Professional Documents
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CLINICAL PAPER
a Institute for Experimental Medical Research, University of Oslo, N-0407 Oslo, Norway
b Norwegian Air Ambulance Foundation, Department of Research and Education, N-1341 Drøbak, Norway
c Division of Prehospital Medicine, Ullevål University Hospital, N-0407 Oslo, Norway
d Laerdal Medical, Tanke Svilands gt. 30, N-4002 Stavanger, Norway
e The National Competence Center for Emergency Medicine, Ullevål University Hospital,
Received 18 April 2006 ; received in revised form 24 May 2006; accepted 26 May 2006
KEYWORDS Summary
Out-of-hospital CPR; Aims: To compare quality of CPR during out-of-hospital cardiac arrest with and with-
Chest compression; out automated feedback.
Ventilation; Materials and methods: Consecutive adult, out-of-hospital cardiac arrests of all
Automated external
causes were studied. One hundred and seventy-six episodes (March 2002—October
2003) without feedback were compared to 108 episodes (October 2003—September
defibrillator (AED);
2004) where automatic feedback on CPR was given. Automated verbal and visual
Advanced life support
feedback was based on measured quality with a prototype defibrillator. Quality of
(ALS); CPR was the main outcome measure and survival was reported as specified in the
Clinical trials protocol.
Results: Average compression depth increased from (mean ± S.D.) 34 ± 9 to
38 ± 6 mm (mean difference (95% CI) 4 (2, 6), P < 0.001), and median percent-
age of compressions with adequate depth (38—51 mm) increased from 24% to 53%
(P < 0.001, Mann—Whitney U-test) with feedback. Mean compression rate decreased
夽 A Spanish translated version of the summary of this article appears as Appendix in the online version at
doi:10.1016/j.resuscitation.2006.05.011.
∗ Corresponding author. Tel.: +47 23016819; fax: +47 23016799.
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2006.05.011
284 J. Kramer-Johansen et al.
from 121 ± 18 to 109 ± 12 min−1 (difference −12 (−16, −9), P = 0.001). There were
no changes in the mean number of ventilations per minute; 11 ± 5 min−1 versus
11 ± 4 min−1 (difference 0 (−1, 1), P = 0.8) or the fraction of time without chest com-
pressions; 0.48 ± 0.18 versus 0.45 ± 0.17 (difference −0.03 (−0.08, 0.01), P = 0.08).
With intention to treat analysis 7/241 control patients were discharged alive (2.9%)
versus 5/117 with feedback (4.3%) (OR 1.5 (95% CI; 0.8, 3), P = 0.2). In a logistic regres-
sion analysis of all cases, witnessed arrest (OR 4.2 (95% CI; 1.6, 11), P = 0.004) and
average compression depth (per mm increase) (OR 1.05 (95% CI; 1.01, 1.09), P = 0.02)
were associated with rate of hospital admission.
Conclusions: Automatic feedback improved CPR quality in this prospective non-
randomised study of out-of-hospital cardiac arrest. Increased compression depth was
associated with increased short-term survival.
Trial registration: ClinicalTrials.gov (NCT00138996), http://www.clinicaltrials.gov/.
© 2006 Elsevier Ireland Ltd. All rights reserved.
