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 applicable)
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: (Perkins, author on one of the included papers)
CoSTR Citation
Perkins GD, Couper K, Grolmusova N, Tay-yibah M, Holt J, Ward A, Chukowry P, Considine J, Chung S, Hung K, Kudenchuk P, Mancini MB, Nishiyama C, Smith C, Smyth M, Morley P, Olasveengen TM on behalf of the BLS Task Force. Firm Surface for CPR – Adults. Consensus on Science and Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) BLS Task Forces, 2019 December 28th. Available from: http://ilcor.org
Methodological Preamble
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of different support surfaces for CPR conducted by two ILCOR evidence reviewers (Perkins and Couper) with involvement of clinical content experts (Grolmusov, Tay-yibah, Holt, Ward, Chukowry). Evidence was sought and considered by the Basic Life Support (BLS) Task Force group and the Pediatric Task Force groups respectively.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults or children in cardiac arrest on a bed (out-of-hospital and in-hospital
Intervention: CPR on a hard surface e.g. backboard, floor, deflatable or specialist mattress
Comparators: CPR on a regular mattress
Outcomes: Survival, survival with a favourable neurological outcome, ROSC, CPR quality
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Randomised manikin / simulation / cadaver studies will only be included if insufficient human studies are identified. Unpublished studies (e.g., conference abstracts, trial protocols), non-randomised manikin / simulation / cadaver studies, animal studies, experimental / lab models, mathematical models, narrative reviews, editorials and opinions with no primary data were excluded.
Timeframe: 1st Jan 2009 to 16th Sept 2019
PROSPERO Registration CRD42019154791
Consensus on Science
This topic was prioritised for review by the BLS Task Force as it had not been updated since 2010. [Koster 2010 e48; Sayre S298]. Members of the Task Force reported variation in backboard use and 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. The identified science has been grouped under the subheadings; Mattress type, Floor versus bed and Backboard.
Mattress type
We did not identify any evidence to address the critical outcomes of favourable neurological outcome, survival and ROSC.
For the important outcome of compression depth we identified low certainty evidence (downgraded for serious indirectness) from 4 RCTs when CPR was performed on resuscitation manikins with different mattress types. Heterogeneity between mattress types precluded a meaningful meta-analysis.[Oh 2013 987; Perkins 2003 2330; Song 2013 469; Tweed 2001 179] Two studies compared a compressed foam mattress with a standard mattress.[Oh 2013 987; Song 2013 469] Each study involved 9 subjects and found similar compression depths (compressed mattress 51 mm, standard mattress 51 mm [Song 2013 469]; compressed mattress 51mm, standard mattress 50mm.[Oh 2013 987] A further randomized cross over trial involving 20 subjects compared a standard foam mattress (compression depth 35mm) with an inflated pressure relieving mattress (compression depth 37mm) and deflated pressure relieving mattress (compression depth 39mm.[Perkins 2003 2330]. An additional, small (n=4) randomised cross over trial reported only small differences between a foam (mean depth 38mm) and 3 different pressure relieving mattresses (range 33mm-39mm).[Tweed 2001 179]
We did not identify any evidence to address the important outcomes of chest compression fraction / interruptions to CPR.
Floor versus bed
We did not identify any evidence to address the critical outcomes of favourable neurological outcome, survival and ROSC
For the important outcome of compression depth we identified low certainty evidence (downgraded for serious indirectness) from 4 RCTs when CPR was performed on resuscitation manikins. Meta-analysis of 2 studies [Jantii 2009 113; Perkins 2003 2330] showed no difference (4 mm (95% CI -1 to 9)) in chest compression depth when CPR was performed on a manikin placed on the floor compared to a bed. One randomized cross over manikin study involving 30 subjects reported no difference in chest compression depth when CPR was performed on the floor median 54 mm (IQR 51–56) on a bed with a hard foam mattress 54 mm (50–56) medium foam mattress 53 mm (48–57) or soft foam mattress 53mm (46–54) (P=0.3).[Ahn 2019 1]. An additional, small (n=4) randomised cross over trial reported only small differences between CPR performed on the floor (mean depth 43 mm) versus a foam mattress on a bed (mean depth 37.5mm) and 3 different pressure relieving mattresses (range 33mm-39mm).[Tweed 2001 179]
We did not identify any evidence to address the important outcomes of chest compression fraction / interruptions to CPR.
