Knowledge and attitudes for CPR quality monitoring
We found a good situation in which 92.1% of respondents considered CPR quality monitoring to be needed during resuscitation. Mechanical compression devices were designed for some special situations and were considered to reduce the physical burden of emergency physicians . Because emergency departments in China were often crowded, the use of mechanical devices during resuscitation was common. Even in this situation, 94.3% of respondents considered CPR quality to need to be monitored. This showed that emergency physicians were concerned about CPR quality.
High-quality CPR was an important link between survival chains, and it may be more important than other links . Unfortunately, only 54.4% of respondents in this survey knew all six criteria of high-quality CPR and 60.9% knew all four criteria of high-quality chest compression. Most respondents were concerned about chest compression depth, rate and chest recoil between compressions. However, it was concluded that emergency physicians in tertiary general hospitals did not pay enough attention to minimizing compression interruptions. Minimizing compression interruption was also an important criterion of high-quality CPR emphasized in guidelines [13, 18]. Continuous chest compressions could maintain adequate coronary perfusion pressure, and increase the likelihood of ROSC . Chest compression fraction over 80% was recommended to ensure that compressions were continued with as few interruptions as possible during CPR. However, in this survey, only 68.0% of respondents knew this criterion. This may become a problem for improving CPR quality and it was important to strengthen the education of emergency phycisians to minimize compression interruption.
Visual observation was the most basic and widely used monitoring method, but objective parameters were recommended for accurate monitoring . We found that 72.4% of respondents knew objective monitoring methods. Clinical guidelines and academic conferences were the main ways emergency phycisians learned about their technology. However, in this survey, Chinese emergency physicians did not know some recommended techniques, especially audiovisual feedback devices.
It was important to find that many respondents had some misunderstandings about CPR quality control. For example, 71.3% of Chinese emergency physicians considered that using CPR quality monitoring devices could improve cardiac arrest patients’ outcomes. While current studies have not demonstrated significant improvement in outcomes related to CPR quality monitoring during resuscitation [13, 17, 22].
Although Chinese emergency physicians were concerned about CPR quality, they lacked an understanding of high-quality CPR criteria, new objective monitoring methods and research results.
Practices of CPR quality monitoring
Chest compression quality was a main problem during actual resuscitation in China. Low quality due to fatigue, inappropriate compression depth, and inappropriate compression rate were the top three problems reported by respondents. In contrast, personal ability and team cooperation were not issues. Because of this, quality control should be placed on a vital position in China. However, CPR quality monitoring was not a routine procedure in Chinese emergency department. Only 63.2% of respondents reported that they always/often monitored CPR quality during actual resuscitation. This showed that Chinese emergency physicians did not comply with the guidelines for CPR quality monitoring.
Accurate measurement of CPR quality was a precondition for high quality CPR. Objective parameters were better than visual observation . Our results showed that recommended methods were rarely used in Chinese emergency departments. ETCO2 was the most widely used among these methods. The opinions and clinical experience of experts strongly supported using ETCO2 to optimize chest compression quality during resuscitation [13, 17]. Endotracheal intubation was not difficult for Chinese emergency physicians, because they had rich clinical experience and visualization devices were widely used. Previous studies showed that advanced airway could be placed in the first few minutes during resuscitation in Chinese emergency departments . In this situation, ETCO2 data was easier to obtain. This could explain why ETCO2 was widely used in China. However, Using an audio-visual feedback device to monitor CPR quality was another recommended method by guidelines [13, 18]. It was a noninvasive technology for real-time monitoring, recording, and feedback about CPR performance [24, 25]. We found that less than 20% of respondents had used this equipment. Pulse oximetry was widely used, and its waveform could reflect peripheral tissue perfusion. Some research found that the appearance of pulse oximetry plethysmographic waveforms was related to CPR quality [26, 27]. Pulse oximetry plethysmographic waveforms, as a monitoring technology, were recommended for CPR quality monitoring by Chinese expert consensus in 2018. However, its usage rate was still lower than that of ETCO2 and invasive arterial pressure. The survey reported that few emergency departments had such equipment, and many emergency physicians did not know this technology.
Unrecommended methods were widely used for quality monitoring in Chinese emergency department and was the biggest problem. Palpation of the arterial pulse, observation of the ECG waveform, and observation of the SpO2 waveform were the top three most widely used methods. Palpation of arterial pulse was the most widely used method to evaluate chest compression quality, but it has been shown to be unreliable and cannot be used for continuous monitoring during actual resuscitation [28, 29]. Therefore, the guidelines did not recommend this method for CPR quality monitoring . Regular ECG waveforms accompanying chest compression can be observed in some patients, but the shape of the waveform had no clear relationship with the quality of chest compressions . The ECG waveform was widely used for quality monitoring, reflecting the misunderstanding of its meaning in Chinese emergency physicians.
Continuing education for emergency physicians was crucial to increase the use of recommended methods . Although CPR quality monitoring had been recommended by CPR guidelines, fewer specific consensus protocols existed that provided detail on how to better implement the monitoring. The development and publication of standardized monitoring protocols would likely help physicians better implement CPR quality monitoring in China.
CPR quality monitoring in training
Basic life support and advanced cardiac life support techniques were the core skills of resuscitation . The CPR training course was a key part of Chinese resident standardized training program. In most tertiary hospitals, all emergency physicians needed to attend basic life support courses and many of them also needed to attend advanced cardiac life support courses. CPR training courses in many hospitals were certified by the American Heart Association .
CPR training was not a one-time training. Retraining was recommended by AHA guidelines, because skills and knowledge may decay within 3 to 12 months after initial training . The concept of retraining was widely accepted in China, where 96.3% of respondents believed it was necessary to retrain after initial training. Responses showed that CPR retraining received great attention, and that a “frequent” retraining concept was more acceptable. A total of 72.8% of respondents considered the ideal interval between trainings to be 3 to 6 months, although there was no clear recommendation on the optimal time interval . Unfortunately, the survey results revealed a large gap between attitudes and practice, as 21.4% of emergency physicians did not receive any retraining after initial training. Among those who did, the actual retraining interval was 6 to 12 months, significantly longer than desired. This showed that most hospitals did not have standard retraining systems. Retraining may be difficult to implement in some hospitals. Short-term frequent retraining may be a solution in China. Because it would not increase the cost, if the total training time was fixed. Physicians were more likely to take part in a short training course after busy work. And frequent retraining was helpful to consolidate skills.
According to AHA’s CPR guidelines, feedback devices should be used in CPR training . This attitude was supported by 90.1% of respondents, who believed that CPR feedback devices can improve performance during training. However, attitudes and practice was so different. The typical training course in Chinese hospitals includes two parts: theory training and skills training. While the structure of the training course was reasonable, only 49.7% of respondents replied that CPR feedback devices were always/often used in training, and 25.1% replied that they never used feedback devices. In developing countries such as China, there were many hospitals that have no ability to purchase these devices. This may become an important barrier to improving CPR quality.