Firm Surface for CPR: An updated Systematic Review BLS-2510

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: Gavin Perkins co-authored included papers.

CoSTR Citation

Dewan M, Perkins G, Schachna E, Eastwood K, Smyth M, Olasveengen TM, Bray J -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Firm surface for the delivery of CPR: An Updated Systematic Review and Meta-analysis. Available from: http://ilcor.org

Dewan 2024 ILCOR Optimal surface

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process to produce the Consensus on Science with Treatment Recommendations (CoSTR) is an update of the 2020 systematic review¹ conducted by the BLS Task Force with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Task Force. These data were accounted for when formulating the Treatment Recommendations.

Systematic Review

Dewan M, Schachna E, Perkins G, Eastwood K, Bray J. The optimal surface for delivery of CPR: An updated systematic review and meta-analysis. Resuscitation Plus 2024;19:100718

https://pubmed.ncbi.nlm.nih.gov/39149224/

PICOST

Risk of bias was assessed via the COCHRANE RoB2 revised tool for the outcome of chest compression depth in mannequin studies.²

Consensus on Science

This topic was prioritized for update by the BLS Task Force following a systematic review in 2020.¹ Members of the Task Force reported variation in backboard use and concern for delays in CPR with the practice of moving a patient from the bed to the floor to improve the quality of CPR, thus it was considered timely to review the published evidence.

In addition to the 11 manikin simulation RCTs^3-13 identified by Holt et al.¹, we identified one observational study¹⁴ and 6 additional manikin RCTs^15-20 published since 2019 addressing this PICOST. The identified science has been grouped by the surfaces examined: Backboard Versus Hospital Mattress, Floor Versus Hospital Mattress, Floor Versus Firm Home Mattress, and Other Surface Types.

Backboard versus Hospital Mattress

One small observational study¹⁴ and 7 manikin RCTs^{5,6,8-10,12,18} compared using a backboard to a hospital-grade mattress. In all studies, CPR was performed by hospital personnel, including one study that used orderlies⁶ and two studies that used medical students.^5,12

No studies reported patient outcomes.

For the important outcome of compression depth, we identified low certainty evidence (downgraded for serious indirectness) from 1 small observational study¹⁴ and 7 manikin RCTs.^{5,6,8-10,12,18} The observational study of 26 in-hospital cardiac arrests (IHCAs), using an accelerometer (CPR feedback device) placed on the chest, reported an increase in the mean proportion of compressions at guideline targets when a backboard was used (72.9% vs 48.7%, p=0.05). However, this study did not adjust for mattress compression, therefore the difference in compressions is unreliable. A meta-analysis of the 7 simulation RCTs using a manikin to measure depth, showed a 2.16 millimeter (95% CI 0.52-3.81) improvement in chest compression depth when a backboard was used on hospital foam mattresses 6cm to 14 cm thick.

For the important outcome of compression rate, we identified low certainty of evidence (downgraded for serious indirectness) from 5 manikin RCTs.^5,6,8,12,18 Meta-analysis using a manikin to measure rate, show no difference in chest compression rate with the use of a backboard (mean difference -0.11, 95%CI: -3.8-3.59).

We did not identify any evidence to address the important outcomes of chest compression fraction / interruptions to CPR.

Floor versus Hospital Mattress

Two manikin RCTs compared the floor to a hospital-grade mattress, in both studies CPR was performed by critical care staff.^4,7

No studies reported patient outcomes.

For the important outcome of compression depth, we identified low certainty evidence (downgraded for serious indirectness) for two manikin RCTs.^4,7 Meta-analysis showed no difference (5.36 millimeter, 95% CI -1.59 to 12.32) in chest compression depth when CPR was performed on a manikin placed on the floor compared to a hospital mattress.

For the important outcome of compression depth, we identified low certainty evidence (downgraded for serious indirectness) for two manikin RCTs.^4,7 Both studies reported no difference in mean compression rates between surfaces.

For the important outcome of no flow time, we identified very low certainty of evidence (downgraded for serious indirectness and imprecision) from 1 manikin RCT.⁷ No difference in mean no flow time was reported, but this was not defined.

Floor versus Firm Home Mattress

Two studies compared the floor to a firm home mattress, CPR was performed by CPR trained hospital personnel¹³ or lay-persons.²⁰

No studies reported patient outcomes.

For the important outcome of compression depth we identified low certainty evidence (downgraded for serious indirectness) from 2 manikin RCTS.^13,20 Meta-analysis of these studies showed no difference (mean difference 2.11 millimeters, 95% CI -3.23 to 7.45) in chest compression depth when CPR was performed on a manikin placed on the floor compared to a firm home mattress. One study also reported data for medium and soft mattress, with no difference reported between surfaces.¹³

For the important outcome of compression rate we identified low certainty evidence (downgraded for serious indirectness) from 2 manikin RCTS.^13,20 Both studies reported no difference in rate when CPR was performed on a firm mattress; one study reported lower median CPR rates when CPR was performed on a soft home mattress and this rate was below guideline recommendations (98.5/min, IQR 91-107).¹³

One manikin RCT reported no difference in chest recoil between the floor or varying mattress surfaces.¹³

One manikin RCT reported significantly less self-reported fatigue and more comfort when CPR was performed on the floor compared to a mattress.¹³

Other Surface Types

Two manikin RCTs examine performing CPR on other surfaces, including sports matting¹⁶ and dental chairs.¹⁷

No studies reported patient outcomes.

