A better understanding of ambulance personnel’s attitude towards real-time resuscitation feedback

A better understanding of ambulance personnel’s attitude towards real-time resuscitation feedback Abstract Objective High-quality chest compressions during cardiopulmonary resuscitation (CPR) play a significant role in surviving cardiac arrest. Chest-compression quality can be measured and corrected by real-time CPR feedback devices, which are not yet commonly used. This article looks at the acceptance of such systems in comparison of equipped and unequipped personnel. Design Two groups of emergency medical services’ (EMS) personnel were interviewed using standardized questionnaires. Setting The survey was conducted in the German cities Dortmund and Münster. Participants Overall, 205 persons participated in the survey: 103 paramedics and emergency physicians from the Dortmund fire service and 102 personnel from the Münster service. Intervention The staff of the Dortmund service were not equipped with real-time feedback systems. The test group of equipped personnel of the ambulance service of Münster Fire brigade uses real-time feedback systems since 2007. Main outcome measure What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? Results The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful. However, this study revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists—the system’s use in daily routine results in better evaluation than the expectations of unequipped personnel. Conclusions Real-time feedback systems receive overall positive ratings. Prejudices and concerns seem to decrease with continued use of the system. quality measurement, quality management, quality improvement, cardiovascular diseases, disease categories, emergency care, setting of care Introduction Survival after cardiac arrest remains low despite continuing research [1, 2]. High-quality chest compressions play a significant role in the chain of survival [3, 4]. Chest compressions and ventilations can be measured by real-time cardiopulmonary resuscitation (CPR) feedback devices [5, 6]. Such devices can be integrated into defibrillators and give rescuers real-time feedback on the quality of CPR delivered to the patient. Feedback can be given by a metronome, voice prompts, visual displays and digital timers. This allows instantaneous correction of inadequate CPR efforts such as shallow chest-compressions. Data are also recorded and available for debriefing, quality management (QM) and identification for future improvement strategies [7]. While real-time feedback systems correct the team at the scene they also allow later analysis of CPR-quality. Rescuers could be prejudiced against such systems due to fear of surveillance which might impede implementation. There is little knowledge about the acceptance of technical support by rescue teams. This article looks at the acceptance of real-time feedback systems. Two groups of EMS personnel were interviewed through standardized questionnaires. One group had no access to such system in their daily routine as standard defibrillators were not equipped with real-time feedback (unequipped personnel). The other group had routine experience with a system since 2007 (equipped personnel). Methods The present study addresses at the following questions: What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? Real-time feedback systems offer different functions. Which functions have the highest or lowest level of acceptance level? To address these questions, we developed a questionnaire to measure different levels of ‘acceptance’. The design follows recommendations of the German Evaluation Society [8]. The questionnaire consisted of closed-ended questions that could be answered on a four-level scale ranging from ‘not useful at all’, ‘not useful’, ‘useful’ to ‘very useful’ or ‘strongly disagree’, ‘disagree’, ‘agree’, strongly agree’, respectively. A total of 40 items were assessed. The four-level scale was chosen intentionally to enforce a positive or negative choice. Unequipped personnel were asked to give answers imagining they had access to a real-time feedback system. This way expectations and experience with system functions were measured. The questionnaire included a short description of the real-time feedback system and a statement on data privacy. The questionnaire was pretested with a group of 20 equipped and unequipped emergency medical services (EMS) staff before final approval. The test group of unequipped personnel were paramedics and emergency physicians of the ambulance service of Dortmund Fire Brigade. The staff did not use or have training on real-time feedback systems at the time of the study. The test group of equipped personnel were paramedics and emergency physicians of the ambulance service of Münster Fire brigade. The service uses real-time feedback systems in all resuscitation attempts since 2007. The system is a product of ZOLL Medical Corporation, Chelmsford, MA, USA, integrated in the defibrillators AED-pro© and E-Series©. The defibrillation electrode pads (CPR-D-Padz® ZOLL Medical Corporation, Chelmsford, MA, USA) incorporate a motion sensor registering