Backboard
We did not identify any evidence to address the critical outcomes of favourable neurological outcome, survival and ROSC
For the important outcome of compression depth we identified low certainty evidence (downgraded for serious indirectness) from 9 RCTs when CPR was performed on resuscitation manikins on hospital beds. Meta-analysis of 6 studies [Andersen 2007 747; Fischer 2016 274; Perkins 2006 1632; Sanri 2019 1; Sato 2011 770; Song 2013 469] showed a 3mm (95% CI 1-4) improvement in chest compression depth associated with backboard use when CPR was performed on a manikin on placed on a mattress / bed. A randomized cross over manikin study involving 24 subjects,[Putzer 2016 594] found no difference in median compression depth during CPR performed on a manikin on standard hospital mattress without (50mm (IQR 44-55)) and with a backboard (51mm (IQR47-55) or a pressure relieving mattress (without backboard 49mm(IQR 44-55) versus with backboard 50mm (IQR 44-53). A further randomized cross over trial involving 16 subjects found similar compression depths when CPR performed on a typical ICU mattress (mean depth 53mm without backboard, 51mm with backboard) and also on a memory foam mattress (mean depth 54mm without backboard and 54 mm with backboard). A further randomized cross over trial involving 9 subjects found similar compression depths when CPR performed on a foam mattress (mean depth 51mm without backboard, 52mm with backboard).[Oh 2013 987]
We did not identify any evidence to address the important outcomes of chest compression fraction / interruptions to CPR.
Treatment Recommendations
We suggest performing chest compressions on a firm surface when possible (weak recommendation, very low certainty evidence)
During in-hospital cardiac arrest, we suggest, where a bed has a CPR mode which increases mattress stiffness, it should be activated (weak recommendation, very low certainty of evidence).
During in-hospital cardiac arrest, we suggest against moving a patient from a bed to floor, to improve chest compression depth (weak recommendation, very low certainty of evidence).
During in-hospital cardiac arrest, we suggest in favour of either a backboard or no-backboard strategy, to improve chest compression depth, (Conditional recommendation, very low certainty of evidence).
Justification and Evidence to Decision Framework Highlights
The context for this question was that when chest compressions are performed on a mattress the compression force is dissipated through both chest compression and compression of the mattress under the patient. Manikin models indicate the amount of mattress compression ranges between 12-57% of total compression depth, with softer mattresses being compressed the most.[Lin 2017 22; Noodergraaf 2009 546; Oh 2013 987; Song 2013 469]. This can lead to reduced spinal-sternal displacement and a reduction in effective chest compression depth.
Effective compression depths can be achieved even on a soft surface, providing the CPR provider increases overall compression depth to compensate for mattress compression.[Beesums 2014 1439; Nishisaki 2012 1013; Sato 2011 770; Song 2013 469; Lee 2015 1425; Oh 2012 500; Ruiz 2016 6596040]. CPR feedback devices which account for mattress compression (e.g. the use of dual accelerometers or increasing compression depth targets) can help CPR providers to ensure adequate compression depth when CPR is performed on a mattress.[Perkins 2006 1632; Lee 2015 1425; Beesems 2014 1439 ; Hellevuo 2014 323; Lin 2017 22; Ruiz de Gauna 2016 6596040]
In making these recommendations the Task Forces highlights the importance of high quality chest compressions for optimising outcomes from cardiac arrest.
The Task Force noted that there were no clinical studies reporting on the critical outcomes of survival and favourable neurological outcome or important outcome of chest compression quality.
The weak recommendations are based on extrapolation from manikin studies, typically undertaken on a mattress placed on a hospital bed, where CPR was performed by a trained healthcare professional. The hospital beds involved in the studies typically had a rigid base. 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 absence of studies simulating out-of-hospital settings (where beds may be softer) and where the CPR provider may be a single untrained rescuer, led to the Task Force focusing recommendations on the in-hospital setting.
The Task Force supported performing chest compressions on a firm surface when possible as this reduces the risks of shallow compressions attributable to performing CPR on a soft surface.
The Task Force considered, where available, activating a CPR function on a mattress, although unlikely to substantially improve compression depth, posed a low risk of harm to rescuers and patients leading to a weak recommendation of support.
In considering whether to transfer a patient from a hospital bed to the floor 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, leading to a weak recommendation against routine use of this practice.
The Task Force made a conditional recommendation for the use of a CPR backboard during in-hospital cardiac arrest. Within the limitations of manikin studies, the available evidence indicates a marginal benefit to chest compression depth from use of a backboard. No studies specifically evaluated backboard deployment and any impact this has on interruptions to chest compressions and / or displacement of tubes and lines during insertion. For healthcare systems which have already incorporated backboards in to routine use during in-hospital arrest, the evidence was considered insufficient to suggest against their continued use. For healthcare systems which 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.[Cloete 2011 1064; Cloete 2011 1167; Cloete 2011 2484; Cheng 2017 364; Perkins 2009 79]
Knowledge Gaps
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 relevant to out of hospital cardiac arrest
- Studies in both high and low resource settings where hospital bed or pre-hospital stretcher configurations may vary
Attachments
Evidence-to-Decision Table: Firm surface for CPR
References
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