Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: As A. Cheng and J. Duff were authors of some articles included in this review, both did not participate in article selection, ROB assessment and data extraction.
CoSTR Citation
Lauridsen KG, Bürgstein E, Nabecker S, Lin Y, Donoghue A, Duff J, Cheng A on behalf of the International Liaison Committee on Resuscitation Education, Implementation, and Teams Task Force. CPR Coaching during adult and pediatric cardiac arrest. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2024 November 1. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
Insert this methodological brief overview and TF chair will adjust specific for the TF and ILCOR priority team that did the work:
This is a Task Force systematic review of CPR coaching on resuscitation teams. The search strategy was finalized by Kasper Lauridsen and information specialist Bente Østergaard. Screening of results, data extraction, and risk of bias assessment was completed by the author group.
A CPR Coach was defined as an assigned role to a resuscitation team member whose primary responsibility is to provide real-time coaching and feedback of chest compression performance during cardiac arrest. CPR Coaches may also perform additional tasks, including: (a) coordinate initiation of CPR; (b) provide feedback on ventilation performance; and (c) coordinate pauses in CPR for defibrillation, intubation, or pulse/rhythm checks. Studies addressing dispatch-assisted coaching of lay people or any other type of coaching where the coach is not an active resuscitation team member were excluded.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Amongst healthcare teams managing adult or pediatric cardiac arrest
Intervention: CPR Coach as a resuscitation team member
Comparators: No CPR Coach on the resuscitation team
Outcomes:
Simulation-based clinical skills: CPR skill performance (important), adherence to guidelines (important), teamwork (important), provider workload (important).
Real life clinical performance: CPR skill performance (critical), adherence to guidelines (critical).
Patient survival: ROSC, survival to hospital discharge/30 days, survival with favorable neurological outcomes, survival beyond discharge/ 30 days (critical).
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies and case series where n>5) are eligible for inclusion.
Timeframe: All years and all languages were included if there was an English abstract. Literature search from inception until October 11, 2024.
PROSPERO Registration CRD42024603212
For randomized trials, we used the revised Cochrane risk-of-bias tool for randomized trials (RoB-2) and for observational trials, we used the ‘Risk Of Bias In Non-randomised Studies - of Interventions’ (ROBINS-I) tool. We assessed the risk of bias per outcome but we report the risk of bias per study in all cases where the risk of bias was assessed as identical across outcomes within a study.
Consensus on Science
We identified seven studies investigating the use of a CPR Coach vs no use of a CPR Coach as a resuscitation team member.1–7 Overall, one study investigated use of CPR Coaches in a clinical setting,1 whereas 6 studies investigated use of CPR Coaches during simulated cardiac arrest resuscitation2–7 of which five of these studies were based on the same randomized controlled trial.2–6 The outcomes of the included studies are presented in Table 1.
