CPR Good to Great

As part of a 2006 study on the force needed to achieve proper CPR compression depth,5 researchers confirmed something that you might consider obvious. Every patient’s chest resistance is different. Age and gender are factors. So is individual patient physiology. Of course.

Is it that obvious, though? According to the AHA, the majority of literature analyzing CPR performance suggests that rescuers often do not compress the chest deeply enough despite recommendations.4 If it is clear that every patient’s chest resistance is different, practitioners may still not be translating this into action during CPR. Real-time feedback can be part of the support practitioners need to ensure quality CPR, chest resistance notwithstanding.

Not only did the study validate that every patient’s chest resistance is different, it confirmed that chest stiffness decreases significantly with an increasing number of compressions performed during CPR.4 In 2006, that finding may not have struck practitioners as it might today. In 2006, there was no upper limit on compression depth. Post-2015 AHA Guidelines, there is: 2–2.4 inches for adults and adolescents.

If this seems overwhelming, keep in mind the objective of creating the best possible conditions for defibrillation success. The science shows that shallower compressions are associated with a decrease in defibrillation success. And, research published by the AHA suggests that compressions at a depth >2 inches may improve defibrillation success.4 The upper limit was added to deter injuries.6

Given that real-time feedback is now a readily available technology, achieving the right compression depth and setting the stage for defibrillation success should not be a guessing game. If you or your colleagues have ever felt like it is a guessing game, introducing real-time feedback into your program can help to eliminate that feeling.

There is a variety of technology available to aid practitioners in meeting some or all of the five key metrics recommended by the AHA for delivering quality CPR. We support any means that enables practitioners such as yourself to save lives.

You’ve likely heard or used the phase, “I’m not in the loop”? “Sorry, I missed that detail. I’m not in the loop.” This expression comes from the U.S. Air Force concept of a “control loop” known as the OODA loop. OODA stands for Observe, Orient, Decide, Act.

When a pilot says he or she is “out of the loop,” it means being out of the control loop. The pilot can no longer observe, orient, decide, and/or act. Being out the OODA loop is a common risk associated with flying on autopilot. The pilot can unknowingly surrender autonomy and ownership to the autopilot feature.

The risk is the pilot will become disengaged from the OODA loop. He or she can become subject to a “vigilance decrement.” This refers to the finding that it is extremely difficult for humans to accurately monitor a repetitive process for long periods of time. The better an automated process works, the more it may encourage the user to zone out. The paradox is that in order to ensure safe operation,
the process still requires the user’s continuous attention.7 “Mode confusion” can develop, leading a user to believe that an automated process is working correctly when in fact it may not be.

Practitioner or pilot, both are high stakes roles in which autonomy and ownership are critical to success. Real-time feedback by its nature gives practitioners little choice but to be engaged in the OODA loop, which improves situational awareness, team performance, and individual attention to detail during CPR.

The adage, “if you don’t measure it, you can’t improve it” applies directly to monitoring CPR quality.4 The organizations most successful in improving outcomes from sudden cardiac have not only used real-time feedback during CPR, but have made the results of that feedback available for immediate and long-term review.

The AHA believes so strongly in this that it recommends that every EMS system, hospital, and other professional rescuer program should have an ongoing CPR CQI (Continuous Quality Improvement) program that provides feedback to the director, managers, and providers. CPR CQI programs can and should implement systems to acquire and centrally store metrics of CPR performance.4

That kind of program might seem like an undertaking, but the technology exists in today’s real-time feedback environment to record and easily provide the kind of feedback the AHA recommends. Among the benefits of integrating data from real-time feedback into an overall CQI program is that it gives providers an opportunity to focus on a long-term vision with long-term goals. Maximizing performance on the five key metrics of quality CPR becomes not only critical to each individual patient case but to the overall success and esprit of the organization. The use of real-time feedback as part of CQI effort is part of where King County EMS earns its credibility in its vision that “Everyone in VF survives."