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CPR feedback device used in resuscitation training: EIT 6404 TF SR

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ILCOR staff

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest (COI) 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 recused as no COI declared.

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: None declared a COI.

CoSTR Citation

Lin Y, Lockey A, Grief R, Donoghue A, Matsuyama T, Farquharson B, Cortegiani A, Banerjee A, Cheng A on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Consensus on Science with Treatment Recommendations International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2023 November 30. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of virtual and augmented reality in resuscitation training as opposed to other approaches to life support course delivery conducted by an information specialist with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Publication in progress

PICOST

PICOST

Description (with recommended text)

Population

All laypersons and healthcare providers in any educational setting

Intervention

Use of CPR feedback/guidance device during resuscitation training

Comparison

No use of CPR feedback/guidance device during resuscitation training

Outcomes

1. Patient survival [CRITICAL]
2. Quality of performance in actual resuscitations [CRITICAL]
3. Skill retention (performance after course conclusion) [IMPORTANT]
4. Skill acquisition (performance at course conclusion) [IMPORTANT]

Study Design

Randomized controlled trials (RCTs)

Timeframe

All years and all languages were included if there was an English abstract. Literature search updated to Jun 13th, 2024.

Prospero Registration: CRD42023376751

Consensus on Science

Recent scientific statements highlight a growing trend in the use of CPR feedback devices during resuscitation training courses.(1) While earlier reviews showed that these devices can improve short-term educational outcomes, the results have been inconsistent.(2) Additionally, there's limited evidence on how they affect learners' CPR skills, the cost-effectiveness of training, and, most importantly, patient outcomes. These factors are essential for evaluating their true effectiveness.

None of the studies examined the impact of CPR feedback device during resuscitation training on the outcomes of patient survival or quality of performance in actual resuscitation. Twenty studies examined CPR skills at the conclusion of the courses as the outcomes (Figure 1), 8 of which were rated as minor concerns for risk of bias, (3-10) 9 of them with some concerns for risk of bias, (11-19) and 3 of them with serious concerns for risk of bias.(20-22) The risk of bias assessment presented in Table 1. Three studies were conducted in lay providers(4, 7, 10) and 17 in healthcare providers.(3, 5, 6, 8, 9, 11-22)

CPR skills

Compression depth

Fifteen randomized controlled trials (RCTs) with a total of 4,185 participants (2,189 in the non-feedback group and 1,996 in the feedback group) evaluated the effect of CPR feedback devices on objectively measured mean compression depth.(3, 7-14, 16-19, 21, 22) The results indicated that participants trained with feedback devices had significantly greater mean compression depth compared to those trained without them (SMD = 0.76, 95% CI: 0.02–1.50, p = 0.04), although there was substantial heterogeneity (I² = 94%). Subgroup analysis showed that the effect of feedback device was larger in the healthcare providers (SMD 0.86, 95%CI: 0.01-1.72) than in the lay providers (SMD 0.15, 95%CI: 0.07 – 0.22), but the difference was not statistically significant (p =0.10). (Figure 2)

Additionally, 16 RCTs involving 4,304 participants (2,272 in the non-feedback group and 2,032 in the feedback group) examined the effect of CPR feedback devices during resuscitation training on compression depth compliance. (3-10, 12-16, 19-21) Compression depth compliance was quantitatively measured as the percentage of compressions meeting the resuscitation guidelines during assessment. The results showed that using CPR feedback devices during training had a large impact on depth compliance (SMD = 0.98, 95% CI: 0.10–1.87, p = 0.03, I² = 94%). Subgroup analysis showed that the effect of feedback device was larger in the healthcare providers (SMD 1.14, 95%CI: 0.04-2.24) than in the lay providers (SMD 0.17, 95%CI: 0.01 – 0.32), but the difference was not statistically significant (p =0.09). (Figure 3)

Compression rate

Seventeen randomized controlled trials (RCTs) involving a total of 4,327 participants (2,286 in the non-feedback group and 2,041 in the feedback group) evaluated the effect of CPR feedback devices on objectively measured mean compression rate. (3, 4, 6-14, 16-19, 21, 22) The results indicated that participants trained with feedback devices had a significantly lower mean compression rate compared to those trained without them, as participants in the non-feedback group tended to compress too quickly (>120 bpm) (SMD = -0.29, 95% CI: -0.49 to -0.10, p < 0.01, I² = 73%). Subgroup analysis showed the effect of the feedback device on mean compression rate was not statistically significant between healthcare providers and lay providers (p = 0.67). (Figure 4)

