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Effectiveness of steps taken to minimise bias during recruitment, data collection and data processing;

Clarity of discussion and whether conclusions are justified by research findings

Main study findings and implications for practice (50-55% of word count)

Resuscitation skills and techniques – how can these be adapted in your practice area?

Team dynamics - how might these be adapted, and what issues might arise if the findings were to be introduced into your practice area

What legal, professional and ethical issues might arise if the findings were to be introduced into your practice area

Search Strategy

Evidence based practice is the process of judicious integration of best research evidence with clinical expertise to engage in decision making for the care of patient (Hamer and Collinson 2014). Its importance is realized in health care practice because of its potential to improve the quality of care and delivering specialized care based on individual circumstances (Hall and Roussel 2016). CPR is a common in-hospital procedure and life saving technique to prevent or delay death in cardiac arrest patient. The common goals of resuscitation team in an emergency department are to restore blood circulation and breathing in person with cardiac arrest (Ojaghi Haghighi et al. 2017). Based on my experience as a member of the team, I have acquired the knowledge that the success of CPR is also dependent on the quality of chest compression. The High quality CPR is to provide chest compression at the rate of 100/min. However, since certain emergency situation or lack of skills may lead to changes in compression, there is a need review evidence to understand how little changes in chest compression rate can affect the quality of chest compression and CPR. Reviewing research evidence in this area is necessary to increase the quality of CPR in the future (Gianotto-Oliveira et al. 2015).

The main aim of this assignment is to critically review a research article regarding the influence of high chest compression rate on quality of CPR and evaluate the research rigour. After analysis of the research methodology, the reliability and credibility of findings is evaluated to determine its implications on emergency care.

As the main aim of the research was to find articles that could explain the effect of higher compression rate on CPR quality, the search strategy was to review research articles from Google scholar. Advanced level of search was also done by using databases like PubMed and Scopus. The key search terms that were used for retrieving specific research article related to the research aim included ‘chest compression rate’, ‘quality of chest compression’, ‘chest compression rate and CPR quality’ and ‘chest compression and CPR’. The search process was refined by setting publication date from 2010 to 2018 and selecting English language, in order to incorporate most relevant and recent data into the study. The criteria for selecting the research article was that it the research aims should be related to evaluating the timing of compression rate and its impact on CPR or Cardiopulmonary resuscitation. A total of 10 articles were retrieved by the method and after reading the methodology and research aim, the study by Lee et al. (2014) has been selected for critical review.

Critique of Research Rigour

The main purpose of Lee et al. (2014) was to evaluate whether quality of chest compression deteriorates when the chest compression rate is more than 120/min.  To get answer to this research question, the researcher utilized retrospective research design and collected data from a high school students who went through CPR training led by American Heart Association. A restropective study is a study design that uses existing evidence to find out answer to research question. The rigour and validity of  retrospective investigation is low as such research is dependent on past data and chances of bias and confounding factor is high in such studies (Claydon 2015). It limits the research process and certain specific outcome variable cannot be analyzed. It increases the likelihood of selection and information bias too (Mehta and Bressler 2016). Hence, the area of research is commendable as the study design is very effective mostly in qualitative genres, however it has to be mentioned that for the heath care sector the efficiency of this study design is limited due to the overabundance of confounding variables in the health care research that have not been controlled for.  Use of research design like randomized controlled trial would have enhanced the reliability of the data as it favors complete evaluation of the effectiveness of any intervention. Lee et al. (2014) gave a proper introduction discussing about the background of the study and the rational for research. It mentioned that the guideline for quality compression rate for AHA and basic life support differs. Hence, the author justified the need for research to clarify the impact of increased compression rate on other chest variables like duty cycle and depression death. Idris et al. (2012) also showed the recommendation for European Resuscitation Council CPR Guideline is different from that of American Heart Association (AHA) as it recommends upper limit of 120 chest compressions/minutes. However, the compression rate has been faster than 100/minute in many emergency setting (Bae, Chung and Je, 2016). Hence, the aim of finding the impact of compression rate exceeding 120/min is a unique research topic that has been taken by the researcher. Research outcome from this study can have great implication for emergency care professionals.


