Willingness to perform Bystander-CPR (EIT #626): Scoping Review

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: Iwami T. is author of 3 studies cited in this scoping review.

Task Force Scoping Review Citation

Iwami T, Scapigliati A, Matsuyama T, Pellis T, Bhanji F, Bigham B, Bray J, Breckwoldt J, Cheng A, Duff J, Glerup Lauridsen K, Gilfoyle E, Hiese M, Lockey A, Ma M, Monsieurs K, Pellegrino JL, Okamoto D, , Yeung J, Finn J, Greif R. - on behalf of the International Liaison Committee on Resuscitation Education Implementation and Team Task Force.

Willingness to perform bystander-CPR Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education Implementation Team Task Force, 2020 January 3. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

We searched for studies investigating factors associated with increasing or decreasing bystander cardiopulmonary resuscitation (bystander-CPR) in actual settings. We excluded simulation studies or studies overlapping other ILCOR systematic reviews / scoping reviews (e.g. dispatcher instructed CPR, Community initiatives to improve CPR, etc.)

According to a recent qualitative review of emergency calls {Case 2018 43}, we considered that these factors can be categorized into three types of facilitators or barriers to perform CPR: personal factors, CPR knowledge, and procedural issues.

Scoping Review

We expect to submit this Scoping Review for Publication in January 2020.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Bystanders (lay persons) in out-of-hospital cardiac arrest (OHCA)

Intervention: Factors that increase or decrease the willingness of bystanders to perform CPR

Comparators: Absence of factors

Outcomes: Bystander CPR performance in actual situation, willingness to provide CPR in actual situation

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.

Timeframe: No limit, Literature search updated to January 4, 2020

Search Strategies

PubMed:

Cochrane:

Inclusion and Exclusion criteria

Inclusion Criteria: Studies investigating factors associated with an increase or decrease in bystander-CPR in actual settings

Exclusion Criteria:

• Simulation studies
• Unpublished studies (e.g., conference abstracts, trial protocols), letters, editorials, comments, case reports, systematic reviews
• Non-English studies
• Studies that overlap with other ILCOR SRs/ScRs (e.g. dispatcher instructed CPR, Community initiatives to improve CPR)

Data tables

Task Force Insights

1. Why this topic was reviewed.

The “chain of survival” is a well-known key concept for the successful resuscitation of patients with out-of-hospital cardiac arrest (OHCA).{Kronick 2015 S397; Nolan 2015 e1}. Many studies have affirmed that bystander-initiated CPR {Deakin 2018 80; Iwami 2009 728} and rapid defibrillation and the use of public access automated external defibrillators (AEDs) {Nakahara 2015 247; Malta 2015 255; Kitamura 2016 1649} significantly increase the chance of survival. The combination of bystander CPR and AED use has a synergistic positive effect on outcome {Sayre 2008 2162}. Lay rescuers therefore play a major role in improving survival in OHCA.

Despite the proven effectiveness of rapid CPR and AED use by bystanders, bystander CPR is provided in less than 50% of cases and AEDs are used even less often in most areas across the world, even though they are frequently available in public places {Mozaffarian 2015 e29; Agerskov 2015 53; Weisfeldt 2010 1713}. Data from the Cardiac Arrest Registries to Enhance Survival show considerable variation among counties with respect to survival and neurologic outcome suggesting these variations in outcome are attributed partially to varying frequencies of bystander CPR and AED use {Girotra 2016 2159; Dyson K 2019 168}. Thus, as previous guidelines have emphasized, increasing the willingness of individuals to respond to a cardiac arrest with early recognition, calling for help, initiation of CPR, and use of an AED is essential to improve survival from OHCA {Mancini 2010 S539}. A better understanding of the reasons why the rate of CPR and AED use by bystanders remains low is vital to develop interventions to increase bystander response and improve survival from OHCA.

The 2010 ILCOR CoSTR did a narrative review for this topic and described both positive and negative factors impacting on the willingness of bystanders (both lay rescuers and health care providers) to provide CPR {Mancini 2010 S539; Bhanji 2010 S920}. The 2015 ILCOR CoSTR recommended the use of BLS training interventions that focus on high-risk populations, based on the willingness to be trained and the fact that there is low harm and high potential benefit (strong recommendation, low-quality evidence). {Finn 2015 e203}.

This topic of willingness of bystanders to perform CPR was chosen for a new scoping review by the EIT Task Force in this current round of evidence assessment because of the low incidence of provision of CPR and AED use by bystanders in most areas across the world and the need to identify barriers and facilitators to provide them more for victims of OHCA.

1. Narrative summary of evidence identified

There was significant heterogeneity among study populations, study methodologies, definitions of factors associated with willingness to provide CPR, outcome measures utilised and outcomes reported.

