 553; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50; Sutton 2014, 70) The included studies were 9 studies in 3716 adults(Kern 1992, 145; Chiang 2005, 297; Kramer-Johansen 2006, 283; Abella 2007, 54; Bohn 2011, 257; Hostler 2011, d512; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50) and 3 studies of 34 pediatric patients.(Berg 1994, 35; Niles 2009, 553; Sutton 2014, 70) Four studies included patients with in-hospital cardiac arrest,(Berg 1994, 35; Abella 2007, 54; Niles 2009, 553; Sutton 2014, 70) 7 studies with OHCA(Chiang 2005, 297; Kramer-Johansen 2006, 283; Bohn 2011, 257; Hostler 2011, d512; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50) and 1 study(Kern 1992, 145) had a mixture of patients from in and out-of-hospital settings. Feedback devices examined included accelerometer-based devices(Kramer-Johansen 2006, 283; Abella 2007, 54; Niles 2009, 553; Bohn 2011, 257; Hostler 2011, d512; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50; Sutton 2014, 70) and audiotape of prompts.(Kern 1992, 145; Berg 1994, 35; Chiang 2005, 297) Compared with the previous evidence review performed in 2010, this review identified 8 new studies that were included for analysis.(Kramer-Johansen 2006, 283; Niles 2009, 553; Bohn 2011, 257; Hostler 2011, d512; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50; Sutton 2014, 70) The nature of using feedback or prompt devices meant that all studies suffered from performance and detection bias because healthcare professionals were not blinded to intervention (feedback or no feedback). For the critical outcome of favorable neurologic outcome, we identified moderate-quality evidence from 1 cluster-randomized study(Hostler 2011, d512) representing 1586 patients, and very-low-quality evidence from 2 observational studies in adults(Bobrow 2013, 47; Sainio 2013, 50) representing 670 patients. All studies were downgraded due to risk of bias. The randomized trial found no difference in the number of patients who achieved favorable neurologic outcome (control 10.1% versus 10.3%, P=0.855). No studies showed a statistically significant difference in favorable neurologic outcome with the use of CPR feedback. Effect of CPR feedback on survival with favorable neurologic outcome ranged from −0.8 to 5.8%. For the critical outcome of survival to hospital discharge, we identified moderate-quality evidence from 1 cluster-randomized study(Hostler 2011, d512) representing 1586 patients, and very-low-quality evidence from 4 observational studies in adults,(Kramer-Johansen 2006, 283; Abella 2007, 54; Bobrow 2013, 47; Sainio 2013, 50) and 1 observational study in children(Sutton 2014, 70) representing 1192 patients. All studies were downgraded due to risk of bias. The randomized trial found no difference in the number of patients who achieved survival to hospital discharge (control 44.7% versus 44.3%, P=0.962). No studies showed a statistically significant difference in survival to hospital discharge with the use of CPR feedback. The effect of CPR feedback on survival to hospital discharge ranged from −0.9 to 5.2. For the critical outcome of ROSC, we identified moderate-quality evidence from 2 randomized studies(Bohn 2011, 257; Hostler 2011, d512) representing 1886 patients, and very-low-quality evidence from 7 observational studies in adults(Chiang 2005, 297; Kramer-Johansen 2006, 283; Abella 2007, 54; Bohn 2011, 257; Lukas 2012, 1212; Bobrow 2013, 47; Sainio 2013, 50) and 1 observational study in children(Sutton 2014, 70) representing 3447 patients. All studies were downgraded due to risk of bias. The randomized trial found no difference in the number of patients who achieved ROSC (control 44.7% versus 44.3%, P=0.962). Only 1 study(Sainio 2013, 50) showed a statistically significant difference in ROSC with the use of feedback; however, in this study, feedback was activated at the discretion of the physician, and no details were provided regarding the decision-making process to activate or not activate feedback. Effect of CPR feedback on ROSC ranged from −4.4% to 17.5%: 1 study demonstrated a 50% increase in ROSC with CPR feedback; however, this small study had only 4 patients in each group.(Sutton 2014, 70) For the important outcome of chest compression rate, we identified moderate-quality evidence from 2 randomized studies(Bohn 2011, 257; Hostler 2011, d512) representing 1474 patients, and very-low-quality evidence from 4 observational studies: 3 in adults(Kramer-Johansen 2006, 283; Abella 2007, 54; Bobrow 2013, 47) representing 777 patients, and 1 in children(Sutton 2014, 70) representing 8 patients. All studies were downgraded due to risk of bias. The cluster RCT(Hostler 2011, d512) found a significant difference of −4.7/min (95% CI, −6.4 to −3.0/min) when feedback was used, and the prospective randomized trial(Bohn 2011, 257) showed no difference in compression rates with and without feedback. In both randomized trials, compression rates were all close to international recommendations of 100/min. One observational study(Abella 2007, 54) showed no difference in chest compression rates with and without feedback, and, again, all compression rates were close to international recommendations of 100/min. The other 2 observational studies(Kramer-Johansen 2006, 283; Bobrow 2013, 47) showed lower compression rates in the group with CPR feedback: 128 to 106/min (difference, −23; 95% CI, −26 to −19)(Bobrow 2013, 47) and 121 to 109/min (difference, −12; 95% CI, −16 to −9).