The first study compared CPR quality including compression depth and rate and rescuer fatigue including perceived exertion and heart rate on three surfaces the floor, low compliance safety sports matting, high compliance safety sports matting with and without a backboard.¹⁶ For CPR quality metrics, high compliance matting with and without a backboard had a significantly lower compression rate and compression depth compared to floor or low compliance matting with or without backboard. Perceived exertion was highest on high compliance matting with no difference in rescuer heart rate. This study had high risk of bias for missing data as five participants were excluded for failure to reach predetermined depth on the solid floor all of which were female.

The second study evaluated chest compression rate and depth in two different dental chairs versus the floor.¹⁷ The percentage of chest compressions ³ 5 cm was significantly lower in both dental chairs as compared with the floor.

Treatment Recommendations

We suggest performing chest compressions on a firm surface when this is practical and does not significantly delay the commencement of chest compressions (weak recommendation, very low certainty evidence).

We suggest activation of the CPR mode to increase mattress stiffness if available for in-hospital cardiac arrest (good practice statement).

For healthcare systems that have already incorporated backboards into routine use during resuscitations, the evidence was considered insufficient to suggest against their continued use (weak recommendation, very low certainty of evidence).

For healthcare systems that have not introduced backboards, the limited improvement in compression depth and uncertainty about harms seemed insufficient to justify the costs of purchasing backboards and training staff in their use (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the Task Force considered the importance of high-quality chest compressions and minimizing delays to the initiation of CPR to improve outcomes from in-hospital and out-of-hospital cardiac arrest.

When performing chest compressions on a mattress, the compression force is dissipated through both chest compression and compression of the surface beneath the patient. Prior studies using mannequins indicate that mattress compression can be as high as 57% of total compression depth, with softer mattresses being compressed the most.^21-23 This can lead to reduced spinal-sternal displacement and a reduction in effective chest compression depth.

It is known that effective compression depths can be achieved on soft surfaces if the CPR provider increases overall compression depth to compensate for mattress compression.^24-27CPR feedback devices, which account for mattress compression (e.g. the use of dual and not single accelerometers or increasing compression depth targets) can help CPR providers to ensure adequate compression depth when CPR is performed on a mattress.^5,27-29

Within the limitations of mannequin studies, the available evidence indicates the use of a backboard on a hospital mattress only results in a marginal depth benefit and one that is unlikely to be clinically significant.

The Task Force also considered:

• The lack of clinical studies reporting on the critical outcomes of favorable neurological outcome, survival, ROSC and delays to commencement of CPR.
• The only human data was measured using a single accelerometer (feedback device) placed on the chest and did not adjust for mattress compression.
• The weak recommendations are based on extrapolation from mannequin studies, where CPR was mostly performed by a trained healthcare professional. Only one study²⁰ examined CPR performed by lay rescuers.
• The hospital beds involved in the studies typically had a rigid base and ranged in thickness between 6 to 14cm. The Task Force noted that although this configuration is common in many developed country hospitals, this may not be applicable to all hospitals or the out-of-hospital setting.
• The addition of two studies simulating out-of-hospital settings (where beds may be softer) and one where the CPR provider may be a single untrained rescuer, led to the Task Force to broaden the recommendations to include in-hospital and out-of-hospital cardiac arrest.
• In considering whether to transfer a patient to the floor when performing chest compressions to improve compression depth, the Task Force considered the risks of harm (e.g. interruption in CPR, risk of losing vascular access if IV lines and more confined space) to the patient and resuscitation team outweighed any small improvement in chest compression depth. In addition, studies on bystander CPR report significant loss of time due to difficulties in moving the patient to the floor³⁰ or that CPR is not performed at all because the patient could not be moved.^30,31 Emergency Medical Services are likely to move patients in confined spaces to perform resuscitation.
• For healthcare systems that have already incorporated backboards into routine use during resuscitations, the evidence was considered insufficient to suggest against their continued use. For healthcare systems that have not introduced backboards, the limited improvement in compression depth and uncertainty about harms seemed insufficient to justify the costs of purchasing backboards and training staff in their use. Where backboards are deployed, users should be aware that mattress stiffness, backboard size and orientation influence their effectiveness.^32-35

Knowledge Gaps

Knowledge Gaps Template for Task Force chairs

Current knowledge gaps include but are not limited to:

• Studies reporting clinical outcomes.
• Studies examining the logistical aspects of backboard deployment or moving a patient from a bed to the floor.
• Studies in both high and low-resource settings where hospital bed or pre-hospital stretcher configurations may vary.

ETD summary table: BLS2510 Optimalsurfacefor CPR2024 ETD Final

References

References listed alphabetically by first author last name in this citation format (Circulation)

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2. Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi: 10.1136/bmj.l4898

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34. Cloete G, Dellimore KH, Scheffer C, Smuts MS, Wallis LA. The impact of backboard size and orientation on sternum-to-spine compression depth and compression stiffness in a manikin study of CPR using two mattress types. Resuscitation. 2011;82:1064-1070. doi: 10.1016/j.resuscitation.2011.04.003

35. Perkins GD, Kocierz L, Smith SC, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation. 2009;80:79-82. doi: 10.1016/j.resuscitation.2008.08.011