compression depth, recoil and frequency. The questionnaire addressed the following functions of the real-time feedback system. Audio feedback A metronome ticks with a frequency of 100 beats/min in line with guideline recommendations. Visual feedback The chest compression depth in cm is displayed on the monitor as variable bar. Voice prompts The device gives feedback through messages such as ‘push harder’ or ‘good compressions’. Pauses Following a period of more than 10 s of inactivity the device will request continuation of chest compressions by a voice prompt: ‘continue CPR’. Timer functions A clock displayed on the monitor starts upon system activation. The device prompts for EKG analysis every 2 min (CPR cycle). This clocking is continued for the complete mission. Data recording The device saves the complete CPR attempt (EKG, chest compressions, pauses). Data are stored for analysis and debriefing. The survey was conducted on an anonymous and voluntarily basis from June 2011 until January 2012. One of the authors (S.T.) was present while the questionnaires were filled in to answer any comprehension questions. Questionnaires were not issued to staff that did not want to participate in the study or those from the group of unequipped personnel that had previously worked with real-time feedback systems elsewhere. Statistical analysis was done with Microsoft Office EXCEL (Microsoft Corporation, Redmond, WA, USA) and SPSS Version 20 (SPSS Inc., Chicago, IL, USA; 2004). Data were aggregated from a four-level scale to a two-level scale. Relative frequencies of characteristics were calculated and two-sided significance between the groups was compared by Chi-squared test. Significance level was set at P < 0.05 and the confidence intervals were set at 95%. The conduct of this questionnaire comparison was approved by the Ethics Committee of the State Medical Board of Registration for Westphalia–Lippe and the University of Münster based on the registration no. 2006-571-f-S. Informed consent to participate in this survey including data processing and publication was obtained from all participants. Results Overall, 205 persons participated in the survey, 102 equipped personnel from the Münster service and 103 unequipped participants from the Dortmund service. There were no differences in epidemiological data or work experience between the two groups (Table 1). Results of the total sample (equipped and unequipped personnel) and detailed results of both groups are shown in Tables 2 and 3 and Fig. 1. Table 1 Epidemiology of the participants. No significant differences between the two groups (equipped vs. non-equipped personnel) regarding their gender, age, qualification and work experience exist   Equipped personnel  Non-equipped personnel  P-value  Sex  Female  1106  55.2%    Male  898  44.8%    Age (in years)  Average age [standard deviation]  34 [8]  35 [8]  0.772 = n.s.  Maximum age  60  59    Minimum age  21  21    Qualification  Emergency physician  27  26  0.841 = n.s.  Paramedic  75  77    Work experience  Average in years [standard deviation]  9 [7]  8 [8]  0.175 = n.s.    Equipped personnel  Non-equipped personnel  P-value  Sex  Female  1106  55.2%    Male  898  44.8%    Age (in years)  Average age [standard deviation]  34 [8]  35 [8]  0.772 = n.s.  Maximum age  60  59    Minimum age  21  21    Qualification  Emergency physician  27  26  0.841 = n.s.  Paramedic  75  77    Work experience  Average in years [standard deviation]  9 [7]  8 [8]  0.175 = n.s.  Table 2 General assessment of the real-time feedback system. Shown are the summed ratings of the answers ‘agree’ and ‘strongly agree’ regarding the given statements in comparison of equipped and non-equipped personnel. The results show a higher acceptance of a real-time feedback system and less doubt about it in the group of equipped personnel when compared to non-equipped personnel Statement  Participants  n  Acceptance  P-value        n  %    ‘Voice prompts promote safety’  Total sample  203  141  69.6    Non-equipped  102  60  58.8  0.001  Equipped  101  81  80.2    ‘I trust the given voice prompts’  Total sample  198  145  73.2    Non-equipped  98  58  59.2  0.001  Equipped  100  87  87.0    ‘Voice prompts disturb me in the field’  Total sample  202  54  26.7    Non-equipped  101  41  40.6  0.001  Equipped  101  13  12.9    ‘Display disturbs me in the field’  Total sample  200  20  10.0    Non-equipped  99  12  12.1  0.322  Equipped  101  8  7.92    ‘I like to work with the RTF-system’  Total sample  198  173  87.4    Non-equipped  96  76  79.2  0.001  Equipped  102  97  95.1    ‘Real-time feedback system is a source of irritation’  Total sample  197  22  11.2    Non-equipped  96  19  19.8  0.001  Equipped  101  3  3.0    Statement  Participants  n  Acceptance  P-value        n  %    ‘Voice prompts promote safety’  Total sample  203  141  69.6    Non-equipped  102  60  58.8  0.001  Equipped  101  81  80.2    ‘I trust the given voice prompts’  Total sample  198  145  73.2    Non-equipped  98  58  59.2  0.001  Equipped  100  87  87.0    ‘Voice prompts disturb me in the field’  Total sample  202  54  26.7    Non-equipped  101  41  40.6  0.001  