Table 1
Outcome |
Evidence |
Certainty of evidence |
Clinical CPR performance (critical) |
One study found that implementation of a CPR Coach improved fraction of compressions at adequate depth from 69.8% to 80.4%; compression depth increased from 43.6mm to 47.2mm, and time to defibrillation was reduced from 13.2s to 7.2s. P-values or confidence intervals for comparisons not reported.1 |
very low certainty evidence (downgraded for risk of bias, indirectness, and imprecision). |
CPR performance in a simulated setting (important) |
One study found higher fraction of excellent chest compressions (63% vs 31%, Diff: 31.8 (17.7, 45.9); higher fraction of compressions within guideline recommendations 38.0 vs. 69.5, Diff: 31.5 (15.7, 47.4); guideline compliant rate (88% vs 80%, p=0.07); CCF (82% vs 77%, p=0.04) for coached vs non-coached teams.2 One study found shorter overall pause durations for coached vs non-coached teams 98.6 s vs 120.85 s, diff: 0.6–43.9 s, shorter pauses for intubation and defibrillation with no significant difference in mean pause frequency.5 One study found shorter time to backboard placement (22s vs. 55s, p=0.02); no difference in compression rate, no flow time, time to first epinephrine, time to first shock, or peri-shock pause duration.7 |
very low certainty evidence (downgraded for risk of bias and imprecision). |
Adherence to guidelines in a simulated setting (important) |
One study measured clinical performance for teams with vs. without a CPR coach. They found that clinical performance tool scores were 73.4 for CPR coached teams vs 68.3 for non-coached teams, (difference: 5.2 points; 95% CI: 1.0-9.3; p=0.016).6 |
low certainty evidence (downgraded for risk of bias, indirectness, and imprecision). |
Teamwork in a simulated setting (important) |
One study found that CPR coached teams had more words/min compared to non-coached teams (160vs134; p<0.05) overall; team leaders and others said less/min (70.2 vs 88.4 and 30.4 vs 45.6, p<0,05), and total questions/min was lower (2.84 vs 3.66, p<0,05).3 |
very low certainty evidence (downgraded for risk of bias, indirectness, and imprecision). |
Workload in a simulated setting (important) |
One study found that workload measured using the NASA TLX questionnaire for team leaders was 54.1 (9.8) vs 52.7 (11.6) for teams without vs with a coach, difference: 1.4 (–5.5 to 8.3). There was also no difference for chest compressors: 55.2 (11.2) vs. 55.6 (9.1), diff: 0.4 (–4.9 to 4.2). For chest compressors, there was lower mental demand and higher physical demand for coached teams vs non-coached teams.4 Another study found no significant differences on any subscales of the NASA TLX for team leaders between the coached vs. non-coached teams. No overall NASA TLX measurement was conducted.7 |
very low certainty evidence (downgraded for risk of bias, inconsistency, and indirectness). |
For the critical outcomes of adherence to guidelines in a clinical setting and patient survival outcomes, we found no evidence. EIT 6314 Evidence table CPR Coach
Treatment Recommendations
The inclusion of a CPR Coach as a member of the resuscitation team during cardiac arrest resuscitation should be considered in settings with adequate staffing (weak recommendation, very low certainty evidence).
Justification and Evidence to Decision Framework Highlights
- Use of a CPR Coach was generally associated with improved outcomes and no harmful effects of using a CPR Coach were observed.
- The certainty of evidence for the included outcomes was low or very low.
- Most of the evidence was based on one randomized simulation-based trial.2 In addition, one clinical observational study1 and a small pilot randomized simulation-based study was identified.7
- CPR Coaches are already implemented as part of the resuscitation teams in many hospitals8 and overcrowding is very frequent in the hospital setting why it is believed that staff members to fill out this role are available.9 However, this may differ in low-resource settings and out-of-hospital settings.
- In addition to the included evidence, one single center clinical study found that implementation of a CPR Coach as part of a bundled intervention was associated with improved fraction of excellent chest compressions.10
- Use of a CPR Coach may be considered a specific way of using shared leadership in resuscitation teams. Shared leadership has been suggested to be useful in several studies on in-hospital cardiac arrest.9,11,12
Knowledge Gaps
- The identified evidence was limited with most studies being based on one randomized simulation-based trial.2 In addition, one clinical observational study1 and a small pilot randomized simulation-based study were identified.7 This suggests an overall need for further evidence on CPR Coaches including randomized trials specifically.
- Evidence on critical outcomes like adherence to guidelines in real cardiac arrest and patient survival outcomes is needed.
- There is insufficient evidence to address the prespecified subgroup analyses of: A) Adult vs. pediatric patients in cardiac arrest, B) Trained vs. untrained CPR Coaches, C) Use of CPR feedback devices vs. no CPR feedback devices during resuscitation in such settings.
- The optimal role of a CPR Coach in the out-of-hospital setting and in-hospital setting may differ and the effectiveness of such coaches may differ as well. This warrants further research.