The review of the research methodology used by Lee et al. (2014) revealed that data was collected from a CPR program done in National Emergency Medical Center in Seoul. The participants has no initial CPR training, however they were given CPR training for 2 weeks. The training manual consisted of lecture on resuscitation and hands-on practice. Although the selection of students with no initial CPR training is a drawback, however the rigour in providing training to participant is seen. For instance, to maximize the effectiveness of training program, the training was conducted in small groups. They were also provided training kit 2 weeks before the skill test. Hence, by reviewing sample recruitment strategy use in the research article, it can be said that the selection of high school student limits the validity and transferability of the research data. This is because it does not represent the population who are likely to conduct CPR in real setting. Hence, the findings cannot be applied to trained CPR professionals. The point of choosing students can have a very limited understanding of the process and hence it served the primary objectives of the study efficiently.  To enhance the validity of research, conducting research with health care professional was necessary as such data are more reliable in the context of practice improvement in the emergency department. Another research study had similar research aim and it used health professionals to perform compression on instrumented manikins at different rate (Field et al. 2012). Use of such sample group was needed by Lee et al. (2014) too.

Steps Taken to Minimize Bias

The data analysis was done based on outcome obtained after the skill test. In the context, participants had to perform CPR in pair. One person has perform five cycle of chest compression and other had to conduct mouth-to-mouth rescue breathing using shield. Then the participants switched roles. The data related to CPR skills in participant was evaluated by means of quality of CPR and chest compression rate. The strength of the data analysis part is the selection of three main quality indicators of compression depth, compression rate and ventilation volume during skill set (Lee et al. 2014). Use of this quality parameter is commendable because all these parameters determine the quality of compression (Crowe et al., 2015). Association between chest compression rate and compression depth is found as limitation of chest compression speed limits chest compression depth too. Rescuer fatigue is also a critical element that determines the quality and efficacy of chest compression and CPR outcome in patients (Bae, Chung and Je 2016). However, this has not been an issue as this was less of an issue as only 5 cycles are used in the test.

Apart from quality parameters for data analysis, Lee et al. (2014) also defined incorrect CPR performances too. This included deep compression, shall compression and incomplete chest recoil. While performing CPR, incomplete chest wall recoil is an undesirable event as presence of this parameter during CPR impedes venous return and decrease arterial pressure. Lack of compression recoil affects hemodynamics. Consideration of this factor during data analysis process is credible because staffs often deviate from consensus resuscitation guideline during actual performance. They are not able to maintain desired ventilation rate, pauses in CPR delivery and chest compression rate (Fried et al. 2011). Hence, based on parameters chosen for evaluating the quality of CPR and compression rate, the study procedure is found to be reliable. This shows research rigour too. The only major drawback is the lack of consideration to take relevant sample population. As any research evidence has implications on actual practice, the focus should always be to take a sample group that is similar to the target population for research. Such consideration enhances the validity of the research and increases the chance of application of data to local population too (Thomas and Magilvy 2011).

Apart from research design, data collection and sample recruitment process, the research rigour and credibility of any research work is also understood from steps taken to minimize bias. Bias may occur at any phase of research such as during data collection, research planning or during the publication phase (Field et al., 2012). However, good understanding about research bias helps researcher to contemplate and eliminate the factors that may contribute to bias. This is also important to enhance the internal validity of research study and promote generalization of findings (Pannucci and Wilkins 2010).  Lee et al. (2014) considered about minimizing bias by ensuring that all participants received same skills training to perform CPR. Although the research participants were high school students, however special consideration for training before CPR test shows equal treatment for all groups. The focus on increasing the effectiveness of intervention is also understood from the fact that instructor to student ration was ratio was kept 1:6. Secondly, the student to manikin ratio was kept 3:1. This ensured that students could get proper attention at the from instructors at the time of training.

