Understanding and improving low bystander CPR rates: a systematic review of the literature

Review Articles

CJEM 2008;10(1):51-65

Abstract

Résumé

Introduction

Cardiac arrest is the leading cause of mortality in North America. The annual incidence of out-of-hospital cardiac arrest in the United States and Canada is estimated to be 55 per 100 000, resulting each year in more than 173 000 cardiac arrests.1,2 Overall survival rate for out-of-hospital cardiac arrest rarely exceeds 5%.1,2 Bystander cardiopulmonary resuscitation (CPR) is associated with increased survival: a victim is almost 4 times more likely to survive a cardiac arrest event when receiving CPR from a bystander.3 Unfortunately, bystander CPR rates have remained low over the past decade, rarely exceeding 20%.2,4

Various attempts have been made in the past to improve bystander CPR rates, including

• the organization of mass CPR training events5-10
• CPR training of family members of patients suffering from heart disease11-22
• promotional CPR videos19,23-25
• CPR training of high school students.24,26-29

None of these initiatives have succeeded in significantly improving bystander CPR or survival rates for out-of- hospital cardiac arrest. CPR instructions through 9-1-1 dispatch assistance have been shown to increase bystander CPR rates,30 but their benefit on cardiac arrest survival remains unknown. While some communities have been able to reach bystander CPR rates as high as 54%,31,32 factors affecting these rates in the population are still unknown.

The objectives of this study were to systematically review the determinants of bystander CPR rates in the community, more specifically:

1. Who should be targeted to receive CPR training?
2. What CPR teaching program should be implemented to maximize understanding and retention?
3. When should maintenance of skills sessions occur?
4. Where should CPR instructions be given?
5. Why do people lack motivation to learn or perform CPR?

Methods

Study design, subjects and interventions

We systematically reviewed experimental and nonexperimental studies published on bystander CPR, including randomized controlled trials (RCTs), quasi-experiments, observational studies, literature reviews, editorials and letters. We included human participants of any age, sex, ethnic background, social status or geographical area. We excluded studies pertaining exclusively to the curriculum of health care professionals such as physicians, medical students, nurses and EMS personnel. We reviewed all educational tools applied at the individual, group or community level. These included computer software, media campaign, CPR instructions given over the phone and various CPR training curricula.

Outcome measures and search strategy

We evaluated various CPR promoting methods for their ability to:

1. Increase the proportion of CPR-trained individuals in the population.
2. Increase the bystander CPR rate for cardiac arrest victims.
3. Increase survival from cardiac arrest as a result of an intervention promoting CPR training.

Our electronic search strategy had no restriction for year, language or status of publication, and it was reviewed by an information specialist (Online Appendix 1). We searched 11 electronic databases using the OVID interface and included subject headings, truncation terms and text words in order to access databases that do not support the use of subject headings. We used an adapted electronic search strategy for the PubMed interface. We reviewed the Cochrane Controlled Trial Registry, hand searched the Canadian Journal of Public Health and the journal Resuscitation, reviewed the bibliography of emergency medicine textbooks (Online Appendix 2) and review articles, visited the websites of numerous scientific associations and contacted content experts in the field. Content specialists were selected based on their contribution to cardiac arrest research or for the recognized success of their respective communities in promoting bystander CPR, or both.

Selection and abstraction process

We imported the references into a bibliographical database library using Endnote version 7.0.0 (Thomson Scientific, Carlsbad, California). Duplicates were removed manually. We used titles and abstracts to make a first selection of references that met the study inclusion criteria. A reference was also selected if a decision could not easily be made from the title or abstract alone. Hard copies of the selected articles were obtained for further examination. One investigator (CV) reviewed the selected printed articles using standardized criteria to determine final eligibility in the systematic review. Studies were considered for meta-analysis if measures of spread were available or obtainable and if clinical homogeneity was present. A single reviewer (CV) performed data abstraction on all the selected articles using a standardized form. Data extraction included information on publication status, year, country and language of publication. Description of the study design, participant, intervention and outcomes was then extracted. The source of the data (i.e., text, table or graph) was also mentioned.

