Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest

A Science Advisory for the Public From the American Heart Association Emergency Cardiovascular Care Committee

Michael R. Sayre, MD; Robert A. Berg, MD, FAHA; Diana M. Cave, RN, MSN; Richard L. Page, MD, FAHA; Jerald Potts, PhD, FAHA; Roger D. White, MD

Key Words: AHA Scientific Statement • cardiopulmonary resuscitation • death, sudden • heart arrest • resuscitation

Introduction
Bystanders who witness the sudden collapse of an adult should activate the emergency medical services (EMS) system and provide high-quality chest compressions by pushing hard and fast in the middle of the victim’s chest, with minimal interruptions. This recommendation is based on evaluation of recent scientific studies and consensus of the American Heart Association Emergency Cardiovascular Care (ECC) Committee. This science advisory is published to amend and clarify the "2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)" for bystanders who witness an adult out-of-hospital sudden cardiac arrest.

Ten years ago, the AHA commissioned a working group of resuscitation scientists to reappraise the Association’s inclusion of ventilations in the recommended sequence for bystander cardiopulmonary resuscitation (CPR). The working group evaluated peer-reviewed reports of laboratory and human research and summarized their findings in a 1997 statement. The key conclusion of that statement was that "Current guidelines for performing mouth-to-mouth ventilation during CPR should not be changed at this time."

In the animal studies cited in the 1997 statement, when ventricular fibrillation arrest was of short (under 6 minutes) duration, the addition of rescue ventilations to chest compressions did not improve outcome compared with chest compressions alone (LOE 6*). Analysis of human data from a national out-of-hospital CPR registry documented no survival advantage to ventilations plus compressions compared with the provision of chest compressions alone during bystander resuscitation (LOE 4*). Although these studies were not deemed sufficient to justify the elimination of ventilations from the bystander CPR sequence, the 1997 statement strongly encouraged further research that would focus on "...the timing, rate, and depth [of ventilations] as well as conditions under which respiratory assistance should be used." The statement also recommended "...more research on real-world obstacles to learning, remembering, and actually performing CPR..." In addition, the statement contained a secondary conclusion that "...provision of chest compression without mouth-to-mouth ventilation is far better than not attempting resuscitation at all."

The AHA’s recent Guidelines for CPR and ECC have reflected the primary and secondary conclusions of the 1997 statement: "Laypersons should be encouraged to do compression-only CPR if they are unable or unwilling to provide rescue breaths (Class IIa), although the best method of CPR is compressions coordinated with ventilations." In addition, the Guidelines have recommended compression-only CPR for dispatcher-assisted instructions for untrained bystanders."

The "2005 AHA Guidelines for CPR and ECC" noted the need to increase the prevalence and quality of bystander CPR. The Guidelines and training materials emphasized the importance of the delivery of high-quality chest compressions, that is, compressions of adequate rate and depth with full-chest recoil and minimal interruptions. To limit the frequency of interruptions, these Guidelines recommended an increased compression-to-ventilation ratio of 30:2 for adult victims. In addition, the AHA courses increased student practice of high-quality chest compressions with interruptions (including interruptions to deliver rescue breaths) limited to 10 seconds or less.

The purpose of this science advisory is to clarify and elaborate on the "2005 AHA Guidelines for CPR and ECC," with a summary of research published since 2005. In this advisory, the studies that were reviewed in preparation for the AHA’s 2000 and 2005 CPR and ECC guidelines are denoted with an asterisk (*). The peer-reviewed studies that have been published since the "2005 AHA Guidelines for CPR and ECC" update are denoted by a double asterisk (**). This advisory uses the Level of Evidence classification scheme developed for the "2005 AHA Guidelines for CPR and ECC."

Chest Compression Rates During Cardiopulmonary Resuscitation Are Suboptimal

A Prospective Study During In-Hospital Cardiac Arrest

Benjamin S. Abella, MD, MPhil; Nathan Sandbo, MD; Peter Vassilatos, MS; Jason P. Alvarado, BA; Nicholas O’Hearn, RN, MSN; Herbert N. Wigder, MD; Paul Hoffman, CRT; Kathleen Tynus, MD; Terry L. Vanden Hoek, MD; Lance B. Becker, MD

From the Emergency Resuscitation Center and Section of Emergency Medicine (B.S.A., J.P.A., T.L.V.H., L.B.B.), Section of Pulmonary and Critical Care (N.S.), and Department of Critical Care (N.O.), University of Chicago Hospitals, Chicago, Ill; Department of Computer Science (P.V.), University of Chicago, Chicago, Ill; Department of Emergency Medicine (H.N.W.) and Respiratory Care Services (P.H.), Advocate Lutheran General Hospital, Park Ridge, Ill; and Department of Internal Medicine (K.T.), MacNeal Hospital, Berwyn, Ill.

