The effect of paramedic position on external chest compression quality: a simulation study
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Out-of-hospital cardiac arrest (OHCA) is a globally important public health issue that continues to be a significant cause of premature death. The incidence of OHCA treated by Emergency Medical Services (EMS) is around 50 to 55/100,000 per person-years across the US, Canada, Australia and New Zealand. There is significant disparity in the rates of survival to hospital discharge from OHCA. For OHCA treated by EMS this rate can vary as much as 1% to 31%. In order to improve outcomes for cardiac arrests the International Liaison Committee on Resuscitation (ILCOR) aims to integrate resuscitation science with real world clinical practice. ILCOR states there is a need to develop a culture of high quality resuscitation using a quality improvement approach. Survival from cardiac arrest is a complex issue with many stakeholders that form the basis of a system of care. ILCOR proposes that individual performance needs to be evaluated so that participants within the system of care are informed and can therefore effectively intervene to improve care Paramedics are the primary treatment providers for OHCA. Recently the resuscitation guidelines, which paramedics use in their practice, have emphasised the performance of quality chest compressions. With this in mind this thesis sought to investigate whether the position of the paramedic performing chest compressions, either from-the-side (FTS) or over-the-head (OTH), influenced the quality of cardiopulmonary resuscitation (CPR). A review literature identified only a few small studies in which OTH CPR was investigated over short durations. There was heterogeneity in the study design, types of participants and quality metrics measured with inconsistencies in the results across the studies. All of the studies identified in the review were manikin studies that used manikin-based technology, such as the Laerdal Skill Reporter (LSR), to measure the quality of CPR. Subsequent to these studies defibrillator technology has evolved and now devices that can measure CPR quality have been integrated into the defibrillator, an example of which is Q-CPR associated with the MRx defibrillator. Such devices enable measurement of CPR quality in both manikin and human studies. The first study (Chapter 3) investigated if the new defibrillator technology could be used to measure CPR quality in a manikin study. This study compared the measurement of CPR quality metrics simultaneously using LSR and Q-CPR, for chest compression performed OTH and FTS. The principle finding of this study was that there is no significant difference in the majority of chest compression quality metrics measured between the LSR and the Q-CPR devices. However, there were significant differences in the measurement of duty cycle and also the depth of compressions between the two devices. The mean difference in the depth of compression was observed to increase with an increasing incidence of leaning. The conclusion was that Q-CPR is a suitable alternative to LSR for measurement of the CPR quality and thus it was used in the main study. The main study compared OTH and FTS CPR quality (performed by 30 paramedics) during two simulated cardiac arrest scenarios, each of approximately 25 minutes duration. There was no significant difference in mean CPR quality between compressions performed OTH or FTS for all metrics measured. We concluded that for two rescuer CPR the composite technique, where the paramedic that is positioned at the head of the manikin performs OTH CPR, is an effective alternative to the traditional method of only performing CPR FTS.