Legal, Professional, and Ethical Issues

Good clarity is seen in discussion and conclusion section of the research. The researcher gave good overview about research findings and its limitation. The consistency of the research outcome were compared with recent literature too. Key weakness and strength of the article and implications for future research were mentioned. The overall conclusion from the analysis of the article is that the research has taken a novel research approach as compression rate is a major challenge for resuscitation team. However, the most significant drawback of this study is the sample group selected for this study. If the sample recruitment aspect is excluded, research rigour is seen in the area of data analysis and process used for conducting the research (Lee et al. 2014).

The research done to investigate about the impact of chest compression on chest compression rate gave many important results. The CPR skills test performed on student revealed that more than 87% of the participants were able to perform chest compression at the rate of 100/min. However, since the study focused on evaluating the quality of compression by means of compression depth, great link between chest compression and chest depth was found. For instance, the study result showed that greater chest compression depth was achieved only when the chest compression rate was higher than 120/min (Lee et al. 2014). Hence, from this evidence, the study gave statistically significant result. It proved the correlation between chest compression rate and depth. Whenever the chest compression rate was greater than 120/min, the compression depth value was also found to be greater than 50 mm. Therefore, the research gave answer to the research aim. It showed that greater compression rate will have an impact on compression depth. This is significant based on quality of CPR because this revelation can pave the way for addressing this issue in emergency care. This is consistent with other research evident too as de Gauna et al. (2016) also showed correlation between compression depth and quality of chest compression. Gauna et al. (2016) proposed use of acceleration signal to provide feedback on compression rate and depth and contribute to enhanced quality of chest compression. 

The study by Lee et al. (2014) proved that exceeding compression rate can have impact on CPR quality. This research evidence is useful for staffs working in the emergency department and has many important implications for improving the process and skills related to resuscitation. Although the research was done with inappropriate sample group where the likelihood of poor quality CPR is high, however providing chest compression at ideal rate and depth is difficult even for well-trained rescuers or health care professional (Rajeswaran and Ehlers 2013). The chain of survival during emergency treatment of cardiac arrests consists of four stages such as recognition of emergency, early CPR, early defibrillation and early access to advanced care (Gauna et al. 2016). The evidence gives implication to improve skills in the area of providing CPR. It showed that chest compression rate and depth are critical element for high quality CPR. Hence, based on this evidence, staffs working with the resuscitation team can take training to improve the quality of CPR rate.

According to the AHA recommendation, the desirable chest compression limit is at least 100/min and in the study, majority of participants performed chest compression at that rate (Eccguidelines.heart.org. 2018). As the result showed possibility of high compression depth when compression rate was 120/min, there is a need to plan methods to improve this area in CPR practice. Hence, future training programs for CPR skills should focus more on training medical staffs to learn ways to control compression rate. This would pave way for automatically improving the accuracy of other quality index of CPR and increasing the success rate of CPR (Zhang et al. 2013). The use of technology as well as clinical skill could help to enhance the CPR in emergency practice. For instance, currently real time feedback devices have emerged that provides accurate signals to improve the compression rate (de Gauna et al. 2016). Many research studies have proved the effectiveness of feedback devices in supporting resuscitation staff to achieve desired chest compression rate and depth during CPR (Gauna et al. 2016; Krasteva, Jekova and Didon 2011). The findings from the study by Contri et al. (2017) also showed that incomplete recoil was achieved when the chest compression rate was greater than 120/min. Drawing upon this finding, it can be said that physical attributes has an impact on complete chest recoil and rescuer fatigue. Hence, CPR trainers need to focus on addressing theses problem too. Preference should be given to taking training in continuous chest compression as this will led to confidence of trainee in performing the procedure. Hence, training in this area can increase the staff’s confidence in delivering CPR and improving rate of survival in cardiac arrest patient (Blewer et al. 2012).  

