Updating of CPR Guidelines
As this issue of Critical Care Nurse went to press, the American Heart Association (AHA) issued its newly revised Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.1 Based on the most comprehensive review of published and peer-reviewed resuscitation research ever compiled, these Guidelines are the product of rigorous documentation, analysis, and evaluation of existing scientific literature related to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) by 380 international experts on resuscitation convened by the International Liaison Committee on Resuscitation over a 3-year period preceding the 2005 Consensus Conference on CPR and ECC.2 (The evidence evaluation worksheets prepared at this conference are available at the AHA Web site, www.c2005.org.)
An editorial published with the revised Guidelines opens with a description of the context within which this research evidence was analyzed and these guidelines were revised:
… [the scientists involved] …began and ended the process aware of the limitations of the resuscitation scientific evidence, optimistic about emerging data that documents the benefits of high-quality … [CPR], and determined to make recommendations that would increase survival from cardiac arrest and life-threatening emergencies.3 (pIV-206)
While acknowledging both the boundaries of the research process as well as opportunities to incorporate new scientific evidence into practice, the editorial both acknowledged the current worldwide survival rate for out-of-hospital CPR as 6% or less and characterized the following as “a striking finding” of the evidence presented at the most recent Consensus Conference:
… the contrast of data that showed the critical role of early, high-quality CPR in increasing rates of survival from cardiac arrest with data that show that few victims of cardiac arrest receive CPR and even fewer receive high-quality CPR. 3 (pIV-206)
As my previous Editorial4 noted, although a wide array of variables may singly or jointly contribute to the alarmingly and chronically low rate of CPR survival regardless of the setting where arrest occurs or the attributes of the rescuer, one distinguishing commonality documented in all CPR provision circumstances is the rapid evaporation of prowess in CPR skills. If few of us trained to perform CPR procedures actually perform them correctly when it counts, then all the new data and revised guidelines generated in global cooperation will not likely raise that single digit survival rate. An alternative consideration proposed in the editorial to help mitigate the decay of CPR skills and improve survival rates was simplification of CPR performance procedures so they could be more readily learned, retained, and demonstrated.
It is discomforting to even consider that ever-evolving science that continually tweaks at how to best perform this fundamental lifesaving skill might be hindering rather than helping to improve its success in saving lives, but some alternate explanation surely seems warranted for the 94% of victims who do not survive following provision of CPR. This Editorial is dedicated to that majority of CPR recipients. Here I’ll attempt to offer both a synopsis of changes incorporated in the 2005 CPR-ECC Guidelines most relevant to critical care nurses and briefly estimate the extent to which the revised guidelines were simplified.
The major changes incorporated in the 2005 CPR-ECC Guidelines can be divided into 3 segments5:
Changes relevant to all CPR rescuers
Changes pertaining to lay CPR rescuers
Changes relevant to healthcare providers of CPR and ECC in basic cardiovascular life support (BCLS) and advanced cardiovascular life support (ACLS)
The most important changes in the 2005 CPR-ECC Guidelines for all CPR providers (except newborn resuscitation) are summarized in Table 1. Emphasis on provision of effective CPR is highlighted so that when CPR is administered, its quality adheres to AHA guidelines and thereby affords victims the best chance for survival and recovery.
More than a dozen substantive changes were made in the 2005 Guidelines that relate to lay rescuer CPR for victims of all ages (except neonates). A summary of those revisions is provided in Table 2.
Tables 3 and 4 summarize 2005 changes in the CPR-ECC Guidelines directed at healthcare staff who provide BCLS and ACLS. As in all other sections of these Guidelines, the underscored emphasis is on provision of high-quality CPR, characterized as push hard, push fast, allow full chest recoil following each compression, and minimize interruptions to compression.
Evidence of Simplification in 2005 CPR – ECC Guidelines
When the most recent iteration of the CPR-ECC Guidelines are considered for their scientific merit, one cannot deny their inestimable value in affording the best and the brightest contributions to evidence-based practice of CPR. Rigorous criteria for what qualifies as evidence as well as for categorizing the strength of that evidence were employed throughout the evaluation process to serve as a basis for recommended changes in the Guidelines. This state-of-the-science notwithstanding, however, can we reasonably expect that these newly disseminated Guidelines will improve the CPR survival rate?
As the previous editorial suggested, simplification of CPR procedures might offer some promise for provision of CPR according to AHA recommendations by making the guidelines easier to learn, retain, and apply when needed. In an admittedly cursory attempt to make this judgment, I’ve designed a wholly subjective and completely unscientific keep it simple, smartie (KISS) index for rating the degree to which the new Guidelines appear to reflect simplification in CPR procedures. The ratings range as follows:
0 = No evidence of simplification
1 = Some/limited evidence of simplification
2 = Clear evidence of simplification
As Tables 1 through 4Table 2,Table 3,Table 4 indicate, the average of my initial assignment of KISS scores ranged from 0.6 for the changes affecting all rescuers to 1.0 for the changes pertaining to lay rescuers and to healthcare providers of ACLS. Although other evaluators could readily make different judgments on this variable, one encouraging finding is that of the 34 aspects of CPR-ECC in which changes were highlighted, ratings of 1 or 2 (indicating at least some evidence of simplification) were assigned to 19% or 56%, respectively, of those aspects. That may not represent a scientific healthcare milestone, yet it may reflect a few beginning avenues toward merging the science of CPR with the science of education so that performance of CPR can be more effectively learned, retained, and provided to victims of cardiac arrest. Between now and the next revision of these guidelines, we await research evidence that supports or disproves this assertion.