- Data on cost-effectiveness or utilization of CPR Coaches in limited resource settings is lacking.
ETD summary table: EIT 6314 Et D CPR coach
References
[1] Infinger AE, Vandeventer S, Studnek JR. Introduction of performance coaching during cardiopulmonary resuscitation improves compression depth and time to defibrillation in out-of-hospital cardiac arrest. Resuscitation 2014;85:1752–8. doi:10.1016/j.resuscitation.2014.09.016.
[2] Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y, et al. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: A randomized simulation-based clinical trial. Resuscitation 2018;132:33–40. doi:10.1016/j.resuscitation.2018.08.021.
[3] Jones KA, Jani KH, Jones GW, Nye ML, Duff JP, Cheng A, et al. Using natural language processing to compare task-specific verbal cues in coached versus noncoached cardiac arrest teams during simulated pediatrics resuscitation. AEM Educ Train 2021;5:e10707. doi:10.1002/aet2.10707.
[4] Tofil NM, Cheng A, Lin Y, Davidson J, Hunt EA, Chatfield J, et al. Effect of a Cardiopulmonary Resuscitation Coach on Workload During Pediatric Cardiopulmonary Arrest: A Multicenter, Simulation-Based Study. Pediatr Crit Care Med a J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc 2020;21:e274–81. doi:10.1097/PCC.0000000000002275.
[5] Kessler DO, Grabinski Z, Shepard LN, Jones SI, Lin Y, Duff J, et al. Influence of Cardiopulmonary Resuscitation Coaching on Interruptions in Chest Compressions During Simulated Pediatric Cardiac Arrest. Pediatr Crit Care Med 2021;22:345–53. doi:10.1097/PCC.0000000000002623.
[6] Buyck M, Shayan Y, Gravel J, Hunt EA, Cheng A, Levy A. CPR coaching during cardiac arrest improves adherence to PALS guidelines: a prospective, simulation-based trial. Resusc Plus 2021;5:100058. doi:https://doi.org/10.1016/j.resp....
[7] Badke CM, Friedman ML, Harris ZL, McCarthy-Kowols M, Tran S. Impact of an untrained CPR Coach in simulated pediatric cardiopulmonary arrest: A pilot study. Resusc Plus 2020;4:100035. doi:10.1016/j.resplu.2020.100035.
[8] Pfeiffer S, Lauridsen KG, Wenger J, Hunt EA, Haskell S, Atkins DL, et al. Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative. Pediatr Emerg Care 2021;37:E431–5. doi:10.1097/PEC.0000000000001748.
[9] Lauridsen KG, Krogh K, Müller SD, Schmidt AS, Nadkarni VM, Berg RA, et al. Barriers and facilitators for in-hospital resuscitation: A prospective clinical study. Resuscitation 2021;164:70–8. doi:10.1016/j.resuscitation.2021.05.007.
[10] Hunt EA, Jeffers J, McNamara L, Newton H, Ford K, Bernier M, et al. Improved Cardiopulmonary Resuscitation Performance With CODE ACES(2): A Resuscitation Quality Bundle. J Am Heart Assoc 2018;7:e009860. doi:10.1161/JAHA.118.009860.
[11] Leary M, Schweickert W, Neefe S, Tsypenyuk B, Falk SA, Holena DN. Improving Providers’ Role Definitions to Decrease Overcrowding and Improve In-Hospital Cardiac Arrest Response. Am J Crit Care an Off Publ Am Assoc Crit Nurses 2016;25:335–9. doi:10.4037/ajcc2016195.
[12] Pallas JD, Smiles JP, Zhang M. Cardiac Arrest Nurse Leadership (CANLEAD) trial: a simulation-based randomised controlled trial implementation of a new cardiac arrest role to facilitate cognitive offload for medical team leaders. Emerg Med J 2021;38:572–8. doi:10.1136/emermed-2019-209298.
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