Equipped  101  13  12.9    ‘Display disturbs me in the field’  Total sample  200  20  10.0    Non-equipped  99  12  12.1  0.322  Equipped  101  8  7.92    ‘I like to work with the RTF-system’  Total sample  198  173  87.4    Non-equipped  96  76  79.2  0.001  Equipped  102  97  95.1    ‘Real-time feedback system is a source of irritation’  Total sample  197  22  11.2    Non-equipped  96  19  19.8  0.001  Equipped  101  3  3.0    Table 3 Assessment of the system’s acceptance in different areas. Shown are the summed ratings of the answers ‘agree’ and ‘strongly agree’ regarding the given statements in comparison of equipped and non-equipped personnel Statement  Participants  n  Acceptance  P-value        n  %    Frequency   ‘Metronome helps to find the correct chest compression rate’  Total sample  200  189  94.5    Non-equipped  102  96  94.1  0.809  Equipped  98  93  94.9     ‘Metronome disturbs me in the field’  Total sample  199  141  29.2    Non-equipped  101  43  42.6  0.001  Equipped  98  15  15.3     ‘I don't need the metronome to find the correct chest compression rate’  Total sample  199  103  51.8    Non-equipped  101  57  56.4  0.18  Equipped  98  46  46.9    Compression depth   ‘Display helps me to achieve correct chest compression depth’  Total sample  202  161  79.7    Non-equipped  101  85  84.2  0.115  Equipped  101  76  75.3     ‘Voice prompt referring to chest compression depth are useful’  Total sample  196  145  74.0    Non-equipped  102  67  65.7  0.006  Equipped  94  78  83.0     ‘Display helps me to achieve full chest recoil’  Total sample  201  134  66.7    Non-equipped  101  77  76.2  0.004  Equipped  100  57  57.0    Timing   ‘Timer function improves temporal orientation’  Total sample  203  179  88.2    Non-equipped  101  94  93.1  0.032  Equipped  102  85  83.3     ‘Timer function improves changeover for rescuers delivering compressions’  Total sample  202  162  80.2    Non-equipped  100  82  82.0  0.525  Equipped  102  80  78.4     ‘I can accomplish temporal orientation in the field without feedback’  Total sample  202  54  26.7    Non-equipped  100  33  33.0  0.046  Equipped  102  21  20.6     ‘Real-time feedback generates unnecessary interruptions in the field’  Total sample  198  110  55.6    Non-equipped  100  65  65.0  0.007  Equipped  98  45  45.9    Quality management   ‘Data concerning the resuscitation quality should be recorded’  Total sample  203  165  81.3    Non-equipped  101  76  75.3  0.028  Equipped  102  89  87.3     ‘Individual performance of team member is controlled’  Total sample  203  139  68.5    Non-equipped  101  69  68.3  0.962  Equipped  102  70  68.6     ‘Debriefing with data analysis should only be conducted with the team’  Total sample  203  165  81.3    Non-equipped  101  78  77.2  0.141  Equipped  102  87  85.3     ‘Quality improvement is achieved through team debriefing’  Total sample  203  183  90.2    Non-equipped  101  96  95.1  0.02  Equipped  102  87  85.3    Statement  Participants  n  Acceptance  P-value        n  %    Frequency   ‘Metronome helps to find the correct chest compression rate’  Total sample  200  189  94.5    Non-equipped  102  96  94.1  0.809  Equipped  98  93  94.9     ‘Metronome disturbs me in the field’  Total sample  199  141  29.2    Non-equipped  101  43  42.6  0.001  Equipped  98  15  15.3     ‘I don't need the metronome to find the correct chest compression rate’  Total sample  199  103  51.8    Non-equipped  101  57  56.4  0.18  Equipped  98  46  46.9    Compression depth   ‘Display helps me to achieve correct chest compression depth’  Total sample  202  161  79.7    Non-equipped  101  85  84.2  0.115  Equipped  101  76  75.3     ‘Voice prompt referring to chest compression depth are useful’  Total sample  196  145  74.0    Non-equipped  102  67  65.7  0.006  Equipped  94  78  83.0     ‘Display helps me to achieve full chest recoil’  Total sample  201  134  66.7    Non-equipped  101  77  76.2  0.004  Equipped  100  57  57.0    Timing   ‘Timer function improves temporal orientation’  Total sample  203  179  88.2    Non-equipped  101  94  93.1  0.032  Equipped  102  85  83.3     ‘Timer function improves changeover for rescuers delivering compressions’  Total sample  202  162  80.2    Non-equipped  100  82  82.0  0.525  Equipped  102  80  78.4     ‘I can accomplish temporal orientation in the field without feedback’  Total sample  202  54  26.7    Non-equipped  100  33  33.0  0.046  Equipped  102  21  20.6     ‘Real-time feedback generates unnecessary interruptions in the field’  Total sample  198  110  55.6    Non-equipped  100  65  65.0  0.007  Equipped  98  45  45.9    Quality management   ‘Data concerning the resuscitation quality should be recorded’  Total sample  203  165  81.3    Non-equipped  101  76  75.3  0.028  Equipped  102  89  87.3     ‘Individual performance of team member is controlled’  Total sample  203  139  68.5    Non-equipped  101  69  68.3  0.962  Equipped  102  70  68.6     ‘Debriefing with data analysis should only be conducted with the team’  Total sample  203  165  81.3    Non-equipped  101  78  77.2  0.141  Equipped  102  87  85.3     ‘Quality improvement is achieved through team