Cardiopulmonary resuscitation (CPR) defined as The study was designed as non-randomised because
chest compressions and ventilations are important feedback-induced increased awareness of quality
for survival after cardiac arrest,1 and quality of CPR problems could spill over to the cases without
influences outcome during basic life support.2—4 feedback, thus potentially improving the quality
We have reported recently that quality of CPR of CPR also in the control group. The study was
during advanced life support (ALS) out-of-hospital approved by the regional ethics committees for
did not adhere to the international guidelines,5,6 Akershus (Norway), Stockholm (Sweden), and Lon-
when measured with new technology incorpo- don (England). Informed consent for inclusion in the
rated in standard defibrillators.7 Chest compres- study was waived as decided by these committees
sions were not given 48% of the time without spon- in accordance with paragraph 26 in the Helsinki
taneous circulation, and only mean 28% (median Declaration.16 In this prospective study registered
24%) of the chest compressions had a depth of at ClinicalTrials.gov (NCT00138996, Initial release
38—51 mm (guidelines recommendation).7 29th August 2005) patients older than 18 years suf-
Others have reported similar findings with fering from out-of-hospital cardiac arrests of all
the same equipment in in-hospital arrests,8 and causes were included. From March 2002 to October
the results correspond with those found with 2003 quality of CPR was recorded from the defibril-
other methods of quality measurements dur- lators without feedback to the rescuers. From Octo-
ing out-of-hospital arrest in first responders and ber 2003 to September 2004 feedback on CPR qual-
paramedics.9—11 ity via the defibrillators was activated. No informa-
Automated verbal feedback consistently has tion of the results from the first period was given to
been reported to improve quality of CPR during the rescuers in any of the involved services or pre-
manikin training,12,13 with faster recovery of CPR sented in any professional forum until the second
skills when tested 6 and 12 months later.14,15 Our period was terminated.
recent publication on quality of CPR during ALS
was a planned baseline-period before studying sim- Equipment
ilar feedback via the defibrillator during CPR on
patients. The hypothesis was that addition of such Prototype defibrillators based on standard Heart-
feedback would reactivate CPR skills and improve start 4000 (Philips Medical Systems, Andover, MA,
quality. USA) defibrillators were deployed in six ambulances
at each site. The defibrillators were approved for
investigational use in Europe by DNV (CE-mark;
Methods 2002-OSL-MDD-0009) and in the US by FDA (IDE#
G020121). The defibrillators had an extra chest
Except for the feedback system and statistical com- pad to be mounted on the lower part of the ster-
parisons between the two groups without and with num with double adhesive tape. The pad was fitted
feedback, all details of the methods in this study with an accelerometer (ADXL202e, Analog Devices,
have been reported in our recent publication,7 and USA) and a pressure sensor (22PCCFBG6, Honey-
a condensed version is therefore presented here. well, USA). The heel of the rescuer’s hand should
Quality of out-of-hospital cardiopulmonary resuscitation 285
be placed on top of the chest pad, and its move- the researchers. Feedback consisted of both verbal
ment was considered equal to that of the ster- messages in the national language and waveforms
num during chest compressions with compression on an extra LCD display on the defibrillator (visual
force >2 kg. A second accelerometer within the feedback). All feedback prompts with time codes
defibrillator allowed cancelling out vertical motion were saved to the extra data card. The paramedics
of the whole patient or supporting surface. The were encouraged to fill out written evaluation
method has been validated in a manikin model.17 forms after each CPR episode. Halfway through
Trans-thoracic impedance was measured by apply- the intervention period we modified the feedback
ing a near constant sinusoidal current across the rules. Findings from the baseline period made us
standard defibrillation pads and accelerometer and at that time aware that inactivity seemed to be a
impedance signals were stored in an extra data card major problem. A verbal prompt was added after
in the defibrillators.18 30, 45, and 60 s without CPR. Based on responses
CPR feedback was based on measured quality from the users a time buffer was added to avoid
compared to set standards (Table 1) based on overwhelming the paramedics with messages,
international guidelines and the expert opinion of especially reducing repetitive prompts. Incorrect
Table 1 Target values and priority rules for automatic verbal feedback versions 1 and 2
Prompts given when Priority Priority Comment
version 1 version 2
Compressions
Leaning >4 kg pad pressure 1 1 Incomplete release of chest
between compressions compression
Depth <38 mm 2 2
Rate <90 min−1 3 3
>120 min−1 3 3
Depth >52 mm 4 4
Duty cycle <30% 5 5
Ventilations
Impedance <0.8 1 1 Only verbal feedback if <0.8
change in version 2
<1.1 1 X
Inspiration time <0.8 s 2 2 Only before intubation was
indicated by pressing a button
on the screen
Rate <6 3 3
>16 3 3
Inspiration time >2.0 s 4 4
Pauses/pattern
>15 s 1 1 Tonal prompt.