Correspondence to Dr L.B. Becker, University of Chicago Hospitals, Section of Emergency Medicine, 5841 S Maryland Ave, MC 5068, Chicago, IL 60637. E-mail lbecker@medicine.bsd.uchicago.edu

Received June 23, 2004; revision received October 8, 2004; accepted October 22, 2004.

Abstract
Background— Recent data highlight a vital link between well-performed cardiopulmonary resuscitation (CPR) and survival after cardiac arrest; however, the quality of CPR as actually performed by trained healthcare providers is largely unknown. We sought to measure in-hospital chest compression rates and to determine compliance with published international guidelines.

Methods and Results— We developed and validated a handheld recording device to measure chest compression rate as a surrogate for CPR quality. A prospective observational study of adult cardiac arrests was performed at 3 hospitals from April 2002 to October 2003. Resuscitations were witnessed by trained observers using a customized personal digital assistant programmed to store the exact time of each chest compression, allowing offline calculation of compression rates at serial time points. In 97 arrests, data from 813 minutes during which chest compressions were delivered were analyzed in 30-second time segments. In 36.9% of the total number of segments, compression rates were <80 compressions per minute (cpm), and 21.7% had rates <70 cpm. Higher chest compression rates were significantly correlated with initial return of spontaneous circulation (mean chest compression rates for initial survivors and nonsurvivors, 90±17 and 79±18 cpm, respectively; P=0.0033).

Conclusions— In-hospital chest compression rates were below published resuscitation recommendations, and suboptimal compression rates in our study correlated with poor return of spontaneous circulation. CPR quality is likely a critical determinant of survival after cardiac arrest, suggesting the need for routine measurement, monitoring, and feedback systems during actual resuscitation.

Key Words: cardiopulmonary resuscitation • death, sudden • heart arrest

Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation

Jim Christenson, MD; Douglas Andrusiek, MSc; Siobhan Everson-Stewart, MS; Peter Kudenchuk, MD; David Hostler, PhD; Judy Powell, BSN; Clifton W. Callaway, MD, PhD; Dan Bishop; Christian Vaillancourt, MD, MSc; Dan Davis, MD; Tom P. Aufderheide, MD; Ahamed Idris, MD; John A. Stouffer; Ian Stiell, MD, MSc; Robert Berg, MD; the Resuscitation Outcomes Consortium Investigators

From the University of British Columbia (J.C., D.A.), Vancouver, British Columbia, Canada; Emergency and Health Services Commission of British Columbia (J.C., D.A., D.B.), Vancouver, British Columbia; University of Washington (S.E.-S., P.K., J.P.), Seattle, Wash; University of Pittsburgh (D.H., C.W.C.), Pittsburgh, Pa; Department of Emergency Medicine (C.V., I.S.), University of Ottawa, Ottawa, Ontario, Canada; University of California at San Diego (D.D.); Medical College of Wisconsin (T.P.A.), Milwaukee, Wis; University of Texas Southwestern Medical Center at Dallas (A.I.); Central Washington University (J.A.S.), Ellensburg, Wash; and University of Arizona (R.B.), Tucson, Ariz.

Correspondence to Dug Andrusiek, MSc, Emergency and Health Services Commission of British Columbia, 302–2955 Virtual Way, Vancouver, British Columbia, Canada V5M 4X6. E-mail dug.andrusiek@gov.bc.ca

Received January 23, 2009; accepted July 10, 2009.

Abstract

Background— Quality cardiopulmonary resuscitation contributes to cardiac arrest survival. The proportion of time in which chest compressions are performed in each minute of cardiopulmonary resuscitation is an important modifiable aspect of quality cardiopulmonary resuscitation. We sought to estimate the effect of an increasing proportion of time spent performing chest compressions during cardiac arrest on survival to hospital discharge in patients with out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia.