debriefing’  Total sample  203  183  90.2    Non-equipped  101  96  95.1  0.02  Equipped  102  87  85.3    Figure 1 View largeDownload slide Selected items assessing the acceptance of the real-time feedback system. Shown are the summarized proportions of the ratings ‘agree’ and ‘strongly agree’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). Asterisks are indicating statistical significance (P < 0.05). Figure 1 View largeDownload slide Selected items assessing the acceptance of the real-time feedback system. Shown are the summarized proportions of the ratings ‘agree’ and ‘strongly agree’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). Asterisks are indicating statistical significance (P < 0.05). General features Six general questions addressed the usefulness of single feedback components. The total sample rated the functions of the real-time feedback system as useful with a mean of 80.5%. There were significant differences between the groups (equipped 86.7% vs. unequipped personnel 74.9%, P = 0.037). The assessment of the usefulness of the feedback systems single components is shown in Fig. 2. Figure 2 View largeDownload slide Assessment of usefulness of the real-time feedback system’s components. Shown are the summarized proportions of the ratings ‘useful’ and ‘very useful’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). All components are more often rated to be useful by the equipped EMS personnel. Asterisks are indicating statistical significance (P < 0.05). Figure 2 View largeDownload slide Assessment of usefulness of the real-time feedback system’s components. Shown are the summarized proportions of the ratings ‘useful’ and ‘very useful’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). All components are more often rated to be useful by the equipped EMS personnel. Asterisks are indicating statistical significance (P < 0.05). In total, 69.4% of all participants agreed that voice prompts promote safety. Agreement to this statement was significantly higher in the group of equipped personnel (80.2 vs. 58.8%, P < 0.001). Overall, 73.2% of all participants agreed that the voice prompts could be trusted. With 87 vs. 59.2% agreement was significantly higher in the group of equipped personnel (P < 0.001). In total, 26.7% of all participants rated voice prompts as disturbing. Unequipped personnel agreed to this statement more often (40.6 vs. 12.9%; P < 0.001). Of all, 29.15% of all participants felt disturbed by the metronome, the group of unequipped personnel agreed significantly more often to this statement (15.3 vs. 42.6%, P < 0.001). A total of 87.4% of all participants agreed to the statement ‘I like working/would like to work with a real-time feedback system’, again there were significant differences between the groups (95.1 vs. 79.2%, P = 0.001). And 11.17% of all participants considered the real-time feedback system as a source of irritation. Equipped personnel agreed in only 3%, where unequipped personnel agreed in 19.8% (P < 0.001). Frequency A total of 94.5% of the total sample agreed to the statement that the metronome helps to find the correct chest compression rate. There were no significant differences between the two groups. Overall, 29.2% of all participants felt disturbed by the metronome in the field; however, equipped personnel agreed less often (15.3 vs. 42.6%, P < 0.001). In total, 51% indicated that they could find the correct compression frequency without any help (56.4 vs. 46.9%, P = 0.18). Chest compression depth A total of 79.7% of all participants found the display helpful to achieve correct compression depth. There was no significant difference between the two groups (75.3 vs. 84.2%, P = 0.115). 74% found voice prompts on compression depth helpful (83.0 vs. 65.7%, P = 0.06). The visual feedback to achieve complete recoil was considered helpful by 66.7% of all participants (57 vs. 76.2%, P = 0.004). Timer function In total, 88.2% of all participants agree that the real-time feedback system improves temporal orientation. In contrast to most other items agreement was higher in the group of unequipped personnel with 93.1% vs. equipped personnel with 83.3% (P = 0.032). 80.2% of all participants agreed that a change of rescuers delivering chest compressions was easier with support of the real-time feedback system (82 vs. 78.4%, n.s.). Asked if temporal orientation in the field was possible without real-time feedback 26.7% of all participants agreed. Agreement was higher in the group of unequipped personnel (33.0 vs. 20.6%; P = 0.046). Overall, 55.6% of all participants agreed that the real-time feedback system generates unnecessary interruptions (65 vs. 45.9%; P < 0.005). Quality management In total, 81.3% of the study sample agreed that data should be recorded and made available for QM. There was significantly higher acceptance in the group of equipped personnel (87.3 vs. 75.3%, P = 0.028). Team debriefings were rated positively by 81.3% (85.3 vs. 77.2%; n.s.) and 90.2% agreed that debriefing will result in quality improvements (95.1 vs. 85.3%; P = 0.02). Discussion Both groups—equipped and unequipped personnel—show homogenous and comparable