(Kramer-Johansen 2006, 283) The pediatric study(Sutton 2014, 70) found a median difference of −10/min with feedback, and, again, the chest compression rate in the control group exceeded 120/min. The use of CPR feedback devices may be effective in limiting compression rates that are too fast. For the important outcome of chest compression depth, we identified moderate-quality evidence from 2 randomized studies(Bohn 2011, 257; Hostler 2011, d512) representing 1296 patients, and very-low-quality evidence from 4 observational studies: 3 in adults(Kramer-Johansen 2006, 283; Abella 2007, 54; Bobrow 2013, 47) representing 777 patients and 1 in children(Sutton 2014, 70) representing 8 patients. All studies were downgraded due to risk of bias. The cluster RCT(Hostler 2011, d512) found a significant +1.6 mm (95% CI, 0.5–2.7) (cluster adjusted) difference in chest compression depth with feedback. However, this is of questionable clinical significance, and the average compression depths in both arms were less than international recommendations of 5 cm (2 inches) in adults (3.96 cm [1.55 inches] and 3.87 cm [1.52 inches]). The prospective randomized trial(Bohn 2011, 257) found no significant difference in compression depth with and without feedback, and all compression depths were close to, but slightly less than, international recommendations of 5 cm (2 inches) in adults. One observational study(Abella 2007, 54) showed no difference in chest compression depth with and without feedback, and all compression rates were close to, but less than, international recommendations of 5 cm (2 inches) in adult patients (4.4 and 4.3 cm or 1.7 inches). Two observational studies(Kramer-Johansen 2006, 283; Bobrow 2013, 47) showed significantly deeper chest compressions in the groups with CPR feedback: Bobrow et al(Bobrow 2013, 47) found a 1.06 cm (0.42 inches) increase with feedback (5.46 versus 4.52 cm, or 2.15 versus 1.78 inches) (mean difference, 0.97 cm; 95% CI, 0.71–1.19 cm), while the findings by Kramer-Johansen(Kramer-Johansen 2006, 283) were more modest (3.4–3.88 cm, or 1.3–1.5 inches) (mean difference, 0.4 cm; 95% CI, 0.2–0.6). The pediatric study(Sutton 2014, 70) found no median difference in compression depth. The use of CPR feedback devices did not seem to make an appreciable difference in chest compression depth. For the important outcome of chest compression fraction, we identified moderate-quality evidence from 1 randomized study(Hostler 2011, d512) and very-low-quality evidence from 3 observational studies in adults(Kramer-Johansen 2006, 283; Abella 2007, 54; Bobrow 2013, 47) and 1 in children.(Sutton 2014, 70) All studies were downgraded due to risk of bias. The randomized study found a cluster adjusted difference of +1.9% (65.9% versus 64.0%; P=0.016) when CPR prompt devices were used. Although statistically significant, such a small difference has questionable clinical significance. The adult studies found no significant difference between groups, and the sample size of the pediatric study was too small to enable inferential statistical analysis. The use of CPR feedback devices did not seem to make an appreciable difference in chest compression fraction. For the important outcome of ventilation rate, we identified very-low-quality evidence from 3 observational studies in adults(Kramer-Johansen 2006, 283; Abella 2007, 54; Bobrow 2013, 47) representing 532 patients. All studies were downgraded due to risk of bias. None of the studies showed a significant difference in ventilation rate with and without CPR feedback. For the important outcome of ETCO2, we identified very-low-quality evidence from 2 observational studies in adults(Kern 1992, 145; Bobrow 2013, 47) representing 131 patients. All studies were downgraded due to risk of bias. Kern(Kern 1992, 145) found that the ETCO2 was significantly higher when CPR feedback was used (+6.3 mm Hg with compression rate feedback of 120/min and +4.3 mm Hg with compression rate feedback of 80/min). Bobrow(Bobrow 2013, 47) found an absolute difference of −2.2 mm Hg with CPR feedback. The clinical significance of these differences is questionable. For the important outcome of leaning force during chest compressions, we identified very-low-quality evidence from 1 observational study in children(Niles 2009, 553) representing 20 patients. This study was downgraded due to risk of bias. Leaning force was decreased by 0.9 kg with the use of feedback.
Treatment Recommendation:
We suggest the use of real-time audiovisual feedback and prompt devices during CPR in clinical practice as part of a comprehensive system for care for cardiac arrest (weak recommendation, very-low-quality evidence). We suggest against the use of real-time audiovisual feedback and prompt devices in isolation (ie, not part of a comprehensive system of care) (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on development of systems of care with continuous quality improvement than on cost. Resource-poor environments may choose not to adopt this technology in favor of allocating resources to other system developments. Devices that provide real-time CPR feedback also document CPR metrics that may be used to debrief and inform strategies aimed at improving CPR quality. Currently available audiovisual feedback devices provide information on key CPR parameters such as compressions and ventilation; however, the optimal targets and the relationships among different targets have not been fully defined.
CoSTR Attachments:
2015_01_05 ILCOR CPR feedback Evidence tables.doc    

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