Methods and Results— This is a prospective observational cohort study of adult patients from the Resuscitation Outcomes Consortium Cardiac Arrest Epistry with confirmed ventricular fibrillation or ventricular tachycardia, no defibrillation before emergency medical services arrival, electronically recorded cardiopulmonary resuscitation before the first shock, and a confirmed outcome. Patients were followed up to discharge from the hospital or death. Of the 506 cases, the mean age was 64 years, 80% were male, 71% were witnessed by a bystander, 51% received bystander cardiopulmonary resuscitation, 34% occurred in a public location, and 23% survived. After adjustment for age, gender, location, bystander cardiopulmonary resuscitation, bystander witness status, and response time, the odds ratios of surviving to hospital discharge in the 2 highest categories of chest compression fraction compared with the reference category were 3.01 (95% confidence interval 1.37 to 6.58) and 2.33 (95% confidence interval 0.96 to 5.63). The estimated adjusted linear effect on odds ratio of survival for a 10% change in chest compression fraction was 1.11 (95% confidence interval 1.01 to 1.21).

Conclusions— An increased chest compression fraction is independently predictive of better survival in patients who experience a prehospital ventricular fibrillation/tachycardia cardiac arrest.

Key Words: heart arrest • cardiopulmonary resuscitation • fibrillation • survival

A SUMMATIVE EVALUATION OF AN EMS PARTNERSHIP AIMED AT REDUCING ED LENGTH OF STAY

Introduction: Freestanding emergency departments are full-service emergency departments with no attached inpatient facility. ED congestion and patient dissatisfaction may occur as patients requiring admission are waiting for ambulance arrival and transfer. A partnership between a freestanding emergency department and a private ambulance company was developed in order to reduce ambulance response times and ultimately ED length of stay. The aim of this manuscript was to describe the Partnership in Care program and evaluate the program’s effectiveness.
Methods: The study used a pre-post/post-test summative evaluation design. A retrospective chart review was done for all patients discharged from the freestanding emergency department by the partnered ambulance company during the pre-test period, April 2004 to June 2004, and the post-test period, April 2005 to June 2005. Data variables included time of triage, time ambulance requested, time ambulance arrived, and discharge time. Institutional Review Board approval was obtained.
Results: There were 507 patients transported at discharge by the ambulance company. There was a 5-minute increase for mean ED length of stay although not significant. Mean ambulance response time was significantly reduced by 8 minutes.
Discussion: The program did not achieve the primary goal of reducing ED length of stay, however the private EMS workers provided countless hours of patient care to the freestanding ED patients without charge to the freestanding emergency department for the EMS providers’ time.

Key words: Emergency medical services; Research; Length of stay

AN OVERVIEW OF DEPENDENCE ON ACTIVITY DAILY LIVING OF POST ACUTE MYOCARDIAL INFARCTION PATIENT BASED ON BARTHEL SCALE

ABSTRACT

Background: Cardiovascular disease is the first cause of death and morbidity in the world as well as in Indonesia. Every year 1.5 million people have acute myocardial infarction leading to 540,400 deaths. Every patient suffering from heart attack will not only have myo-cardio vascular function disorder but alsoo ther disorders such as physical deterioration, psychological disorder, nutrition disorder, and social disorder. High prevalence of acute myocardial infarction and the impact caused by it requires particular attention. The dependence caused by the impact of acute myocardial infarction greatly varies as manifested by the patient through the capability in doing activiy daily living(ADL). Barthel Index is an instrument which can be used to measure dependence on daily basic activities.

Objective: To get an overview of dependence on activity daily living of post acute myocardial infarction based on Barthel Scale.

Method: The study was non experimental which used crosssectional design. Samples were taken using accidental total sampling technique with as many as 22 people. Research instruments used were observation sheets based on Barthel Scale.

Result: The result of Barthel scale evaluation showed that out of 22 acute post myocardial infarction patients the average dependence level in day 1 was 34.09% day 2 was 37.95%; day 3 was 50.00%; day 4 was 67.50%; day 5 was 78.64%; day 6 was 87.95; and day 7 was 88.00%.

Conclusion: The patients of acute myocardial infarction hospitalized at Bethesda Hospital of Yogyakarta in average had maximum dependence at day 1 and day 2; where as minimum dependence occurred in day 3 today 7.

Keywords: acute myocardial infarction, activity daily living; Barthel scale

RELATIONSHIP BETWEEN WORK STRESS AND HEALTH PROBLEM OF HIGH CARE INTENSIVE-CARE UNIT AND EMERGENCY DEPARTMENT NURSES OF PERSAHABATAN CENTRAL HOSPITAL

ABSTRACT

Background: Nursing is a work with risk for stress due to use of modern equipments; inadequate ratio of nurses within ward; conflict with supervisors, managers and peer groups; workload; discriminative treatment; patients' serious condition and so on. Higher level of stress among nurses can cause health problems (physical, psychological and social) which affect achievement, quality of nursing care and others (peer nurses, patients, family, institution and so on).