Time without
>30 s 1 1 Changed to verbal prompt in
compressions
version 2
>45 s and >60 s X 1 Additional verbal prompts at 45
and 60 s introduced in version 2
Time without >30 s X 1 Introduced in feedback version
ventilation 2. If both compressions and
ventilations were lacking, a
verbal prompt addressing both
were given
Change from Only prompts on X Removed in feedback version 2
compressions ventilations and
to ventilation compressions in a 2:15
pattern before intubation
was indicated by pressing
a button on the screen
286 J. Kramer-Johansen et al.
ventilations, which had been a large problem in The actual number of compressions and ven-
manikin studies,13—15 was not so in the baseline tilations per minute are presented as well as
period, and was therefore given lower priority. The NFR, NFRadj and compression characteristics as
changes are summarised in Table 1. described above. Average values can obscure the
existence of short time segments with very high or
Training and treatment protocol low values; we therefore also report the number of
ventilations for all 1 min segments.
All ambulances were staffed with paramedics
trained once a year in ALS according to standard Outcome measure
international guidelines.5,6 Only Stockholm had a
Primary outcome was change in quality variables
two-tiered system with a nurse anaesthetist in the
after introduction of automated verbal feedback.
second car attending cardiac arrests. After all per-
Target values are given in Table 1. Secondary out-
sonnel had been trained in the use and meaning
comes were rate of hospital admission with sponta-
of the feedback software, concurrent with yearly
neous circulation and survival to hospital discharge
retraining, feedback was implemented in October
with neurological outcome.
2003 (London and Stockholm) and January 2004
(Akershus). During the whole data collection period
Statistical analyses
ambulance personnel in Akershus used the defib-
rillator in manual mode and used a modified CPR In the baseline period 176 patients had been
protocol with 3 min of CPR before the first DC shock included for quality analysis.7 Sample size for the
and between unsuccessful series of up to three DC feedback period was set at a minimum of 100
shocks.19 No involved hospital had implemented patients. This was based on calculations with Sam-
post-resuscitation therapeutic hypothermia during ple Power 2.0 (SPSS Inc.) with desired power 0.85
the data collection period. and alpha 0.05. An increase in the average chest
compression depth to within guidelines from 34 ± 9
Data collection and processing to 38 mm required a total of 246 (176 versus 70)
patients, and a reduction in no flow ratio from
Data from each episode included scanned patient 0.48 ± 0.18 to 0.38 a total of 211 (176 versus
report forms and locally adapted versions of 35) patients (equal variances from baseline-period
Utstein style forms. ECG-signals, time signal, assumed for the two phases).
events, accelerometer signals, and trans-thoracic Data were collected and organised using a
impedance were collected from the defibrillators. spreadsheet program (Excel 2003, Microsoft Corp.,
Each case was viewed and annotated with a cus- Redmond, WA) and statistical analyses performed
tom PC programme designed for this study (Sister with SPSS for Windows (SPSS ver. 12.0, Chicago, IL)
Studio, Laerdal Medical, Stavanger, Norway). Anno- by one of the authors (JK-J). Confidence intervals
tations were scrutinised and corrected manually if for medians were calculated using normal approx-
needed by consensus of one of the authors (JK-J) imation described by Altman.20 Unless otherwise
and one engineer with in-depth knowledge of the stated, results were expressed as means ± standard
sampling technology. deviation (S.D.), implying close to normally dis-
Each compression was coded as too deep, too tributed data. Differences were reported as means
shallow, or acceptable according to the goals in with 95% confidence intervals (95% CI). Comparisons
Table 1. Compression part of the duty cycle was of continuous data were done with independent
defined as the fraction of time with subzero posi- samples t-test or Mann—Whitney U-test as appro-
tion of the chest pad for each compression. Resid- priate, and comparisons of proportions were made
ual force between compressions exceeding 4 kg with odds ratios (OR) with 95% CI with P-values
was coded as incomplete release. No flow time from 2 -test with continuity correction. Two-sided
(NFT) was defined as all pauses between compres- P-values less than 0.05 were considered signifi-
sions longer than 1.5 s. The sum of such inter- cant. A logistic regression model assessed admis-
vals was divided by segment length and represents sion to hospital as a dependent factor and qual-
the fraction of time without circulation (no flow ity variables as independent factors in addition
ratio (NFR)). NFR adjusted (NFRadj ) for allowable to factors previously reported to influence sur-
time for rhythm analysis, defibrillator charging and vival (time from ambulance dispatch to ambulance
shock delivery, and pulse checks was calculated as crew arrives at patient (response time)), witnessed
described previously.7 Ventilations were detected arrest (yes/no), bystander CPR (yes/no), place of
by changes in thoracic impedance corrected for arrest (public/private), and initial rhythm (VF/non-
compression and blood flow related signals.18 VF).21 Sex and age were also included in the model.
