How EMS and medicine community instruction on CPR can improve survival rates

Cardiac arrest refers to the abrupt cessation of cardiac pumping activity which is confirmed by the absence of one, a detectable pulse, two, signs of circulation, three, breathing and finally the lack of a response to stimulation. The immediate management for cardiac arrest entails chest compressions performed during cardiopulmonary resuscitation (CPR) and defibrillation that is delivery of shocks via a defibrillator to stop the ventricular fibrillation that prompted the cardiac arrest. CPR is an essential emergency measure which consists of a series of measures for delivering oxygenated blood to vital organs like the heart and the brain through artificial respiration and manual cardiac massage till spontaneous and effective circulation is restored.
The chest compressions performed during CPR are purposed to supply oxygenated blood flow to vital organs like the heart and the brain until circulation can be restored via defibrillation or any other form of therapy (Abella et al., 2011). Whilst they do not restart the heart, chest compressions help to delay tissue death and hence extend the window of opportunity for successful resuscitation without permanent neurological impairments. CPR is part and parcel of training for all healthcare personnel; however it can also be taught to and performed by laypersons in the community. This paper seeks to describe how Medicine and EMS can promote an improvement of survival rates for out-of-hospital sudden cardiac arrests (SCAs) via community instruction on CPR.

Body

The recognition of a victim of a SCA and the emergency care in the initial critical moments following a cardiac arrest depends on the actions taken by the people near the victim. However, despite the benefits that bystander CPR portends on the victims survival rates, findings from numerous studies show that only 15 to 30% of out-of-hospital SCA victims receive bystander CPR. Studies that have investigated the reasons behind the low rate of bystander CPR have identified a number of factors that contribute to this. Lack of confidence or the fear of failure is the most cited reason for failure to perform bystander CPR. The lack of confidence is in part due to the complexity of resuscitation instructional materials and guidelines which make it hard for community members to learn or even recall the CPR steps and thereby they end up lacking the confidence necessary to effectively deliver CPR (Sayre et al., 2008; Abella et al., 2008). Findings from an array of studies show that training of community members on CPR greatly boosts their confidence in their abilities to perform it effectively and in effect the probability of bystanders intervening in emergency situations (Goddard et al., 2010). In one such study by Garcia et al. (2010), the average score of the participants’ pre-and post-training was 9 and 12 respectively. Notably, the greatest improvement in pre-and post-training test scores were on the questions relating to the appropriate chest compressions versus breath ratio and correct AED operation. In a similar study by Goddard et al. (2010), the participants’ confidence level in providing CPR increased from an average 48% during the pre-training period to 88% post-training. Whilst these studies did not measure future recall or the actual ability of the trainees to effectively perform CPR in real life situations, community instruction programs are a viable option for improving the confidence of community members in providing bystander CPR and consequently the number of community members willing to provide bystander CPR. An increase in the number of out-of-hospital SCA victims who receive bystander CPR will eventually result in improved survival rates for these victims.
The American Heart Association has also made efforts to simplify CPR guidelines and instructions. This will in turn improve the ability of community members to learn and perform CPR effectively. Simplification of CPR instructions also reduces the time delay in starting CPR in dispatcher assisted bystander CPR (Sayre et al., 2008). EMS and Medicine can follow suit and come up with innovative methods to teach CPR to community members in a manner that fosters their comprehension and recall abilities. In the end, simplification of CPR instructions will make it easier for community members to master the skills necessary to provide CPR effectively and thus boost their confidence in providing the same. This will in turn increase the likelihood of bystander CPR and thus translate to improved survival rates for SCA victims.
Fear of transmission of infections such as HIV and hepatitis B especially during mouth-to-mouth resuscitation is another reason that makes bystanders reluctant in providing CPR. This is despite the fact that findings from a number of studies suggest that the risk for transmission of infectious diseases during CPR is almost non-existent (Abella et al., 2008). Community instruction on CPR may help to correct such misinformation and thus act as a prompt to action for more bystanders to provide CPR to SCA victims. In view of the concerns about transmission of infections during mouth-to-mouth ventilations, the AHA ECC committee in its 2008 advisory (as cited in Sayre et al., 2008) recommended the hands only bystander chest compressions for out-of-hospital SCA victims except for unwitnessed cardiac arrest, cardiac arrest thought to be of non-cardiac origin and cardiac arrest in children. This decision was informed by findings from studies which have shown that the survival rate for out-of-hospital SCA victims who receive cardiac compressions only is similar to that of those who receive conventional CPR (Iwami et al., 2007; Sayre et al., 2008). Therefore, community instruction on CPR will make the public understand that bystander CPR doubles or triples the victim’s chances of survival at little or no risk to the rescuer and in effect increases the likelihood of bystander CPR and hence improve the chances of survival for victims following SCAs.
