Emergency. 2018; 6 (1): e46 BR I E F RE P O RT Quality of Cardiopulmonary Resuscitation in Emergency Department Based on the AHA 2015 Guidelines; a Brief Re- port Ali Vafaei1,2, Amin Shams Akhtari1, Kamran Heidari1,2, Somayeh Hosseini1∗ 1. Department of Emergency Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences , Tehran, Iran. 2. Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: June 2018; Accepted: July 2018; Published online: 21 July 2018 Abstract: Introduction: Adhering to existing guidelines on cardiopulmonary resuscitation (CPR) can increase the survival rate of the patients. The present study has been designed with the aim of determining the quality of CPR per- formed in the emergency department based on the latest protocol by the American heart association (AHA). Methods: In this prospective cross-sectional study CPR process was audited in patients above 18 years old in need of CPR presenting to the emergency departments of 3 teaching hospitals based on the AHA 2015 guide- lines. Less than 60% agreement was considered as fail, 60-70% as poor, 70-80% as moderate, 80-90% as good, and 90-100% as excellent. Results: 80 cases of CPR were audited (55% male). Location of arrest was the hospital in 58 (72.5%) cases and 48 (60.0%) of the cases happened during the day. 28 (35.0%) cases had orotracheal intu- bation before the initiation of CPR. 30 (37.5%) patients had a shockable rhythm at the initiation of CPR. Based on the findings, out of the 31 studied items, 9 (29.03%) had excellent agreement, 10 (32.25%) had good, 4 (12.90%) had moderate, 2 (6.45%) had poor, and 6 (19.35%) had fail agreement rate. Conclusion: Based on the findings of the present study, the quality of applying the principles of basic and advanced CPR in the emergency depart- ment of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA 2015 in at least one third of the cases. Keywords: Physical Education and Training; Cardiopulmonary Resuscitation; Clinical Audit; Emergency Service, Hospital; Internship and Residency © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Vafaei A, Shams Akhtari A, Heidari K, Hosseini S. Quality of Cardiopulmonary Resuscitation in Emergency Department Based on the AHA 2015 Guidelines; a Brief Report. 2018; 6(1): e46. 1. Introduction T hrough the centuries, human has used various and in- teresting methods for resuscitation of people close to death. Paracelsus was the first person that used black- smith bellows for blowing in the lungs of people who had faced sudden death. This method was commonly used for about 300 years in Europe. In the middle of 20th century the term cardiopulmonary resuscitation (CPR) was used for de- scribing the technique of simultaneous cardiac massage and mouth to mouth respiration in a person without a pulse (1, ∗Corresponding Author: Somayeh Hosseini ; Emergency Medicine Depart- ment, Loghman Hakim Hospital, Kamali Street, Karegar Avenue, Tehran, Iran. Tel: +989126054128 Email: hosseini.Somayeh1392@gmail.com. 2). This technique has significantly improved in a few years, especially regarding use of resuscitation operation in the hos- pital. In 2000, the international liaison committee on resuscita- tion held the first international conference of resuscitation for developing international guidelines for CPR and emer- gency cardiac care so that all individuals working in medical teams and rescuers follow the same protocols when perform- ing resuscitation (3). Based on these conditions, high qual- ity CPR is associated with: ensuring sufficient chest massage, proper depth, allowing chest recoil, minimizing the delay in massage, and avoiding too much ventilation. Currently, despite many attempts at CPR being unsuccess- ful, it is still an internationally accepted treatment operation (4, 5). Adhering to latest existing guidelines and perform- ing these guides with high quality in CPR can increase the This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Vafaei et al. 2 survival rate of the patients. Proofs of this claim are stud- ies that show with correct training and giving proper feed- back to the resuscitation team, percentage of successful CPR and its proper performance increase significantly (6-9). Yet, some researchers express that there isn’t a proper agreement between what happens at the clinic with international CPR guidelines (10, 11). These inadequacies lead to improper per- fusion in the cardiac and brain tissues and result in the poor outcome of the patient. Normally, evaluating the existing state is the first step taken in planning for other steps to improve the quality. Therefore, the present study has been designed with the aim of deter- mining the quality of CPR performed in the emergency de- partment based on the latest protocol by the American heart association (AHA). 