Methodologic quality of reports, data synthesis and assessment of retrieval bias

We evaluated the quality of RCTs using allocation concealment and the validated Jadad scoring system.33 This system allocates points (out of a maximum of 5) for quality and description of randomization, blinding and dropouts. Case-control and cohort studies were evaluated using the validated Newcastle-Ottawa scales.34-36 These scales allocate stars (out of a maximum of 9) for quality of selection, comparability, exposure and outcome of study participants. We grouped studies by topic and issued a "statement of evidence" for each topic. This statement of evidence is based on the scientific quality of the studies reviewed (Box 1) and the documented effect of the intervention on bystander CPR or cardiac arrest survival rates. We have calculated the recall and precision of our electronic search strategy. Recall is defined as the number of papers included in the systematic review found by the electronic search strategy divided by those found by the full search strategy; precision is defined as the number of papers included in the systematic review found by the electronic search strategy divided by all papers found by the electronic search strategy. Expected values for recall and precision are up to 90% and 20%, respectively.37

Results

We completed the search strategy in September 2005, and we identified 2408 potentially relevant papers. Using predetermined selection criteria, we rejected 1997 publications based on manuscript title and abstract. We used the same criteria to review full-text copies of the remaining 411 papers. Characteristics of the 159 publications rejected at this stage are presented in Figure 1. We were unable to locate 15of the 159 rejected publications despite exhaustive research and librarian support.

Our systematic review includes 252 publications. Meta-analysis was not possible because of the lack of homogeneity.

Our electronic search strategy was successful in retrieving 77.8% of all papers included in the systematic review. This high recall rate was achieved at the cost of having to review a large number of publications not relevant to our topic (with a precision of 8.6%). With 22.2% of all publications included in the systematic review coming from a source other than the electronic search, we are confident that a significant effort was made to find most of the information pertaining to our topic of interest.

Characteristics of the 252 papers that were included in our systematic review are presented in Table 1. Over 62% of the literature on CPR originates from the United States and is predominantly published in English. Most publications are hypothesis generating rather than hypothesis testing. Nearly 50% of the information comes from surveys or descriptive analysis. We came across 2 systematic reviews: one on the effectiveness of life support courses38; the other on infections that were potentially acquired during CPR.39 Hypothesis-testing studies are described in more detail in Online Appendix 3, including RCTs (42), quasi-experimental (25), before-after (11), case-control (1) and cohort studies (1).

Findings from the systematic review

The large number of studies included in our systematic review precludes their individual detailed description. Instead, we grouped the studies by topic and summarized their findings. At the end of each topic we included a statement along with a measure of the quality of the evidence supporting it (Box 1). A summary of all the statements of evidence appears in Table 2.

Who should be targeted to receive CPR training?

One approach to improving bystander CPR rates has been to train as many CPR providers as possible in mass training events. Such events can reach groups of a few hundred to thousands of participants.5-10 Although some efforts have been made to target groups at risk,40-42 mass training events usually attract young participants unlikely to witness cardiac arrest,23,43,44 they are not cost-effective45 and the effect of such interventions on survival of cardiac arrest has not been demonstrated in the literature. (Class II-3 evidence; see Box 1)

Up to 15% of the population suffers from long-term disabilities that may require tailored teaching strategies.46,47 Some people may not be able to sustain the effort associated with providing CPR,48,49 which is an aerobic exercise that could elicit ischemic symptoms in people with heart disease50-53 (Class I-2). Until further information is available, patients with known cardiac disease should seek the approval of their treating physician before attempting to perform CPR.

Spouses of individuals with cardiac disease are the most likely to witness cardiac arrest.54-56 Many authors suggest we should target family members of those individuals.11-22 The estimated rate of CPR training in this target group ranges between 9% and 47%.56-61 Although the addition of counselling to deal with the stress associated with being a potential CPR provider may be required,62,63 CPR training has been shown to reduce anxiety and increase emotional adjustment and the sense of empowerment in family members of cardiac arrest survivors.64-66 Family members of individuals with cardiac disease should be trained in CPR. (Class I-2)

Some authors suggest that physicians should "prescribe" CPR training to family members of individuals with cardiac disease.67-69 This is currently being done by 6% to 50% of surveyed physicians60,70-74; another 70% to 90% said they were interested in doing so in the future.74,75 The real benefit of physician-prescribed CPR training for family members of patients with cardiac disease remains unknown. (Class II-3)

Other groups have been targeted for CPR training. Students and children as young as 10 years of age, although unlikely to encounter cardiac arrest, can be taught CPR.24,26-29,76-86 Parents of young infants are another group that can learn CPR before leaving the nursery.87-97 Anecdotally, CPR training is mandatory in some countries at the time of obtaining or renewing one's driver's licence.24,26 (Class III) Unfortunately, despite a few well-designed trials demonstrating the possibility of teaching CPR to children and parents of young infants, there is little evidence supporting the benefit of these interventions to bystander CPR and survival rates. (Class I-2)

What CPR training program should be implemented to maximize understanding and retention?