Team dynamics plays an important role in emergency care practices (Gillman et al. 2016). In area of CPR practice too, the findings can be applied to improve the efficiency of resuscitation team members. This is said because resuscitation is a stressful procedure, hence team members must be clear about their approach to provide high quality CPR.  Many variations in resuscitation event are seen due to rescuer or patient characteristics. The chances of incomplete recoil increases when rescuer cannot apply downward force from chest wall after a chest compression (Fried et al. 2012). Hence, rescuscitation should sit together to plan ways to address this limitation during practice. When rescuers lean forward to provide CPR, it reduces negative intrathoracic pressure and impedes blood flow thus affecting the efficacy of CPR. The team discussion can assess whether certain patient or rescuer characteristics lead to leaning or not. To ensure that each member understand the factors influencing CPR quality, the team leader can also provide scenario based training. Post-event briefing should also be provided so that member learn and improve the skills to performing CPR (Crowe et al. 2015). Along with that a regular training and demonstrative sessions with precise instruction manuals given to the teams working in the environment can be beneficial in real life events. To utilize the research outcomes by Lee et al. (2014) for evidence based practice, it will be necessary to consider about legal, professional and ethical issues that might arise in implementing the findings to practice area. To ensure that legal and ethical standards are maintained, it is necessary to consult current CPR practice guideline before incorporating any of the information in actual practice. Secondly, since this evidence is utilizing the information to find ways to reduce high compression rate, the chances of legal and ethical issues is lesser when compared to other more critical techniques. In addition, to use the information for CPR training, there is a need to take permission from relevant health care authorities in the hospital. Before this, the validity of the research and applicability of the evidence in relation to hospital protocol and guidelines also needs to be judged (Hamer and Collinson 2014). Hence, the prospective of autonomy and proper approval is necessary before the evidence can be applied in practice setting. This study has helped me to understand the relation between compression rate and compression depth to achieve the most optimal results so that in emergency situations I can perform CPR with precise efficiency and competence

Conclusion:

The report looked at the issue of difficulty of resuscitation staff in achieving recommended chest compression rate during CPR and critically reviewed the outcome of research evidenced by Lee et al. (2014) to understand how chest compression rate of 120/min can affect the quality of chest compression. By the analysis of the research evidence, it can be concluded that high chest compression rate affects other quality parameters during the CPR process. For instance, high chest compression was found to have an impact on complete chest recoil and chest compression depth. Hence, this finding gave implications for providing advanced training regarding improving this skill in resuscitation staffs. As many factors such as rescuer characteristics and tending to lean affected quality of CPR, the report suggested ways to address this area in training programs. Apart from this, the application of latest technology in providing appropriate feedback and improving chest compression rate was also found. By reviewing the research evidence, the key recommendation for practice improvement is that there is a need to integrate the traditional means of providing CPR training with innovative approaches too. Another advantage of fully utilizing such course is that such training takes lesser time and provide updates and advanced information to newly trained individuals (Wang, Ma and Lu 2015). Apart from this, as team dynamics is also essential part of emergency practice, the recommendation to improve the performance of the whole resuscitation team is that they should engage in pre and post event discussions to eliminate patient and rescuer characteristics that affect CPR. Taking effective steps in this area is likely to improve CPR quality and survival rate of patient.

Reference:

Bae, J., Chung, T.N. and Je, S.M., 2016. Effect of the rate of chest compression familiarised in previous training on the depth of chest compression during metronome-guided cardiopulmonary resuscitation: a randomised crossover trial. BMJ open, 6(2), p.e010873.

Blewer, A.L., Leary, M., Esposito, E.C., Gonzalez, M., Riegel, B., Bobrow, B.J. and Abella, B.S., 2012. Continuous chest compression cardiopulmonary resuscitation training promotes rescuer self-confidence and increased secondary training: a hospital-based randomized controlled trial. Critical care medicine, 40(3), p.787.

Claydon, L.S., 2015. Rigour in quantitative research. Nursing Standard (2014+), 29(47), p.43.

Contri, E., Cornara, S., Somaschini, A., Dossena, C., Tonani, M., Epis, F., Zambaiti, E., Fichtner, F. and Baldi, E., 2017. Complete chest recoil during laypersons' CPR: Is it a matter of weight?. The American journal of emergency medicine, 35(9), pp.1266-1268.

