Bystander Intervention in Improving Survival Changes of CPR

Pre-Hospital Care

On Scene

 Time. In response to a call for a possible cardiac arrest, the time that it takes for first responders to arrive on scene greatly influences the survival rate of those that receive CPR. In the cases of non-survivors, those who either received care from uneducated bystanders (83.8%) or did not receive any care prior to EMS presence (87.3%). Comparatively, when EMS professionals were involved in BLS and CPR the proportion of those who died as a result of their arrest dropped 20%. (Bakran, 2019)

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 Quality. As the ACLS guidelines for CPR are updated, the methods and expectations of care can change. It is the responsibility of the responders to keep up to date with the new ACLS guidelines. The ability for responders to adjust and perform these changes appropriately will affect the survival rates of those who experience cardiac arrest. Another way of improving the quality of care provided by first responders is consistent assessments of performance. In a study conducted in the pediatric intensive care unit at Nationwide Children’s Hospital aimed to show how even certified nurses and trained professionals could still improve their quality of CPR with practice and adequate feedback. (Bishop, 2018)

 Number of Providers. The providing of team-based CPR has been shown to lead to a higher rate of success among all of those who suffered from a cardiac arrest. The ability for a single responder to adequately and steadily perform CPR for an extended period of time is greatly improved by the assistance of another responder. The ability to cycle compressions and provide feedback to one another is shown to be monumentally influential in the survival rate of patients. In 2016 it was shown through an analysis of the cardiac arrest registry for enhanced survival by DA Pearson (2016) that “good neurologic outcome was higher with TFCPR… vs. standard CPR.”

Bystander Awareness

 Rarely are EMS providers the first people to find the victim of a cardiac arrest. People often witness friends or family undergo the event and call 911. When this happens, it’s important that a bystanders can step in and perform CPR while the emergency responders are on their way. The faster that CPR can begin, the understanding is that the patient’s chance of survival increases. There are costs and benefits to having people who are not certified in the procedure performing it.

Bystander intervention. The intervention of bystanders in cardiac arrestsis greatly supported by a national Swedish study performed by the Sahlegrenska University Hospital that found that in cases where bystanders attempted to resuscitate a victim, the likelihood of the patient surviving a month was 3.5 times more likely than any patient that did not receive bystander assistance. Along with overall survival, CPR is used to prevent the effects of brain damage that will occur after minutes of the heart stopping. A victim of cardiac arrest is more likely to fully recover if CPR is performed within 6 minutes of the heart stopping in order to prevent this damage from occurring. (Becker, 2017)

 Influencing Factors. As the circumstances surrounding an individual’s cardiac arrest are unique to their situation, there are factors that influence the effectiveness of bystander intervention. Sometimes there are obstacles or uncertainties that can hinder the ability of a person to begin CPR.

  Time. Especially in cases of cardiac arrests at a person’s home, the time between collapse and discovery can be very vague. The length of time between the patient collapsing and a bystander coming across them is an extension of the idea that faster care is more effective.

  Nerves. The chances in which an ordinary citizen encounter’s a cardiac arrest is very unlikely. This makes the occurrence a stressful event that can cause reckless and irrational decision making on the part of whomever is responsible for administering care to the individual. The vast percentage (60%) of cardiac arrests occur in people’s homes, and therefore, likely around friends or family members who may not have any CPR experience. This can result in “any hesitation in initiating bystander CPR will simply decrease the odds of survival and good neurological outcome” (Becker, 2017).

Bystander knowledge. There have been many studies done to find out the public’s awareness of how to perform basic life support, and this study was done to find, out of 500 subjects, who could successfully perform resuscitation. As found in the Journal of Family Medicine & Primary Care

The awareness of participants about relief operations were only acceptable in 9 cases. Only 1 (0.2%) of them was able to detect a pulse and blood circulation as well as to relieve any airway obstruction. 7 (1.4%) were able to correctly find the position on the chest where external cardiac massage (ECM) should be performed. And only 1 could perform ECM at a rate of 100-120 compressions/min. (Ghasemi 2019)

 Due to time being a critical aspect of caring for a cardiac arrest, the influence of bystanders can be the key to saving time while first responders are on their way. The negative results of this study suggest that everyday bystander’s likely don’t know how to perform proper basic life support. This lack of knowledge is dangerous, as performing poor or negligent CPR will not help the patient and will not have the positive effects that bystander intervention provides.