CPR teaching guidelines are slightly different among national resuscitation councils. All programs share similar content delivery methods, and no clear support can be given to one over the other.98,99 Assar and colleagues proposed a staged teaching program.100-102 In the bronze stage, students are taught to recognize a cardiac arrest, call for help, open the airway and perform chest compressions; in the silver stage, they are taught how to provide ventilation and pediatric first aid; and in the gold stage they learn pediatric CPR and neonatal first aid. Although students finishing all 3 stages have better skills than conventionally trained students, only 38% completed the program.102 Staged training is not recommended because of its low rate of completion. (Class I-2)

Course length also varies. While 8-hour training sessions are associated with better retention of skills at 1 year,49,103,104 CPR can be taught successfully in 4-, 3- or even 2-hour sessions.18,81,105 There is good evidence demonstrating CPR skill acquisition during short CPR classes. (Class I-2)

A study using validated readability formulas (Smog and Flesch-Kincaid) determined that transcripts of CPR classes corresponded to a 10th grade level.106 Because of this, Daiker estimated that 23 million American adults may not be able to comprehend the content of CPR classes.106 Anecdotes and digression from the CPR curriculum are associated with poorer comprehension.107 There are various cognitive and behavioural approaches to teaching CPR.13,108-112 The content of CPR classes should be reduced and simplified. (Class II-1) This is supported by 3 literature reviews24,25,113 and 1 quasi- experimental study.105

Good quality CPR involves chest rising with each ventilation and a palpable pulse with each chest compression.114 But even health care professionals cannot rapidly and accurately determine if a victim is breathing or if a pulse is present.115-118 Laymen have even more difficulty in verifying whether there is a pulse.119 Laymen should not check for the absence of a pulse before initiating CPR.46,120 (Class I-2)

Another debate involves teaching chest compression alone or with ventilation.121,122 Most of the evidence supporting the chest compression alone approach comes from animal data.123-126 Contrary to animal anatomy, the human upper airway does not stay open spontaneously thus preventing the free flow of air during chest compressions.127,128 Among 885 observed cardiac arrest cases receiving bystander CPR, 16% of people survived with conventional CPR, compared with 10% who received chest compressions alone.129 Another study reported survival rates of 6.8% with chest compression alone, compared with 9.7% with traditional CPR (p < 0.001).130 In a study on dispatch instructions, 62% of 9-1-1 callers were able to perform CPR according to directives, and 81% of those were able to at least perform chest compressions correctly (p = 0.005).131 While chest compressions alone may be appropriate for instructions over the phone,132 airway and breathing management should continue to be taught as part of the CPR curriculum. (Class I-2)

Students' CPR skills improve significantly with more time spent practising on a manikin.82,133-135 Although sophisticated interactive manikins have been designed,136-138 cheaper basic models may do just fine.139 Other small portable prompt devices are arriving on the market.140 Efforts should be made to maximize the time spent practising the skills during CPR training.25,113,141-143 (Class I-2)

Modular self-training courses can address the different pace at which various people can learn.95,144 Participants in self-training modular courses perform similarly to those taking conventional CPR classes.38,77,145-147 There are a small number of well-designed trials supporting the use and benefit of modular self-training courses. (Class I-2)

Another popular self-training method uses videos.19,23-25 They can give results similar to conventional CPR training.79,81,94,148-153 Fewer studies found conventional CPR teaching superior to video self-teaching.93,154,155 Very good results have been obtained using a video developed by Braslow and colleagues.156 The video was validated on a group of medical students,157 and its effectiveness confirmed in a Baptist Church volunteer group.158 There is good evidence supporting the use of the Braslow self-training video. (Class I-2)

Another self-training method involves peer teaching (where a family member or friend becomes the instructor after having received basic CPR training).159-162 A peer teaching program successfully trained 1303 laymen over a few weeks in Norway.160 However, there is insufficient data to support the use of peer teaching at the moment. (Class II-3)

When should maintenance of skills sessions occur?