Additionally, nine RCTs involving 905 participants (460 in the non-feedback group and 445 in the feedback group) examined the effect of CPR feedback devices during resuscitation training on compression rate compliance. (3, 5, 6, 8, 10, 14, 15, 19, 20) Compression rate compliance was quantitatively measured as the percentage of compressions within the guideline-recommended rate of 100–120 bpm. The results demonstrated that using CPR feedback devices during training had a substantial impact on rate compliance (SMD = 0.45, 95% CI: 0.23–0.66, p < 0.01, I² = 61%). Subgroup analysis showed the effect of the feedback device on rate compliance was not statistically significant between healthcare providers and lay providers (p = 0.80) (Figure 5)

Chest recoil

Ten randomized controlled trials (RCTs) involving a total of 3,496 participants (1,803 in the non-feedback group and 1,693 in the feedback group) evaluated the effect of CPR feedback devices during training on chest recoil.(3, 5, 7, 10, 12, 14, 15, 17, 19, 20) Chest recoil was quantitatively measured as the percentage of compressions with full chest recoil. The results demonstrated that using CPR feedback devices during training had a significant impact on recoil compliance (SMD = 0.53, 95% CI: 0.31–0.75, p < 0.01, I² = 87%). Subgroup analysis showed that the effect of the feedback device on recoil compliance was significantly in the healthcare providers (SMD: 0.67, 95%CI: 0.52-0.82), but not statistically significant in the lay providers (SMD: 0.20, 95%CI: -0.24, 0.64). (Figure 6)

Overall quality CPR

Eight RCTs involving a total of 3261 participants (1687 in the non-feedback group and 1574 in the feedback group) evaluated the effect of CPR feedback devices on overall CPR quality during resuscitation training. (3, 6, 7, 10, 12, 14, 15, 17) Overall quality of CPR was assessed by computer software integrating all three metrics of chest compression (depth, rate and recoil) with limited validity evidence. The results showed that the use of feedback devices significantly improved the overall quality of CPR, with a pooled effect size of 0.71 (95% CI: 0.40–1.05, p < 0.01), although heterogeneity was high (I² = 86%). Subgroup analysis showed that the effect of the feedback device on the overall CPR score was significantly higher in the healthcare providers (SMD: 0.87, 95%CI: 0.53 – 1.21) than in the lay providers (SMD: 0.33, 95%CI: 0.03 – 0.63), and the difference was statistically significant (p = 0.02). (figure 7)

Three randomized controlled trials (RCTs) involving a total of 349 participants (178 in the non-feedback group and 171 in the feedback group) evaluated the effect of CPR feedback devices on overall CPR quality during resuscitation training.(5, 16, 18) CPR quality was assessed dichotomously, based on whether compression depth, rate, and recoil all met guideline standards. The results showed that the use of feedback devices significantly improved the overall quality of CPR, with a pooled effect size of 0.19 (95% CI: 0.01–0.38, p = 0.04, I² = 78%). (Figure 8)

Treatment Recommendations

We recommend the use of CPR feedback devices during resuscitation training for healthcare providers and lay providers. (Strong recommendation, moderate certainty of evidence)

Justification and Evidence to Decision Framework Highlights

In making this recommendation, the EIT taskforce considered the following:

  • In the meta-analyses, we found the results strongly favor the use of feedback devices during training across all CPR quality outcomes with moderate to strong association.
  • Subgroup analyses showed the effect of feedback device on resuscitation training was higher in healthcare providers than in the lay providers, but there was still a significant effect for most CPR metrics in lay providers.
  • The certainty of evidence is overall moderate to high
  • No undesirable effects were detected in the review
  • Overall good acceptability, feasibility with negligible costs

Knowledge Gaps

We identified several knowledge gaps in the literature:

  • The relative and synergistic effect of feedback device use when combined with other educational strategies and instructional design features is unclear.
  • Further studies are required to examine the impact of improved CPR skills from training with feedback devices on patient outcomes is required.
  • The costs associated with implementing feedback devices during resuscitation training, as well as its cost effectiveness needs to be explored further.

Summary tables and diagrams: EIT 6404 FB devices Tables and Figures Co STR Oct21, EIT 6404 Feedback device during training evidence table

EtD: EIT 6404 Et D Feedback device

References

1. Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, et al. Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S551-S79.

2. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review. Resuscitation. 2009;80(7):743-51.

3. Wagner M, Bibl K, Hrdliczka E, Steinbauer P, Stiller M, Gropel P, et al. Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study. Pediatrics. 2019;143(2).

4. Meng XY, You J, Dai LL, Yin XD, Xu JA, Wang JF. Efficacy of a Simplified Feedback Trainer for High-Quality Chest Compression Training: A Randomized Controlled Simulation Study. Front Public Health. 2021;9:675487.

5. Lin Y, Cheng A, Grant VJ, Currie GR, Hecker KG. Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers - A randomized controlled trial. Resuscitation. 2018;130:6-12.