Fear of legal liabilities has also been linked to bystander inaction. Community instruction is therefore paramount since through it, community members can access important information on legislations such as the “Good Samaritan” legislation that protects them against legal repercussions whenever they provide CPR. This will make them less hesitant to provide CPR and hence impact positively on the survival outcomes of SCA victims (Sayre et al., 2008; Abella et al., 2008).
Apart from breaking down the barriers that contribute to bystander inaction and thus increasing the number of out-of-hospital SCA victims likely to benefit from bystander CPR, community training on CPR helps to improve the quality of bystander CPR. Accumulating evidence from a number of studies shows that more often than not, the CPR provided by both laypersons and health providers is of very low quality and is not per AHA guidelines. Such CPR is normally characterized by shallow chest compressions which are interrupted frequently beyond the recommended time limit of 0.16 seconds between chest compressions and an excessive rate of mouth-to-mouth ventilations (Sayre et al., 2008). Community instruction on CPR therefore provides the opportunity to improve the quality of CPR provided by laypersons in the communities and thus promotes an improvement of survival rates for SCA victims. The EMS and medicine achieve this by using evidence-based information to guide the training of laypersons on CPR. For instance, the AHA ECC committee recommended the hands only CPR in its 2008 advisory (as cited in Sayre et al., 2008) for bystanders who may be unable or even unwilling to provide conventional CPR. The hands only CPR is easier to understand because it does not have the step of mouth-to-mouth ventilations which many bystanders find hard to provide with some expressing an aversion to it. This latter approach to resuscitation therefore improves the quality of bystander chest compressions by making them more continuous. This in turn increases the survival rates for SCA victims.
On the other hand, EMS can employ conventional and innovative methods to instruct community members on CPR and thereby improve their knowledge base and likelihood of them providing CPR to SCA victims which would then impact positively on the survival rates of such victims (Garcia et al., 2010). Conventional methods include planned programs facilitated by staff from the emergency department whereby community members attend for a designated time period. As a matter of fact, some medical schools have made it a qualification requirement for all medical students trained on CPR to carry out CPR instruction sessions for a certain number of community members. Staff from the EMS can also come up with innovative methods such as iphone applications that would enable laypersons to access information on CPR and hence enable them to respond appropriately to emergency situations. Similarly, the emergency department can help bystanders conduct CPR by conveying instructions via phone also called dispatcher-instruction assisted CPR. This would ensure that such laypersons are able to initiate CPR in the first critical moments following a SCA. Preliminary findings on the effectiveness of dispatcher telephone delivered instruction on CPR indicate that this innovative modality of bystander CPR seems to improve the survival rates for cardiac arrest victims (Rea et al., 2001).
All the aforementioned EMS system and medicine initiated community instruction on CPR would in the long term promote an improvement of survival rates by increasing the number of people with CPR skills in the community and thus the probability of emergency care during the first critical minutes following an SCA. Studies have shown that an SCA’s victims’ chance of survival decreases by 7 to 10% every minute that defibrillation is delayed if bystander CPR is not provided (Abella et al., 2008). This is because bystander CPR if provided within the first few minutes of an SCA prevents significant neurological impairments that would otherwise occur due to ischemia and cell death. Therefore, community instruction on CPR increases the competency as well as the number of community members able to provide CPR effectively which translates to an increased probability of bystander CPR for out-of-hospital SCA victims. Consequently, more SCA victims will receive bystander CPR which will lead to improved survival outcomes.

Conclusion

In conclusion therefore, evidence from a myriad of studies shows that bystander CPR significantly improves the survival chances for sudden cardiac arrest victims in out-of-hospital settings. Despite the fact that immediate CPR doubles or triples the survival chances for SCA victims in the communities, research shows that only 15 to 30% of these victims benefit from bystander CPR. EMS and Medicine community instruction on CPR has a mitigating effect on the factors that contribute to bystander inaction such as lack of confidence, concerns relating to infectious diseases and legal repercussions. Bystander inaction has adverse effects on the survival rates of victims; therefore, breaking down these barriers increases the likelihood as well as the number of SCA victims likely to receive bystander CPR and its associated benefits. Further, community training on CPR whether using innovative or conventional methods helps to improve the quality of bystander CPR as well as the probability of bystander CPR which eventually translates to an increase in survival rates for out-of-hospital SCA victims.

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