2. Methods 2.1. Study design and setting In this prospective cross-sectional study on resuscitation, pa- tients above 18 years old in need of CPR presenting to the emergency departments of Loghmane Hakim, Imam Hos- sein, and Shohadaye Tajrish Teaching Hospitals, Tehran, Iran, from March 2017 to March 2018 were evaluated. Pro- tocol of this study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences. In the eval- uated emergency department all CPRs were performed by a team of emergency medicine and internal medicine resi- dents. 2.2. Data gathering The standard technique was defined based on the latest stan- dard guidelines of AHA 2015 for CPR. The evaluated items included: status of CPR initiation, status of applying pres- sure on the chest, the proper place for applying pressure, the number and depth of pressure applied, the number of ventilations per minute, ceasing pressure application for 10 seconds, evaluating the patient’s pulse, using electric shock, rapid initiation of CPR after shock, using vasopressor, switch- ing personnel for applying pressure, using anti-arrhythmic medications, time interval between vasopressor doses, tim- ing of using vasopressor drugs, timing of reaching safe air- ways, duration of CPR performance, correct prescription of alternative drugs, considering the 5H/5T, airway manage- ment, continuous evaluation of patient’s situation, express- ing measures such as checking level of consciousness, respi- ration and pulse, status of the team members (proper, im- proper), status of oxygen therapy and monitoring of the pa- tient and establishing venous flow. A trained senior emergency medicine resident was respon- sible for data gathering (approved by 3 emergency medicine professors) in various shifts (day, night), using consecutive sampling by being present at the bedside of patients who needed CPR. 2.3. Statistical analysis Considering 29% proper CPR performance (8), 95% confi- dence interval, 90% power, and the minimum considerable clinical significance of 10% the sample size was estimated to be 79 cases. In this study, based on Likert scale, less than 60% agreement rate with the AHA 2015 guidelines was considered as fail, 60-70% as poor, 70-80% as moderate, 80-90% as good, and 90-100% as excellent. 3. Results: 80 cases of CPR were evaluated in the mentioned emergency department (55% male). Location of arrest was the hospital in 58 (72.5%) cases and 48 (60.0%) of the cases happened dur- ing the day. 28 (35.0%) cases had orotracheal intubation be- fore the initiation of CPR. 30 (37.5%) patients had a shockable rhythm at the initiation of CPR. The rate of adherence to the principles of CPR by the resuscitation team has been summa- rized in table 1. Based on the findings, out of the 31 studied items, 12 (38.70%) had moderate or worse agreement with the principles recommended by the AHA 2015 guidelines. 4. Discussion Based on the findings of the present study, the quality of ap- plying the principles of basic and advanced CPR in the emer- gency department of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA 2015 in at least one third of the cases. The final success rate of in-hospital CPR that leads to discharge of the patient from hospital has been estimated to be 9% to 12% (10-12). Ko et al. assessed the quality of CPR in pre-hospital settings and showed that performance of CPR had an acceptable quality in only 29% of the cases (8). Hossein-Nejad et al. also per- formed a study in Rasoole Akram Hospital and showed that in only 25 (75.75%) of their studied CPR cases chest massage, pulmonary ventilation, pulse check, insertion of peripheral vein and intubation were performed correctly (13). Taha et al. in 2014 expressed that performance of quality CPR had a considerable effect on the survival of the patients and evaluated various factors affecting the initiation of sponta- neous blood circulation and survival of the patients after car- diopulmonary arrest in hospital. These researchers showed that applying pressure in the chest is done in 99.2% of the patients, applying pressure with at least 