Crowe, C., Bobrow, B.J., Vadeboncoeur, T.F., Dameff, C., Stolz, U., Silver, A., Roosa, J., Page, R., LoVecchio, F. and Spaite, D.W., 2015. Measuring and improving cardiopulmonary resuscitation quality inside the emergency department. Resuscitation, 93, pp.8-13.

de Gauna, S.R., González-Otero, D.M., Ruiz, J. and Russell, J.K., 2016. Feedback on the rate and depth of chest compressions during cardiopulmonary resuscitation using only accelerometers. PloS one, 11(3), p.e0150139.

Eccguidelines.heart.org. (2018). [online] Available at: https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf [Accessed 30 Mar. 2018].

Field, R.A., Soar, J., Davies, R.P., Akhtar, N. and Perkins, G.D., 2012. The impact of chest compression rates on quality of chest compressions–a manikin study. Resuscitation, 83(3), pp.360-364.

Fried, D.A., Leary, M., Smith, D.A., Sutton, R.M., Niles, D., Herzberg, D.L., Becker, L.B. and Abella, B.S., 2011. The prevalence of chest compression leaning during in-hospital cardiopulmonary resuscitation. Resuscitation, 82(8), pp.1019-1024.

Gianotto-Oliveira, R., Gianotto-Oliveira, G., Gonzalez, M.M., Quilici, A.P., Andrade, F.P., Vianna, C.B. and Timerman, S., 2015. Quality of continuous chest compressions performed for one or two minutes. Clinics, 70(3), pp.190-195.

Gillman, L.M., Brindley, P.G., Blaivas, M., Widder, S. and Karakitsos, D., 2016. Trauma team dynamics. Journal of critical care, 32, pp.218-221.

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Hamer, S. and Collinson, G., 2014. Achieving Evidence-Based Practice E-Book: A Handbook for Practitioners. Elsevier Health Sciences.

Idris, A.H., Guffey, D., Aufderheide, T.P., Brown, S., Morrison, L.J., Nichols, P., Powell, J., Daya, M., Bigham, B.L., Atkins, D.L. and Berg, R., 2012. The relationship between chest compression rates and outcomes from cardiac arrest. Circulation, pp.CIRCULATIONAHA-111.

Krasteva, V., Jekova, I. and Didon, J.P., 2011. An audiovisual feedback device for compression depth, rate and complete chest recoil can improve the CPR performance of lay persons during self-training on a manikin. Physiological measurement, 32(6), p.687.

Lee, S.H., Kim, K., Lee, J.H., Kim, T., Kang, C., Park, C., Kim, J., Jo, Y.H., Rhee, J.E. and Kim, D.H., 2014. Does the quality of chest compressions deteriorate when the chest compression rate is above 120/min?. Emerg Med J, 31(8), pp.645-648.

Mehta, P. and Bressler, N.M., 2016. Identification and Recognition of Limitations of Retrospective Studies in Select Peer-reviewed Journal. Investigative Ophthalmology & Visual Science, 57(12), pp.5556-5556.

Ojaghi Haghighi, S.H., Shams Vahdati, S., Mahmoudie, T., Sepehri Majd, P. and Mirza-Aghazadeh-Attari, M., 2017. Outcomes of cardiopulmonary resuscitation in the emergency department. Journal of Emergency Practice and Trauma, 3(2), pp.49-52

Pannucci, C.J. and Wilkins, E.G., 2010. Identifying and avoiding bias in research. Plastic and reconstructive surgery, 126(2), p.619.

Rajeswaran, L. and Ehlers, V.J., 2013. Cardio-pulmonary resuscitation challenges in selected Botswana hospitals: Nurse managers' views. Health SA Gesondheid (Online), 18(1), pp.1-8.

Thomas, E. and Magilvy, J.K., 2011. Qualitative rigor or research validity in qualitative research. Journal for specialists in pediatric nursing, 16(2), pp.151-155.

Wang, J., Ma, L. and Lu, Y.Q., 2015. Strategy analysis of cardiopulmonary resuscitation training in the community. Journal of thoracic disease, 7(7), p.E160.

Zhang, F.L., Yan, L., Huang, S.F. and Bai, X.J., 2013. Correlations between quality indexes of chest compression. World journal of emergency medicine, 4(1), p.54.

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