6. Labuschagne MJ, Arbee A, de Klerk C, de Vries E, de Waal T, Jhetam T, et al. A comparison of the effectiveness of QCPR and conventional CPR training in final-year medical students at a South African university. Afr J Emerg Med. 2022;12(2):106-11.

7. Kong SYJ, Song KJ, Shin SD, Ro YS, Myklebust H, Birkenes TS, et al. Effect of real-time feedback during cardiopulmonary resuscitation training on quality of performances: A prospective cluster-randomized trial. Hong Kong Journal of Emergency Medicine. 2020;27(4):187-96.

8. Jiang J, Yan J, Yao D, Xiao J, Chen R, Zhao Y, et al. Comparison of the effects of using feedback devices for training or simulated cardiopulmonary arrest. J Cardiothorac Surg. 2024;19(1):159.

9. Jang TC, Ryoo HW, Moon S, Ahn JY, Lee DE, Lee WK, et al. Long-term benefits of chest compression-only cardiopulmonary resuscitation training using real-time visual feedback manikins: a randomized simulation study. Clin Exp Emerg Med. 2020;7(3):206-12.

10. Cortegiani A, Russotto V, Montalto F, Iozzo P, Meschis R, Pugliesi M, et al. Use of a Real-Time Training Software (Laerdal QCPR(R)) Compared to Instructor-Based Feedback for High-Quality Chest Compressions Acquisition in Secondary School Students: A Randomized Trial. PLoS One. 2017;12(1):e0169591.

11. Allan KS, Wong N, Aves T, Dorian P. The benefits of a simplified method for CPR training of medical professionals: a randomized controlled study. Resuscitation. 2013;84(8):1119-24.

12. Gonzalez-Santano D, Fernandez-Garcia D, Silvestre-Medina E, Remuinan-Rodriguez B, Rosell-Ortiz F, Gomez-Salgado J, et al. Evaluation of Three Methods for CPR Training to Lifeguards: A Randomised Trial Using Traditional Procedures and New Technologies. Medicina (Kaunas). 2020;56(11).

13. Kardong-Edgren SE, Oermann MH, Odom-Maryon T, Ha Y. Comparison of two instructional modalities for nursing student CPR skill acquisition. Resuscitation. 2010;81(8):1019-24.

14. Katipoglu B, Madziala MA, Evrin T, Gawlowski P, Szarpak A, Dabrowska A, et al. How should we teach cardiopulmonary resuscitation? Randomized multi-center study. Cardiol J. 2021;28(3):439-45.

15. Lee PH, Lai HY, Hsieh TC, Wu WR. Using real-time device-based visual feedback in CPR recertification programs: A prospective randomised controlled study. Nurse Educ Today. 2023;124:105755.

16. Pavo N, Goliasch G, Nierscher FJ, Stumpf D, Haugk M, Breckwoldt J, et al. Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: a randomised simulation study. Scand J Trauma Resusc Emerg Med. 2016;24:70.

17. Suet G, Blanie A, de Montblanc J, Roulleau P, Benhamou D. External Cardiac Massage Training of Medical Students: A Randomized Comparison of Two Feedback Methods to Standard Training. J Emerg Med. 2020;59(2):270-7.

18. Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, et al. "Booster" training: evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of Pediatric Basic Life Support providers during simulated cardiac arrest. Pediatr Crit Care Med. 2011;12(3):e116-21.

19. Zhou XL, Wang J, Jin XQ, Zhao Y, Liu RL, Jiang C. Quality retention of chest compression after repetitive practices with or without feedback devices: A randomized manikin study. Am J Emerg Med. 2020;38(1):73-8.

20. Ghaderi MS, Malekzadeh J, Mazloum S, Pourghaznein T. Comparison of real-time feedback and debriefing by video recording on basic life support skill in nursing students. BMC Med Educ. 2023;23(1):62.

21. Min MK, Yeom SR, Ryu JH, Kim YI, Park MR, Han SK, et al. Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition. Clin Exp Emerg Med. 2016;3(3):158-64.

22. Spooner BB, Fallaha JF, Kocierz L, Smith CM, Smith SC, Perkins GD. An evaluation of objective feedback in basic life support (BLS) training. Resuscitation. 2007;73(3):417-24.


Discussion

GUEST
Remi Garceau

Good day,

I was wondering if you have any clinical data that would indicate if the resuscitation that occured, if the providers was trained with QCPR feed back or not. We are telling groups like the Heart and stroke foundation that this should be impleted and yet, they are imposing it in the instructor guidelines.

Would it not be more concluent to have the QCPR feedback mandatory on all health care provider AED or manual AED? This would have a direct impact not on a dummy, but on a real person.

A provider is trained once per year with a QCPR, but all resuscitation could be done with a QCPR device and improve the quality on a real life person.

Thanks

Reply

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