2 inches of depth in 92.4% of the patients, and stopping it for less than 10 seconds is done in only 48.7% of the patients (14). Sutton et al. also showed that CPR of children in hospital is not in agreement with the AHA guidelines in most cases (7). A study by Christopher Crowe et al. in 2015 in the United This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e46 Table 1: The rate of adherence of the resuscitation team to the principles of cardiopulmonary resuscitation (CPR) based on the recommen- dations of American heart association (AHA) 2015 Activity Number (%) Asking for help, ringing the bell, rapidly informing the CPR team 78 (97.5) All members of CPR team being present 74 (92.5) Having a predefined place and role for CPR team members 46 (57.5) Starting CPR without delay 58 (72.5) Proper management of the team by the leader 64 (80.0) Loudly expressing the measures taken by the team 14 (17.5) Applying the basic principles of airway management 28 (53.8) Applying advanced principles of airway management 47 (81.1) Doing intubation at the proper time 47 (81.1) Delay in intubation 23 (28.7) Proper number of ventilations in the intubated patient 44 (55.0) Applying the 30 to 2 ratio in cardiac massage 10 (20.8) Performing proper number of cardiac massages per minute 40 (50.0) Applying the standard depth for cardiac massage 48 (60.0) Doing the cardiac massage correctly 64 (80.0) Allowing chest recoil after applying pressure 48 (60.0) Applying the 80% ratio of massage duration to the total time of CPR 80 (100.0) Not putting cardiac massage before venipuncture 8 (8.7) Massagers changing every 2 minutes 61 (76.3) Checking the pulse for 10s between massages every 2 minutes 65 (81.5) Connecting the patient to monitor or defibrillator 80 (100.0) Using electroshock if needed 24 (80.0) Precautions for connection for the team before performing a shock 16 (66.7) Applying the proper cycle of shock-massage 16 (66.7) Proper medication with the proper dose after giving each shock 22 (91.7) Performing massaging for 2 minutes after each shock 48 (96.0) Prescribing epinephrine each 3 to 5 minutes 50 (100.0) Assessing and treating the cause of arrest during CPR 36 (45.0) Covering the patients during CPR 70 (87.5) Applying the standards of giving bad news to the relatives 71 (87.7) The in-charge physician informing the relatives 63 (87.7) Table 2: The overall status of applying the principles of resuscita- tion in the studies cases based on the standards of American heart association (AHA) 2015 Status Number (%) Excellent 9 (29.03) Good 10 (32.25) Moderate 4 (12.90) Poor 2 (6.45) Fail 6 (19.35) States with the aim of evaluating the quality of CPR in emer- gency deaprtment and the effect of receiving simultaneous audio visual feedback and receiving a report after the inci- dent. The results of the study showed a significant improve- ment in some CPR indices such as depth of chest massage and the speed of massage, and no considerable change in some indices such as chest massage not being continuous (9). In addition, the results of a systematic review introduced planning, leading and communication as the 3 main entan- gled mechanisms of coordination during CPR performance (15). It seems that by using tools such as continuous and up to date training as well as getting reports and giving audio vi- sual feedback during CPR we can take steps towards improv- ing the quality of CPR and increase its agreement with the ex- isting standards. This can lead to an increase in the number of successful CPR cases and survival of more patients. 5. Conclusion Based on the findings of the present study, the quality of ap- plying the principles of basic and advanced CPR in the emer- gency department of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA guidelines 2015 in at least one third of the cases. 6. Appendix 6.1. Acknowledgements The authors would like to thank the Clinical Research De- velopment Unit(CRDU) of Loghman Hakim Hospital, Shahid This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Vafaei et al. 4 Beheshti University of Medical Sciences, Tehran, Iran for their support, cooperation and assistance throughout the pe- riod of study (Grant number : 12944). 6.2. Author contribution All the authors of this article met the standard criteria of authorship based on the recommendations of international committee of medical journal editors. 6.3. 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