Objective: The study aimed to identify relationship between work stress and health problems of High Intensive–Intensive Care Unit and Emergency Department of Persahabatan Central Hospital, Jakarta.

Method: This was a correlated analytical descriptive study using a quantitative approach with cross sectional method. Data of work stress level and health problems were obtained through questionnaires. Subject of the study were as many as 40 High Intensive and Intensive Care Unit and Emergency Department nurses with the criteria of not off duty/on study leave, non head of ward and willing to become respondents. The study was carried out in August 2–13, 2007.

Result: Average work stress of the nurses belonged to medium category (38.90) within interval 39-55; and average level of health problems belonged to low (33.90) within interval 22-38. Hypothetical test using Pearson Product Moment Correlation with confidence interval 95% or �� = 0.05 indicated that rxy = 0.696 or p = 0.0001 and the result of regression analysis showed that adjusted R2 = 0.622.

Conclusion: There was positive significant relationship between work stress and health problems of High Intensive-Intensive Care Unit and Emergency Department nurses of Persahabatan Central Hospital, Jakarta. Workload was the most dominant factor which affected the prevalence of health problems.

Keywords: Work Stress, Health Problems, High Care Unit, Critical Nurses

RELATIONSHIP BETWEEN FACTORS AFFECTING BREASTMILK PRODUCTION AND NEONATUS BREASTMILK ALLOWANCE AMONG POST SECTIO CAESAREAN PATIENTS

ABSTRACT

Background: The risk of sectio caesarean is becoming more minimum; however, this does not mean that there is no impact for mothers and their babies. During the first 12 hours post sectio caesarean mothers cannot take care of their babies, including breastfeed because they are still under the effect of surgery. This reduces the chances of mothers giving the best nutrition for the babies. Factors causing constraints for breastfeeding are maternal stress, limited time to access the baby, substitute foods, separating mothers from babies, anemia, mechanical factors, types of anesthesia, sucking response of the baby due to drug effect, late breast milk production due to medication.
Objective: To find out the relationship between factors affecting breast milk production and breast milk allowance at Melati ward of Sleman Hospital, Yogyakarta.
Method: The study observed 26 post sectio caesarean mothers and babies using cross sectional design and quantitative approach. Chi Square with α=0.05 and logistic regression analysis were used for processing data collected from 17th March to 7th April 2008 at Melati Ward of Sleman Hospital, Yogyakarta. Samples were purposively chosen with criteria being hospitalized for at least 4 days, minimum infant weight 2500 grams, the babies did not get photo therapy or intensive care. Research instruments were observation sheets and questionnaires.
Result: As much as 88.5% of mothers did not have adequate breast milk. Out of 26 mothers, 38.5% of them did not practice good breastfeeding technique; 38.5% had serious anxiety; 88.5% had delayed access to their babies; and 19.2% had anemia. Factors affecting breast milk allowance were breastfeeding technique and anxiety with p=0.022 and p=0.046. The result of logistic regression showed that the most dominant factor was breastfeeding technique.
Conclusion: Breastfeeding technique and anxiety were factors affecting neonatus breastmilk allowance.

Keywords: breast milk production, neonates, post section caesarean

THE DIFFERENCE IN EFFECTIVENESS OF CHRONIC WOUND CARE BETWEEN MODERN AND CONVENTIONAL TECHNIQUE AT SLEMAN REGIONAL GENERAL HOSPITAL YOGYAKARTA