There were no randomised controlled trials identified. We included 18 observational studies (Swor 2006 596; Case 2018 43; McCormack 1989 283; Blewer 2018 e004710; Matsuyama 2019 577; Tanigawa 2011 523; Matsui 2019 e195111; Chiang 2014 53; Dahan 2017 107; Moncur 2015 105; Vaillancourt 2008 417; Sasson 2012 1067; Chang 2017 26; Langlais 2017 163; Axelsson 1996 3) reporting factors associated with the willingness of actual bystanders to perform CPR. Findings are grouped into three types of barriers (personal factors, CPR knowledge, and procedural issues) according to a recent qualitative review of emergency calls {Case 2018 43}.

Factors that reduce bystanders’ willingness to respond to a cardiac arrest with early recognition, call for help, perform CPR, and use an AED

a. Personal factors (emotional barriers and physical factors)

We identified 14 observational studies (Swor 2006 596; Case 2018 43; McCormack 1989 283; Blewer 2018 e004710; Matsuyama 2019 577; Tanigawa 2011 523; Matsui 2019 e195111; Chiang 2014 53; Dahan 2017 107; Moncur 2015 105; Vaillancourt 2008 417; Sasson 2012 1067; Chang 2017 26; Langlais 2017 163) addressing personal factors that reduce bystanders’ willingness to perform CPR.

In a study of actual bystanders interviewed following an emergency call in which the EMS dispatcher encouraged performance of CPR, non-responders most frequently cited panic (37.5%) as the reason why they were unable to perform CPR {Swor 2006 596}. Emotional factors such as hysteria and panic were identified in 20% of the emergency calls for bystander-witnessed arrests and were primary emotional barriers to dispatcher-assisted CPR during witnessed arrests {Case 2018 43}.

A study interviewing emergency medical service personnel and bystanders who initiated or participated in the administration of CPR described that disagreeable physical characteristics such as vomiting were present in 59% of OHCA and affected the willingness of bystanders to perform CPR {McCormack 1989 283}. Some observational studies of OHCA from different geographical regions demonstrated that female patients were less likely to receive CPR {Blewer 2018 e004710; Matsuyama 2019 577; Tanigawa 2011 523} or have AED pads applied {Matsui 2019 e195111}, especially in public settings {Blewer 2018 e004710; Matsuyama 2019 577} or when they were of reproductive age {Matsui 2019 e195111}. Observational studies of OHCA from different parts of the world consistently demonstrated that patients who suffered OHCA in low socioeconomic status areas were less likely to receive bystander CPR, although the association with survival outcomes was different across studies {Chiang 2014 53; Dahan 2017 107; Moncur 2015 105; Vaillancourt 2008 417}. The association between race and provision of CPR is controversial but again it is likely to be due to socioeconomic differences among neighborhood subgroups rather than to ethnical differences per se {Sasson 2012 1067}, since it has been described even in local contexts where ethnicity but not economic composition is homogeneous {Moncur 2015 105}. It was reported that in paediatric OHCA cases, family members were more likely than strangers to perform CPR except in communities with the lowest educational level {Chang 2017 26}.

A study reviewing emergency calls demonstrated that physical factors impacted on their ability to administer CPR in 37.5% cases, however this was primarily in relation to their ability to position the patient flat on their back on the floor, rather than to deliver compressions {Case 2018 43}. Another study reviewing audio recordings of telephone CPR also noted barriers to patient positioning for dispatcher-assisted CPR and demonstrated that inability to move patients to a hard, flat surface is associated with a reduced rate of CPR and increased time to first compression {Langlais 2017 163}.

b. CPR knowledge (skill deficits, perceived benefit)

We identified 3 observational studies (Case 2018 43; Axelsson 1996 3; Swor 2006 596) addressing lack of CPR knowledge as factors reducing bystanders’ willingness to perform CPR.

In a study reviewing emergency calls, a lack of CPR knowledge or skills was reported most frequently (81.3% of calls) as a barrier to start CPR, with many bystanders reporting poor confidence and sense of incompetence due to a lack of prior CPR exposure even in cases in which dispatcher instructions were provided {Case 2018 43}. The study also showed that patient assessments and dispatcher-assisted CPR instructions were resisted because bystanders perceived that the patient was already deceased in 28.1% calls.

Similarly, a study reviewing actual experiences of OHCA bystanders showed that hesitation was mostly due to fear of causing injury or doing something wrong or because of the rescuer considered the intervention to be futile {Axelsson 1996 3}. In another study in which actual bystanders were interviewed, lack of confidence (9.1%) was cited as the reason why they were unable to perform CPR {Swor 2006 596}.

c. Procedural issues

We identified 2 observational studies (Case 2018 43; Axelsson 1996 3) addressing procedural issues as barriers of bystanders’ willingness to perform CPR.