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 Education. The education of individuals on the importance and effectiveness of CPR is key in promoting bystander intervention. As levels of understanding will vary from person to person, in cases of cardiac arrest the importance of having someone nearby that knows how to properly perform CPR is important. As of 2016, a survey was done in Daegu Metropolitan City, in which 2141 people were involved. This survey was done in order to find the percentage of people who had the correct knowledge of CPR and the confidence of these individuals if they came in contact with a cardiac arrest.

Understanding. Compared to a similar survey done in 2012 by the same institution, the numbers reflected an understanding of CPR, as 11.7% of participants had adequate knowledge. This is a 10% improvement from the same survey that was done in 2012.

Confidence. Within this same group, they tested the willingness of these individuals to perform CPR on a stranger. Compared to the 54% of people in 2012, only 35% of people stated that they would be willing to perform CPR on someone that they don’t know. (Moon, 2019)

Technology

 Training. Receiving feedback about given CPR is important within a training environment. Technology is a key aspect of receiving feedback. While performing compressions on a manikin, feedback in the form of a chest compressor sensor can be accessed to determine the quality. Application of corrective feedback is important for the instructor and the individual being trained. The addition of voice prompts on AED’s has also proven to improve and simplify the providing of care. (Bishop, 2018)

 Mechanical CPR. The use of artificial means of CPR is not common practice among the EMS community. In mechanical compression devices (Thumper, AutoPulse, and LUCAS) the measurement of chest compressions is not a perfect science. Acting on the ACLS 5-6cm compression depth requirement, these machines don’t take into account the irregularity of the patients. Weighing the pros and cons of using a device for compressions is a “trade-off between the benefits of improved blood perfusion and the risks of liver laceration, rib fracture or other injuries is still not resolved” (Guang, 2015).

  Implementation. As of right now, the use of mechanical compression devices is not viewed as a potential replacement for manual CPR. As far as advancing this technology, the research being done to create a responsive software to be implemented into these devices could lead to improvement, but the lack of cost-effectiveness could hinder the widespread use of these devices.

Conclusion

 The most effective progress in improving the effects of CPR revolve strongly around the effects of bystander intervention. Along with that, the ability to decrease the length of time between a cardiac arrest and proper medical care is fundamental in improving the effects of CPR. At this point in time, there is no better method of delivering CPR than by manual application. In order to improve the effects of CPR there needs to be further efforts and time put into educating emergency medical responders and everyday citizens on how to perform CPR.

References

• Bakran, K., & Šribar, A. (2019). Cardiopulmonary resuscitation performed by trained providers and shorter time to emergency medical team arrival increased patients’ survival rates in Istra County, Croatia: a retrospective study. Croatian Medical Journal, 60(4), 325-332. doi: 10.3325/cmj.2019.60.325
• Becker, T., & Michael, B. (2017). Bystander Cardiopulmonary Resuscitation: A Civic Duty. American Journal Of Bioethics, 17(2), 51-53. doi: Bystander Cardiopulmonary Resuscitation: A Civic Duty
• Bishop, R., Joy, B., Moore-Clingenpeel, M., & Maa, T. (2018). Automated Audiovisual Feedback in Cardiopulmonary Resuscitation Training: Improving Skills in Pediatric Intensive Care Nurses. Critical Care Nurse, 38(5), 59-66. doi: 10.4037/ccn2018490
• Ghasemi, Y., Jouzi, M., & Hemmatipour, A. (2019). Evaluating the awareness of ordinary people about relief operations and cardiopulmonary resuscitation when facing out-of-hospital cardiac arrest. Journal Of Family Medicine And Primary Care, 8(7), 2318. doi: 10.4103/jfmpc.jfmpc_408_19
• Holmberg, M. (2001). Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. European Heart Journal, 22(6), 511-519. doi: 10.1053/euhj.2000.2421
• Moon, S., Ryoo, H., & Lee, K. (2019). A 5-year change of knowledge and willingness by sampled respondents to perform bystander cardiopulmonary resuscitation in a metropolitan city. PLOS ONE, 14(2), 1-13. doi: 10.1371/journal.pone.0211804
• Pearson, D., Darrell Nelson, R., Monk, L., Tyson, C., Jollis, J., & Granger, C. et al. (2016). Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation, 105, 165-172. doi: 10.1016/j.resuscitation.2016.04.008
• Zhang, G., & Wu, T. (2015). A mechanical chest compressor closed‑loop controller with an effective trade‑off between blood flow improvement and ribs fracture reduction. Springer, 53, 487-497. doi: 10.1007/s11517-015-1258-y