epidemiological characteristics. Factors potentially influencing the acceptance of technical support such as gender, age, education or work experience are equally distributed in both groups. The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful and more than 95% of equipped personnel enjoy working with it. Only 11% consider it a source of irritation. These results show a positive attitude towards real-time feedback systems. However, this study also revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists. This documents scepticism by unequipped personnel that cannot be confirmed by experienced users—system use in daily routine results in better evaluation than the expectations of unequipped personnel. Participants were asked whether they could adhere to CPR guideline recommendations for frequency and timing without support of a real-time feedback system. Both groups estimate their own capability higher than actual performance that has been documented in studies. More than 50% of participants believe that they are able to deliver chest-compressions at the correct frequency without technical support; a quarter of participants believe that they are able to safely time CPR cycles without help. This is in contrast to Wik et al. [9] who could show that in 176 real-life missions (without real-time feedback) the time without any chest compressions was 48% and the effective chest compression rate was only 64/min [9]. In a study by Stiell et al. the mean compression depth achieved without real-time feedback (37,3 mm) was far below guideline recommendations. Only 8.4% of cases where in adherence with the ERC-guidelines [10]. Thus, the present study documents an unjustified feeling of competence in delivering ‘high-quality chest-compressions’. This is in accordance with studies documenting limited guideline adherence [11, 12]. Acceptance of real-time feedback systems was high, could however be raised even further if insufficient CPR-quality without the use of such systems was demonstrated more often. Frequency The Resuscitation Outcomes Consortium looked at 3098 patients in 2012 and could show a correlation of chest-compression frequency and the probability of a return of spontaneous circulation (ROSC). The probability for ROSC was the highest at chest-compression frequencies around 125 min−1 [13]. Real-life data often document frequencies that are higher or lower. Frequencies that are too high result in a significant reduction of compression depth [14–17]. Both equipped and unequipped personnel rated metronome support as helpful to achieve recommended compression frequencies. In total, 42% of unequipped personnel imagined the metronome to be disturbing, while only 15% of equipped personnel find it disturbing under real-life conditions. This is a good example of unjustified concerns by unequipped personnel. Chest compression depth Chest compression depth is an important target in CPR efforts, a strong relationship between chest compression depth and survival has been shown [10, 18, 19]. Wutzler et al. [20] proved that the use of audiovisual feedback resulted in significantly improved chest compressions in a manikin study. In our survey, 84% of unequipped personnel in our study believed that an index on the display could help find the correct compression depth, 75% of equipped personnel agreed. The value of the display regarding chest recoil was rated similarly. Answers regarding the voice prompts were contrary. Overall, 66% of unequipped personnel found voice prompts helpful while 83% of equipped personnel felt supported by voice prompts. This is in contrast to a study that found no benefits of voice prompts [21]. One explanation might be the design of the tested defibrillators. The AED Pro has a monochrome display and is hard to notice during chest compressions. The device has primarily been designed for audio feedback. This might explain the lower acceptance by equipped personnel. Again this is in contrast to the results for voice prompts where unequipped personnel assume less support while equipped personnel appreciate this support. This might reflect an alternative strategy due to the limited display of the system. Another reason might be reduced attention in stressful situations. Resuscitation attempts require complex performance and lead to limited attention [22–24]. Voice prompts and a metronome in the ‘background’ are easier to note and follow than a visual frequency indicator. The importance of deep chest compressions and the perceived support from the real-time feedback system by the majority of participants are important arguments for the use of such devices. Negative evaluations of the display show options for future improvements; newer models have larger displays and offer a better visual support. Another option for improvement could be an acoustic feedback on compression depth. This could be achieved by modulating the pitch of the metronome like in pulse oximeters. Timer The timer function of the real-time feedback system receives an overall good evaluation. Unequipped personnel are more likely to agree that interruptions by the device could be inaccurate in certain situations than