Quality of out-of-hospital cardiopulmonary resuscitation 287
A forward stepwise approach using likelihood ratios Table 2 Demographic and Utstein characteristics of
with cut-offs at 0.15 in and 0.20 out were used baseline and feedback cohorts
and P-values less than 0.05 were considered sig-
nificant. The resulting model of logistic regression All sites
was then applied to all episodes. The factors pre- Baseline Feedback
viously described were also introduced into the Episodes, N 241 117
final model. Admission to hospital was chosen as Age 68 ± 15 68 ± 14
a dependent factor as this was thought to reflect Males (%) 172 (71) 80 (68)
out-of-hospital treatment and not differences in in- Usable (%) 176 (73) 108 (92)
hospital treatment.22 Ambulance witnessed (%) 18 (7) 12 (10)
Bystander witnessed (%) 160 (72) 73 (70)
Bystander CPR (%) 94 (42) 45 (43)
Results Response time (min) 8 (7, 8) 7 (6, 8)
Shocks per episode 1 (1, 2) 1 (0, 1)
The annual statistics and demographic data for Episodes with ≥1 shock (%) 139 (58) 62 (53)
Shocks per episode in 4 (3, 6) 2 (2, 4)
the three emergency medical service systems have
episodes with ≥1 shock
been described previously.7 Two hundred and forty-
three episodes were collected in the baseline All variables gives as numbers (percentages in parenthesis)
except age (mean ± S.D.), response times (minutes, mean
period and 120 in the feedback period. Two patients with 95% CI) and shocks per episode (median with 95% CI).
during baseline and three with feedback did not Ambulance personnel witnessed cases are not included in
receive CPR and were excluded leaving a total of bystander witnessed, bystander CPR, and response time
241 and 117, respectively. For quality of CPR analy- calculations.
sis 65 additional patients were excluded from base-
line (27%) and 9 (8%) from feedback. This was due to compressions (Table 1). Table 4 summarises CPR
technical problems in 27 and 5, and failure to apply quality with the two versions of feedback software.
the extra chest pad in 38 and 4, respectively. The The number of compressions per minute increased
resulting number of episodes with quality data on from 60 to 69 due to reduction of the mean frac-
compressions was 176/241 (73%) in baseline group tion of time without chest compressions from 0.47
and 108/117 (92%) in feedback group; OR for com- to 0.40. This apparently occurred at the expense of
pleteness of data 4.4 (2.1, 9.2). Due to suboptimal compression depth which decreased from mean 39
signal quality during parts of the episode ventila- to 36 mm with the new feedback priorities.
tion count could only be determined for 163/176 Incomplete release of force on the chest pad
(93%) in baseline group and 98/108 (91%) in feed- between compressions was a minor problem in both
back group (OR 0.8 (0.3, 1.9)). phases and was detected at 10,985/373,390 (3%)
There were no differences in demographic and of the compressions. The median fractions of com-
resuscitation episode characteristics between the pressions with incomplete release were still below
two periods (Table 2). This also applies to each site 1% (Table 3) suggesting that this was a significant
analysed separately (data not shown). problem in some episodes. Indeed episodes with
Performance of compressions changed with more than 10% incomplete release accounts for
introduction of feedback (Table 3). Average com- more than 50% of these compressions and the num-
pression depth increased significantly, and the per- ber of such episodes were 15/176 and 7/108 in the
centage of compressions with correct depth dou- baseline and feedback group.
