Reducing barriers for implementation of bystander-initiated cardiopulmonary resuscitation

A unified effort by the public, educators and policymakers is needed to reduce deaths from sudden cardiac arrest by increasing the use and effectiveness of cardiopulmonary resuscitation (CPR), according to a new statement from the American Heart Association.

The statement, “Reducing barriers for implementation of bystander-initiated cardiopulmonary resuscitation,” appears online in Circulation: Journal of the American Heart Association.

“Bystander cardiopulmonary resuscitation rates are woefully inadequate, resulting in an enormous missed opportunity to save lives from cardiac arrest,” said Benjamin S. Abella, M.D., M.Phil., clinical research director for the Center for Resuscitation Science at the University of Pennsylvania in Philadelphia, and lead author of the statement.

Studies indicate that in many communities only 15 percent to 30 percent of out-of-hospital cardiac arrest victims receive bystander CPR before emergency medical services (EMS) personnel arrive at the scene. Considering that cardiac arrest survival falls an estimated seven percent to 10 percent for every minute without CPR, the low rate of bystander CPR has a big impact on outcomes, he explained.

Approximately 166,200 out-of-hospital sudden cardiac arrest deaths occur annually in the United States. Sudden cardiac arrest often results from an irregular heartbeat called ventricular fibrillation (VF) which causes the heart to quiver so that it cannot generate blood flow. Treatment of VF requires CPR to keep blood moving through the body until the patient's heart can be shocked to terminate the VF and allow the heart's pacemaker cells to establish a normal rhythm. In the last decade, automated external defibrillators (AEDs), portable defibrillation machines, have become increasingly common in public buildings such as casinos, airports and schools.

However, Abella said defibrillation is only one of the four links in the Chain of Survival, a sequence of four actions that must occur quickly to help assure the best chances of survival.

The Chain of Survival requires: (1) early recognition of the emergency and phoning 911 for EMS, (2) early bystander CPR, (3) early delivery of a shock via a defibrillator if indicated and (4) early advanced life support and post-resuscitation care delivered by healthcare providers.

“Quick initiation of CPR, as well as providing high quality CPR, is crucial to survival,” Abella said. “What's needed is a two-pronged approach: first, substantially increase the number of bystanders trained in CPR who then provide CPR during an actual emergency and second, improve the quality of training and actual CPR performance through measures of its effectiveness.”

“In communities where widespread CPR training has been provided, survival rates from witnessed sudden cardiac arrest associated with VF have been reportedly as high as 49 percent to 74 percent,” Abella said. “Unfortunately, on average, approximately six percent of out-of-hospital sudden cardiac arrest victims survive to hospital discharge in the United States.”

The statement identifies specific potential barriers to improving U.S. cardiac arrest survival rates including: fear of infectious disease, fear of litigation and fear of poor performance, all of which Abella said could be overcome with adequate education, training and public awareness.

Specific recommendations in the statement include:

• Local, state and federal government agencies should provide CPR education in such settings as school systems and government-funded hospital and clinic systems.
• Communities should create and support emergency dispatcher-assisted CPR training programs with an emphasis on recognizing the symptoms of cardiac arrest.
• The public should understand that when bystanders perform CPR immediately, the victim's chance of surviving cardiac arrest can double or triple at little risk to the rescuer.
• The public should be made aware of Good Samaritan laws through CPR training materials and by including information with community AEDs.
• Community lay rescuer and EMS programs should include a process for continuous quality improvement that includes a review of resuscitation efforts, quality of CPR and CPR instructions provided to bystanders by dispatchers. CPR instructional programs should always include an objective CPR quality assessment for certification.
• Research funds should be targeted toward improving methods of CPR education, skill retention and creative methods to widen the scope of current CPR training and education.

Abella said creative approaches to CPR education include initiatives such as the American Heart Association's Family and Friends CPR Anytime™, a 22-minute, individual training program that provides an instructional video and an inflatable manikin, and other approaches such as Internet-based instruction. Another idea is to provide hospital-based training for family members of patients at risk for cardiac arrest.

The statement also recommends directing research dollars to learn more about ways to increase the use of bystander CPR.

“By broadening training and encouraging the public to perform CPR, we believe we can save thousands of additional lives each year in the United States,” Abella said.