Irrespective of the teaching method, retention of CPR knowledge and skills is poor,24,27,38,163-169 and can significantly decrease as early as 6 weeks88,105 after a CPR class. Retrainingmay be protective against decline in CPR skills.170 Retention of CPR knowledge and skills may be poor because students never learned them well in the first place. In 1 study, investigators independently examined students at the completion of their CPR class; although all students received their CPR certification, none of them passed according to strict American Heart Association (AHA) criteria.171 This being said, there is no data suggesting outcomes are superior if a bystander were to perform CPR skills perfectly.55,172 Prior CPR training, even if completed a long time ago, appeared to result in better survival compared with the victims who received no CPR (11% v. 3%).173 While there is good evidence that retraining should take place on a regular basis in order to meet the AHA certification standards (Class I-2), there is little evidence that regular retraining is necessary for bystander CPR to be effective.

Where should CPR instructions be given?

Television has an influence on awareness and understanding of CPR.108,174-177 It is considered a privileged window into the population segment that is aged 50 years and older.178 In Seattle, Washington, repeated CPR instructions on television have led to a significant rise in bystander CPR rates.179 Although promising, there are currently limited data supporting the use of television to promote or teach CPR. (Class II-3)

CPR instructions over the phone could improve the low bystander CPR rates observed in residential dwellings.18,67,180,181 The ability of dispatchers to recognize cardiac arrest over the phone ranges between 68% and 90%.173,182 Agonal breathing, present as frequently as 30% in cardiac arrest victims, can limit their ability to recognize cardiac arrest.183,184 In Seattle, dispatchers overcalled cardiac arrest 14% of the time, leading to 4.3% inappropriate CPR administrations, though no adverse events were incurred.185 CPR instructions may only be possible in 30% to 37% of cases.186-190 While callers are emotionally capable of following instructions,173,191,192 they are not always in close range with the victim,31,191,192 or they struggle with the mouth-to-mouth instructions.193-195 In a randomized controlled trial of instructions to provide full CPR versus chest compressions alone, complete delivery of the instructions was achieved in 62% and 81%, respectively.131 Dispatch-assisted CPR instructions have been shown to increase bystander CPR rate,30 and possibly survival for cardiac arrest victims.173,196 There is strong evidence that 9-1-1 dispatchers should provide CPR instructions to callers. (Class I-2)

Why do people lack motivation to learn or perform CPR?

Although interest in CPR training decreases with advancing age,197-201 all but 1 study107 show a high success rate in an older age group (> 55 yr).148,202,203 Common reasons for not learning CPR include

• lack of time or interest
• inconvenience of having to leave the house
• cost
• inability to find a course
• bad health or physical limitations
• fear of contracting HIV
• fear of being sued.6,81,112,152,199,204-206

While no CPR provider has ever been successfully sued,207,208 failure to provide support could have legal consequences.209 We have descriptive evidence that modifiable factors exist and influence the knowledge translation of CPR skills in the community (Class II-3), but little is known about how to modify behaviour.

People are afraid they may contract an infectious disease when learning CPR on a manikin or when providing CPR to a victim. Historically, tuberculosis and polio were major concerns on the minds of potential rescuers.108 Today, HIV and hepatitis B cause the greatest concerns.108,210-213 But no case of HIV, hepatitis B, hepatitis C, or Creutzfeld-Jakob disease has ever been reported as a result of providing CPR to a victim or a manikin.13,39,214,215 Only 15 cases of Neisseria meningitidis, 3 cases of enteric pathogens, 2 cases of labial herpes, 1 case of tuberculosis and 1 potential case of SARS216 have ever been linked to providing CPR.39 It is extremely safe to practise CPR. Fears about disease transmission should be addressed in CPR classes. (Class II-3)

Mouth-to-mouth ventilation is an intimate act that may dissuade rescuers from performing CPR.129,217 Willingness to perform CPR is influenced by the relationship with the victim,7,15,40,58,218-222 as well as by the presence of vomit, dentures, blood, body odour and alcohol smell.161,223-225 Information on what to expect when required to perform CPR should be provided. (Class II-3)