equipped personnel. Actual use leads to higher confidence and acceptance of the system. Equipped personnel rate the ‘need’ for timing significantly higher than unequipped personnel. An explanation might be that timing and temporal orientation are not a core function of the device but are found beneficial by users. The awareness for correct timing may also be intensified by repeated use. The time without chest compressions was 48% in Wik et al.'s study, median chest compression fraction was 65% in the study by Stiell et al. [9, 11]. The chest compression fraction is an independent factor of survival [4, 25]. The fact that equipped personnel rate the timer functions positively could be a sign that CPR cycles are timed more precisely and no-flow times are limited. A meta-analysis by Kirkbright et al. demonstrated better chest-compression depth and frequencies with less no-flow times in study groups with audiovisual feedback [26]. Quality management Resuscitation quality still often is inadequate leaving room for improvement. Many studies without the use of real-time feedback systems in different settings documented that chest compression rates and frequencies in real life are insufficient and not in line with current guidelines and many pauses occur [9, 27–29]. This has also been documented in well trained staff. One option to improve CPR quality is team debriefings. Data from real-time feedback systems can be used to illustrate (low) quality. Edelson et al. [30] could show that debriefings supported by data improve compression depth and ROSC rates. In a study by Lukas et al. [6], the use of a real-time feedback system and team debriefings including CPR quality data led to higher ROSC rates than predicted by a prognostication score. To our knowledge there have been no studies on the acceptance of data recording and team debriefings. In our experience recording scene data even for QM is a sensitive issue. Staff may easily feel monitored and controlled. Our results however show a high acceptance of data recording. We also noticed that equipped personnel are less sceptical than unequipped personnel. Prejudices and concerns decrease with the use of a real-time feedback system. Data recording of real-time feedback systems can only register a team effort and is unable to document individual performance. However, fear of individual monitoring does not decrease in equipped personnel. Our study did not address whether this is experienced negatively. More participants in the equipped group consider data recording beneficial than in the control group. This might indicate a shift from fear of being monitored to a more positive understanding of the possibilities for quality improvement. Ambulance services can support a higher acceptance level by ensuring that team debriefings are committed confidentially and that any deviations from guideline recommendations are followed-up with the intention of system-wide improvements and not sanctions towards individual team members. Limitations This study looks at one specific real-time feedback system used in one ambulance service. The results might not be transferable to other services. It is hard to measure acceptance of or prejudices against medical devices. Ratings are subjective and can easily be influenced by recent positive or negative experiences. The control group of unequipped personnel could answer the questions only based on imaginative use of the device according to their individual expectations. Reasons for limited acceptance are often not given. Only few participants used the option of further free text feedback. Therefore, the reason for concerns and reduced acceptance of real-time feedback systems in unequipped personnel cannot be determined by this survey. Further research needs to be conducted to understand the reasons for limited acceptance in the unequipped group. Conclusions In our survey, real-time feedback systems receive overall positive ratings. Over 95% of equipped personnel like to work with the system and 79.2% of unequipped personnel would like to use such systems. Furthermore, the system is perceived less irritating in actual use than imagined by unequipped personnel. Prejudices and concerns seem to decrease with continued use of the system. Users appreciate the benefits and added safety. At present only few sites in Germany use real-time feedback systems. The fact that actual use will reduce fears and concerns should be another reason for implementation. Acknowledgements We would like to thank psychologists Liv Harding and Monika Rammert for helping with the design of the questionnaire. We also thank the Münster Fire Brigade and the Dortmund Fire Brigade for supporting the study. Furthermore, we thank all emergency physicians and paramedics of both brigades for their active support and participation in the study. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1 Nolan JP. Optimizing outcome after cardiac arrest. Curr Opin Crit Care  2011; 17: 520– 6. Google Scholar CrossRef Search ADS PubMed  2 Perkins GD, Brace SJ, Smythe M et al.  . Out-of-hospital cardiac arrest: recent advances in resuscitation and effects on outcome. Heart  2012; 98: 529– 35. Google Scholar CrossRef Search ADS PubMed  3 Callaway CW, Soar J, Aibiki M et al.  . 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All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

