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Firm Surface for CPR (BLS): Systematic Review

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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 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

Ahn HJ, Cho Y, You YH et al. Effect of using a home-bed mattress on bystander chest compression during out-of-hospital cardiac arrest. Hong Kong Journal of Emergency Medicine. 2019;1024907919856485.

Andersen LØ, Isbye DL, Rasmussen LS. Increasing compression depth during manikin CPR using a simple backboard. Acta Anaesthesiol Scand. 2007;51(6):747-50.

Beesems SG, Koster RW.Accurate feedback of chest compression depth on a manikin on a soft surface with correction for total body displacement. Resuscitation. 2014;85(11):1439-43.

Cheng A, Belanger C, Wan B, Davidson J, Lin Y. Effect of Emergency Department Mattress Compressibility on Chest Compression Depth Using a Standardized Cardiopulmonary Resuscitation Board, a Slider Transfer Board, and a Flat Spine Board: A Simulation-Based Study. Simul Healthc. 2017;12(6):364-369.

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(8):1064-70.

Cloete G, Dellimore KH, Scheffer C. Comparison of experimental chest compression data to a theoretical model for the mechanics of constant peak displacement cardiopulmonary resuscitation. Acad Emerg Med. 2011;18(11):1167-76.

Cloete G, Dellimore K, Scheffer C. The impact of various backboard configurations on compression stiffness in a manikin study of CPR. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:2484-7

Fischer EJ, Mayrand K, Ten Eyck RP. Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study. Am J Emerg Med. 2016;34(2):274-7.

Hellevuo H, Sainio M, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. The quality of manual chest compressions during transport--effect of the mattress assessed by dual accelerometers. Acta Anaesthesiol Scand. 2014;58(3):323-8.

Jäntti H, Silfvast T, Turpeinen A, Kiviniemi V, Uusaro A. Quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed. Acta Anaesthesiol Scand. 2009;53(9):1131-7.

Lee S, Oh J, Kang H, Lim T, Kim W, Chee Y, Song Y, Ahn C, Cho JH. Proper target depth of an accelerometer-based feedback device during CPR performed on a hospital bed: a randomized simulation study. Am J Emerg Med. 2015 Oct;33(10):1425-9.

Lin Y, Wan B, Belanger C, Hecker K, Gilfoyle E, Davidson J, Cheng A. Reducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study. Adv Simul (Lond). 2017;2:22.

Nishisaki A, Maltese MR, Niles DE, Sutton RM, Urbano J, Berg RA, Nadkarni VM. Backboards are important when chest compressions are provided on a soft mattress. Resuscitation. 2012;83(8):1013-20.

Noordergraaf GJ, Paulussen IW, Venema A, van Berkom PF, Woerlee PH, Scheffer GJ, Noordergraaf A. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation. 2009;80(5):546-52.

Oh J, Song Y, Kang B, Kang H, Lim T, Suh Y, Chee Y. The use of dual accelerometers improves measurement of chest compression depth. Resuscitation. 2012 Apr;83(4):500-4.

Oh J, Chee Y, Song Y, Lim T, Kang H, Cho Y. A novel method to decrease mattress compression during CPR using a mattress compression cover and a vacuum pump. Resuscitation. 2013;84(7):987-91.

Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mattresses affect the quality of cardiopulmonary resuscitation? Intensive Care Med. 2003;29(12):2330-2335.

Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B, Thickett DR. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med. 2006;32(10):1632-5

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(1):79-82

Putzer G, Fiala A, Braun P, Neururer S, Biechl K, Keilig B, Ploner W, Fop E, Paal P. Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study. J Emerg Med. 2016;50(4):594-600.

Ruiz de Gauna S, González-Otero DM, Ruiz J, Gutiérrez JJ, Russell JK. A Feasibility Study for Measuring Accurate Chest Compression Depth and Rate on Soft Surfaces Using Two Accelerometers and Spectral Analysis. Biomed Res Int. 2016:6596040.

Sanri E, Karacabey S. The Impact of Backboard Placement on Chest Compression Quality: A Mannequin Study. Prehosp Disaster Med. 2019;34(2):182-187

Sato H, Komasawa N, Ueki R, Yamamoto N, Fujii A, Nishi S, Kaminoh Y. Backboard insertion in the operating table increases chest compression depth: a manikin study. J Anesth. 2011;25(5):770-2.

Song Y, Oh J, Lim T, Chee Y. A new method to increase the quality of cardiopulmonary resuscitation in hospital. Conf Proc IEEE Eng Med Biol Soc. 2013:469-72.

Tweed M, Tweed C, Perkins GD. The effect of differing support surfaces on the efficacy of chest compressions using a resuscitation manikin model. Resuscitation. 2001;51(2):179-83.


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