Most CPR providers describe their experience as being positive.43,226,227 CPR certification is associated with greater confidence in one's ability to provide care, which in turn is associated with an increase in helping behaviour.17,57,142,228-231 But CPR training is still not an assurance of action.187,232-235 People are often unable to make a decision, rather than choosing not to help (the concept of ambiguity).235 Overall helping behaviour decreases with an increasing number of bystanders (the concept of diffusion of responsibility).234,236-239 Simple and complex behavioural methods exist to address those issues.240-242 CPR teaching should include information on the concepts of ambiguity and diffusion of responsibility. (Class I-2)

Discussion

The findings of our systematic review of the literature on bystander CPR can be summarized in the following way:

Who

There seems to be clear evidence that family members of potential victims of cardiac arrest should be targeted for CPR training. Those include spouses of individuals with known coronary disease and all senior citizens, perhaps with the exception of individuals who may not be able to sustain the physical effort required to perform CPR, such as patients who themselves suffer from coronary disease.

What

The content of most CPR classes need to be simplified and shortened. Time spent training on a manikin should be maximized, ventilations should continue to be taught and checking for a pulse should be omitted for laymen. CPR classes should include information about the very low-risk of disease transmission and about the concepts of ambiguity and diffusion of responsibility. The use of visual aids such as the Braslow video and self-training methods should be encouraged.

When

Although the ability to pass a CPR competency test starts to fade within months of the initial training, there is acceptable evidence that prior training in CPR may help save lives regardless of how long it has been since the training last occurred.

Where

Perhaps the most attractive intervention to increase bystander CPR rates is providing CPR instructions over the phone to callers reporting a victim of cardiac arrest. There is clear evidence that such an intervention is associated with higher bystander CPR rates.

Why

The lack of motivation to leave the house and register for a CPR class seems to be a major determinant of low bystander CPR rates, perhaps more so than the fear of disease transmission or litigation. We need to consider measures that will actively recruit individuals for CPR training.

Our search strategy identified 2 other systematic reviews of the literature pertaining to CPR.38,39 Jabbour and colleagues reviewed the effectiveness of basic and advanced life support courses on the basis of mortality and morbidity, retention of knowledge and change in practice behaviour. With regard to basic life support, they conclude that knowledge retention is poor, that modular courses are effective and that more studies on provider behaviours are warranted.38 The Mejicano and Maki review addresses only the issue of disease transmission during CPR.39 We found 2 other large reviews of the literature on CPR.19,24 Neither review describes the methodology by which publications were identified and selected. Chehardy used a recommendation classification system similar to our statement of evidence.19 The 2005 AHA Resuscitation Guidelines,243 published 2 months after we completed our search strategy, concentrated on the science of CPR rather than on determinants of its practice among bystanders.

Limitations

Our review had several potential limitations. First, because there was a significant amount of information to be reviewed and synthesized, a non-negligible amount of time elapsed between the completion of our search strategy and the publication of our results. A number of pertinent papers that could have affected our findings and recommendations may have been published during that period of time. For example, a recent study by Nagao may have influenced our recommendations against removing the ventilation component of CPR.244 Second, manuscript selection and data extraction were completed by a single reviewer; the potential selection bias resulting from this practice was limited by the use of standardized criteria for study selection and data extraction. Third, while we could not evaluate selection and extraction bias with formal statistical testing such as Funnel plots or file drawer numbers, our search strategy recall was in agreement with current methodologic standards for systematic reviews.37 In other words, we found an adequate number of studies in sources other than electronic searching. Fourth, we could have restricted our search strategy to experimental or well-designed observational studies, but felt that important information could be missed if we neglected to review other types of publications such as editorials, letters and expert communications. Finally, while the diversity of patient populations, interventions and outcome measures precluded a formal meta-analysis, we were able to group studies by topics and suggest statements of evidence, along with the quality of the evidence supporting that statement. To receive a high score, an intervention needed to be based on solid research methodology and show an effect on bystander CPR rates or survival for out-of-hospital cardiac arrest.

Conclusion

This systematic review of the literature examines the determinants of bystander CPR. Lack of interest and motivation play a major role in the lack of CPR training in the community. Targeted efforts are required to recruit learners most likely to witness cardiac arrest. CPR class format and content need to be shortened and simplified; learners need to spend more time practising on manikins; reassurance with regard to infectious diseases should be maintained; and more attention should be paid to behavioural aids that promote helping attitudes. Improved strategies to provide dispatcher-assisted CPR instructions should also be developed.

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