bled. Average compression rate, which tended to The great majority of rescuer comments on the
be higher than guidelines recommendations in the feedback software were positive; 89/103 (86%)
baseline period, fell. Average compression part of indicated that they felt it helped them perform
duty cycle and average number of ventilations per better CPR. Only 3 of 103 (3%) evaluation forms
minute was within target during baseline, and did included negative comments from bystanders ver-
not change. The proportion of 1 min segments with sus 10/103 (10%) that reported positive comments
excessively high ventilation rates (>21 min−1 ) was from bystanders. At the discretion of the ambu-
reduced significantly after introduction of feedback lance personnel in charge it was possible to turn
from 396/4109 (10%) to 170/2274 (7.5%) (OR 0.8 down the volume of the feedback, switch to tonal
(0.6, 0.9), P = 0.004). Mean no flow ratio was 0.48 prompts only or turn off audible feedback alto-
in baseline and 0.44 with feedback (P = 0.08). gether. While 19/108 (18%) chose to turn off audi-
As described in the Methods section, the feed- ble feedback before the end of the resuscita-
back rules were changed during the intervention tion episode (mean time from start of monitor-
period towards more weight on inactivity of chest ing; 7 min), visual feedback on the screen was
288 J. Kramer-Johansen et al.
still given. There were no significant differences range); 36% (17, 57) versus 55% (32, 69), P = 0.07
between these episodes and those with continued (two-tailed Mann—Whitney U-test).
feedback for NFR (0.39 ± 0.18 versus 0.46 ± 0.16, Outcome measures are presented by an intention
difference; 0.07 (−0.01, 0.16), P = 0.1), compres- to treat analysis (241 versus 117 patients) in Table 5
sions depth (38 ± 8 mm versus 38 ± 6 mm, differ- and include results for subgroups of patients with
ence; 0 (−3, 3) mm, P = 0.9), or compression rate VF and non-VF (Asystole and PEA) as initial rhythm.
(113 ± 10 min−1 versus 109 ± 13 min−1 , difference; Seven patients (2.9%) survived to hospital discharge
−4 (−11, 2), P = 0.2), respectively. A tendency in the baseline group and five (4.3%) in the feed-
towards lower percentage of compressions with back group. Neurological status for the survivors
correct depth was found in the group that turned was good (Cerebral Performance Category (CPC) 1)
verbal feedback off (medians and inter quartile for all except for one patient in the baseline group
Table 6 Unadjusted odds ratios with 95% confidence intervals (95% CI) for rate of admittance to hospital
Factor Number of OR for admittance 95% CI for P-value
observations (exp (ˇ)) exp (ˇ)
Witnessed arrest (yes/no) 284 (77/207) 4.6 1.7, 12.0 0.002
Average compression depth (per 284 1.05 1.01, 1.09 0.009
1 mm increase)
Initial rhythm (VF/non-VF) 284 (111/173) 2.0 1.1, 3.6 0.022
Sex (female/male) 282 (76/206) 1.7 0.93, 3.3 0.082
Adrenaline given (yes/no) 272 (233/39) 0.6 0.27, 1.2 0.161
Feedback (yes/no) 284 (108/176) 1.5 0.81, 2.7 0.208
Response time (per 1 min increase) 284 1.04 0.96, 1.1 0.314
Average number of ventilations 261 (216/45) 0.7 0.33, 1.5 0.363
6—16 min−1 (yes/no)
Average compression rate 284 (167/117) 1.1 0.58, 1.9 0.841
90—120 min−1 (yes/no)
Age (years) 279 1.0 0.98, 1.02 0.956
OR > 1 indicates improved survival compared to the reference group (reference group were absence of feature or lower value of
continuous variables).