A qualitative review of emergency calls listed communication or language barriers and late identification of arrest as procedural issues {Case 2018 43}. A study reviewing actual experiences of bystanders also showed causes for hesitation, for example uncertainty as to whether it was a cardiac arrest {Axelsson 1996 3}. The difficulties of early recognition of cardiac arrest both by bystanders and dispatchers were mentioned in the past CoSTRs {Sayre 2010 S298; Perkins 2015 e43} and continue to be a major issue to overcome.

Factors that increase bystanders’ willingness to perform CPR (excluding dispatcher instructions, community initiatives, and social media technologies)

We identified 5 observational studies (Swor 2006 596; Tanigawa 2011 523; Nishiyama 2019 63; Iwami 2015 415; Ro 2016 17) addressing factors increasing bystanders’ willingness to perform CPR.

A study interviewing actual bystanders suggested that CPR provision was more common in CPR-trained bystanders with more than a high-school education and when CPR training had been attended within five years {Swor 2006 596}. Another observational study interviewing actual OHCA bystanders demonstrated that people who had experienced CPR training had a greater tendency to perform bystander CPR than people without experience of CPR training (AOR, 3.4; 95% CI 1.31–8.85) {Tanigawa 2011 523}. A cross sectional survey interviewing 5549 university students in Japan who attended hands-on mass training of CPR and AED use showed that the incidence rate of encountering suspected OHCA patients was 1.1 per 100 person-years and half of those who encountered a collapsed person performed at least one resuscitation action {Nishiyama 2019 63}.

Large nationwide observations in Japan demonstrated that wider dissemination of chest compression-only CPR was associated with an increase in bystander-initiated CPR and in survival with favorable neurological outcome suggesting a benefit of simplified chest compression-only CPR to increase bystanders’ willingness to perform CPR {Iwami 2015 415}. Interestingly, a study conducted in US reported that a very low proportion (1.1%) of actual bystanders objected to perform mouth-to-mouth ventilation suggesting that mouth-to-mouth ventilation is not a barrier to perform CPR for bystanders {Swor 2006 596}.

A large cross-sectional study in Korea using an OHCA registry database demonstrated that higher CPR capacity (e.g. CPR-Awareness, CPR-Any-Training, CPR-Recent-Training, CPR-Manikin-Training, and CPR-Self-Efficacy) at community level was associated with higher bystander CPR and survival to discharge rates after OHCA {Ro 2016 17}.

1. Narrative Reporting of the Task Force discussions

Before starting the evidence review for this topic, the Task Force discussed which type of review should be done (i.e. a narrative summary on barriers or facilitators to perform CPR as in CoSTR 2010 or a systematic review to evaluate some interventions to improve willingness to perform CPR as in CoSTR 2015). After discussion, the EIT Task Force decided to perform a scoping review with a narrative summary on factors associated with the provision of CPR, AED use, or other lay rescuers’ actions in actual emergency settings. Even though the EIT Task Force was conducting reviews of the effectiveness of other interventions such as training, community initiatives, social media technologies, and dispatcher-assisted CPR to improve bystander CPR rate, it was considered that it would be useful to summarize the positive and negative factors associated with bystanders’ actions in real emergency settings. Therefore, the EIT Task Force decided to focus on lay rescuers (excluding health care providers) and evidence from actual emergency situation and experiences (excluding simulation study or survey not targeting actual experience).

Task force discussions suggested to categorize the factors associated with bystanders’ actions as used in a recent qualitative review of emergency calls {Case 2018 43} as follows; procedural issues, CPR knowledge, and personal factors.

The 2010 ILCOR Treatment Recommendation for rescuer willingness to respond stated: To increase willingness to perform CPR

• Laypeople should receive training in CPR. This training should include the recognition of gasping or abnormal breathing as a sign of cardiac arrest when other signs of life are absent.
• Laypeople should be trained to start resuscitation with chest compressions in adult and pediatric victims.
• If unwilling or unable to perform ventilations, rescuers should be instructed to continue compression-only CPR.
• EMS dispatchers should provide CPR instructions to callers who report cardiac arrest.
• When providing CPR instructions, EMS dispatchers should include recognition of gasping and abnormal breathing.

These studies suggest that a number of factors are present in actual settings which either inhibit or facilitate lay rescuers’ performance of CPR. BLS training, regional and national education programs, and dispatch instructions may be more effective (translate into actual performance of CPR) if these factors are considered.

Knowledge Gaps

Although this scoping review has not identified sufficient evidence to prompt a systematic review, it highlights significant knowledge gaps related to willingness to perform CPR by lay rescuers.

• There is a need to assess the efficacy of interventions aiming to address known barriers and enhance facilitators for actual bystanders to provide CPR, use of AEDs, and call for help for OHCA victims
• There is a need to assess the best methods to teach how to overcome known barriers to perform CPR in CPR training course.

There is a need to better understand those factors that enhance the willingness of bystanders to perform CPR and the barriers for those bystanders who were unwilling to perform CPR.

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