ABSTRACT

Background: Wound Treatment Care has an important function as a part of the professional nursing care. Nowadays, Wound care that is based on the humid condition has been followed by any kind of modern wound bandage care. The research has a purpose to observe The difference between the Effectiveness of chronic wound care by modern and conventional techniques at Sleman Regional General Hospital Yogyakarta viewed by the period to reach granulation including epythelization, medication frequency and regular using material.
Method: The research is using quasi design experiment that is a group of treatment by giving a modern technique and a group of control treatment by giving the conventional technique. The wound care should be completed until the granulation and epythelization are appeared with the longest period of 15 days. The data collection should be done by an observation technique, taken by cohort prospective. Meanwhile, the research population may whole of the hospitalize patients with chronic wound. Furthermore, the sample withdrawal, taken by purposive sample has the amount of 30 samples. Finally, groups of both treatment and control are determined by randomization.
Result: By a significant rate 5% (P=0,05) it is known that a wound care by modern technique is significantly different by point p =0,000 in reaching the granulation comparing with a conventional technique, which is clinically gained that there is a 5 days faster treatment of granulation to the group with modern technique. The difference of medication frequency is significantly different with point p =0,000, that is medication which is doing 19 times more frequently by conventional technique. Wound care with modern technique is significantly different with point p =0,021 in line with the regular using material although the regular using material by using modern technique 55% more than a conventional one. Epythelization to group of treatment is generally happen on the 8th day, meanwhile to the control group may not be founded until the 15th day of wound treatment.
Conclusion: Finally, it can be concluded that modern technique is more effective than conventional one in order to conduct a chronic wound care at Sleman Regional General Hospital Yogyakarta viewed by the period of time in granulation and epythelization, the medication frequency and cost of regular using material as well.

Keywords: effectiveness, modern technique, conventional technique

THE CORRELATION BETWEEN EXERSICE AEROBIC AND SEXUALLITY IN MARRIED WOMAN

ABSTRACT

Background : A healthy sexual life is one of happiness factor in marriage. Sex plays a part on marriage badly. Based on interview with exercise aerobic participants in Santika gymnastic, we got that one of their aim doing this was to make a healthy life and to lose their body weight, which bothering their various activities including their sexual life.
Objective : To know the difference of sexuality level on exercise woman’s and unexercised woman’s.
Method : This research was a non experimental, using comparative analytic description with cross sectional approach. This research was taken in February 18 to March 16, 2008 at Santika gymnastic and Sendowo village Yogyakarta. The variable of this research were exercise and sexuality variable. Data were collected in two groups, the exercise woman’s and unexercised woman’s. Each group was 30 respondents.
Result : Based on the result, we got that in exercise group, 15 respondents doing exercise for 3-5 times a week. Thirteen respondents (43,3%) of exercise woman were highly sexual desires and the others in Sendowo village Yogyakarta, which didn’t do exercise, their sexual desire’s only 11 (36,6%). Eighteen respondents (60%) of exercise woman were highly sexual responses than the unexercised women were sexual response only 2 (6,7%) respondents. On sexual activities, we got that in exercised woman, 18(60%) respondents were highly activities sexual and the unexercised exercise group were the sexual activities only 4(613,3%). The result of Chi Square statistic test calculation showed that there was difference sexual desire’s between exercise woman and unexercised woman (p=0,00< 0.05), sexual response (p=0,002 <0,05) and the sexual activities (p=0,00<0,05).
Conclusion : there is difference of sexual desire’s, sexual response and activities sexual on exercise woman and unexercised woman.

Keywords : exercise, sexuality, aerobic

PRE HOSPITAL TREATMENT FOR PATIENT WITH HEAD INJURY

Abstract

Background: Well organized pre-hospital management of trauma is increasingly important to be sure patient with trauma can arrive at emergency room safely. Safety of patient with severe trauma very depends on early intervention, mean of transportation with its facility and time required to arrive at hospital. Old philosophy state "take patient and bring to hospital" has gradually changed to be "keep at site and stabilize patient first", and pre-hospital care is done at site. Regardless trauma mechanism, intervention should have been done in accident site or on the way to hospital.
Research objective: To know description of pre-hospital treatment in term of personnel sub system, communication, transportation, and aid that have been done in incident site on patient with head injury that is got to emergency rooms of hospitals in Yogyakarta Province.
Method: This study was descriptive quantitative study with using cross sectional design. Data we collected by accidental sampling. This study was participated by 59 patients with head injury at emergency rooms of Sardjito Central Hospital, Bethesda Hospital, Pku Muhammadiyah Hospital, Sleman Regional Hospital and Wates Regional Hospital from January 11th 2008 until February 14th 2008 with 10 assistants.
Result and conclusion: Most pre-hospital treatment of patient with head injury in Yogyakarta province was done by common people who have not followed first aid/PPGD training yet (76.27%). There were 77.97% helper did not call or give information early before patient arrived at emergency room. They used private automobile for transportation 55.93% and 22.03% used special vehicle/ambulance. About aid in incidence site, 78% helper has asked aid to people around and 71.2% helper oversee patient during trip, 25.4% helpers checked patient awareness when gave help and 23.7% helpers considered security around before providing help.

Keywords: Pre Hospital Treatment, Head Injury