290 J. Kramer-Johansen et al.
Table 7 Adjusted odds ratios (adj. OR) with 95% confidence intervals (95% CI) for improved rate of admittance to
hospital for the factors included in the regression model
Factor Adj. OR for admittance 95% CI for P-value
(exp (ˇ)) exp (ˇ)
Witnessed arrest (yes/no) 4.3 1.6, 11.3 0.003
Average compression depth (per 1 mm increase) 1.05 1.01, 1.09 0.011
Sex (female/male) 1.6 0.84, 3.1 0.153
OR > 1 indicates improved survival compared to the reference group, N = 282.
described factors to the model did not alter the ity decreases skill performance during CPR,26 and
overall coefficients and are not shown. from psychological literature there is evidence for
reduced attention to new stimuli during attention
demanding tasks supporting the popular notion that
Discussion there is a finite capability for simultaneous tasks.27
The poor quality of CPR defined as chest com-
In this prospective, clinical trial chest compression pressions and ventilations can also be due to the
depth and rate improved during a period with auto- long list of interventions included in the guidelines
matic verbal and visual feedback on CPR quality occurring at the expense of chest compressions, as
compared to the time period immediately before recently suggested in an editorial by Sanders and
feedback was introduced. A limitation is that the Ewy.28 It is illustrative that on 31 of 103 (30%) eval-
study was sequential, not randomised. This was uation forms rescuers commented that they chose
done on purpose to avoid possible spill-over effects not to follow feedback at times when they were
to the control group of feedback-induced increased concentrating on other tasks such as intubation or
awareness of quality problems. This spill-over was placement of an iv. needle. This indicates that to
anticipated to be a problem even if cluster ran- reduce time without chest compressions further
domisation within the same ambulance services might depend on changes in the guidelines and
was applied. The study was planned prospectively more emphasis on avoiding hands-off intervals in
with a formulated hypothesis that the intervention training.29 Chest compressions have been shown to
would affect the outcome measure and both posi- improve survival,2—4 while there have been no stud-
tive and negative results would have been of inter- ies relating increased survival to hospital discharge
est. It conforms to the features for studies without with tracheal intubation or intravenous drugs.
internal controls described by Bailar et al.24 An The evaluation forms from the users of the feed-
increased attention to CPR quality was probably back system helped us identify and improve feed-
present from the baseline period as the partici- back software and they assured us that the possible
pants knew the purpose of the study from the start. annoyance of another source of noise at the scene
The measured effect of feedback is thus not only a was outweighed by the perceived benefit from the
Hawthorne effect.25 feedback. However, the lack of systematic debrief-
Feedback failed to significantly reduce the frac- ing after each episode may introduce bias in a way
tion of time without chest compressions (no flow that only the most positive and negative responses
ratio). This was the most striking quality problem are written down.
during the baseline period.7 When designing the In a logistic regression analysis compression
study, we had not anticipated this to be a large depth was significantly associated with short-term
problem, and thus feedback was only a tonal signal survival. This was equally true whether the per-
after 15 and 30 s hands-off, while all other feed- centage of compressions with adequate depth or
back was verbal with higher priority. New priorities average compression depth in mm were used in the
in the feedback software significantly improved no model (data not shown). Of the previously shown
flow ratio, apparently at the expense of compres- determinants of survival21 only witnessed arrest
sion depth. It could be speculated that this was ended up as significant in our model. Forced entry
due to an inability to respond to many types of of the other factors did not change the model. The
feedback simultaneously. When feedback on hands- logistic regression method does not imply causal-
off periods increased, the rescuers were less able ity. Increased chest compression depth improved
to concentrate on compression depth, although by cardiac perfusion and cardiac output in animal
nature these two types of error could not appear experiments,30,31 but this has not been possible
simultaneously. It is known that increased complex- to study directly in humans. We feel that a ran-
Quality of out-of-hospital cardiopulmonary resuscitation 291
role in the design of the study and interpretation of 17. Aase SO, Myklebust H. Compression depth estimation for
the data and had no part in the decision to submit CPR quality assessment using DSP on accelerometer signals.
Biomed Eng, IEEE Trans 2002;49:263—8.
the paper for publication. All authors’ (except HM)
18. Pellis T, Bisera J, Tang WC, Weil MH. Expanding automatic
work were independent of the study sponsors. external defibrillators to include automated detection of
cardiac, respiratory, and cardiorespiratory arrest. Crit Care
Med 2002;30:S176—8.
19. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to
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