A better understanding of ambulance personnel’s attitude towards real-time resuscitation feedback

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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10.1093/intqhc/mzx189
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Abstract

Abstract Objective High-quality chest compressions during cardiopulmonary resuscitation (CPR) play a significant role in surviving cardiac arrest. Chest-compression quality can be measured and corrected by real-time CPR feedback devices, which are not yet commonly used. This article looks at the acceptance of such systems in comparison of equipped and unequipped personnel. Design Two groups of emergency medical services’ (EMS) personnel were interviewed using standardized questionnaires. Setting The survey was conducted in the German cities Dortmund and Münster. Participants Overall, 205 persons participated in the survey: 103 paramedics and emergency physicians from the Dortmund fire service and 102 personnel from the Münster service. Intervention The staff of the Dortmund service were not equipped with real-time feedback systems. The test group of equipped personnel of the ambulance service of Münster Fire brigade uses real-time feedback systems since 2007. Main outcome measure What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? Results The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful. However, this study revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists—the system’s use in daily routine results in better evaluation than the expectations of unequipped personnel. Conclusions Real-time feedback systems receive overall positive ratings. Prejudices and concerns seem to decrease with continued use of the system. quality measurement, quality management, quality improvement, cardiovascular diseases, disease categories, emergency care, setting of care Introduction Survival after cardiac arrest remains low despite continuing research [1, 2]. High-quality chest compressions play a significant role in the chain of survival [3, 4]. Chest compressions and ventilations can be measured by real-time cardiopulmonary resuscitation (CPR) feedback devices [5, 6]. Such devices can be integrated into defibrillators and give rescuers real-time feedback on the quality of CPR delivered to the patient. Feedback can be given by a metronome, voice prompts, visual displays and digital timers. This allows instantaneous correction of inadequate CPR efforts such as shallow chest-compressions. Data are also recorded and available for debriefing, quality management (QM) and identification for future improvement strategies [7]. While real-time feedback systems correct the team at the scene they also allow later analysis of CPR-quality. Rescuers could be prejudiced against such systems due to fear of surveillance which might impede implementation. There is little knowledge about the acceptance of technical support by rescue teams. This article looks at the acceptance of real-time feedback systems. Two groups of EMS personnel were interviewed through standardized questionnaires. One group had no access to such system in their daily routine as standard defibrillators were not equipped with real-time feedback (unequipped personnel). The other group had routine experience with a system since 2007 (equipped personnel). Methods The present study addresses at the following questions: What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? Real-time feedback systems offer different functions. Which functions have the highest or lowest level of acceptance level? To address these questions, we developed a questionnaire to measure different levels of ‘acceptance’. The design follows recommendations of the German Evaluation Society [8]. The questionnaire consisted of closed-ended questions that could be answered on a four-level scale ranging from ‘not useful at all’, ‘not useful’, ‘useful’ to ‘very useful’ or ‘strongly disagree’, ‘disagree’, ‘agree’, strongly agree’, respectively. A total of 40 items were assessed. The four-level scale was chosen intentionally to enforce a positive or negative choice. Unequipped personnel were asked to give answers imagining they had access to a real-time feedback system. This way expectations and experience with system functions were measured. The questionnaire included a short description of the real-time feedback system and a statement on data privacy. The questionnaire was pretested with a group of 20 equipped and unequipped emergency medical services (EMS) staff before final approval. The test group of unequipped personnel were paramedics and emergency physicians of the ambulance service of Dortmund Fire Brigade. The staff did not use or have training on real-time feedback systems at the time of the study. The test group of equipped personnel were paramedics and emergency physicians of the ambulance service of Münster Fire brigade. The service uses real-time feedback systems in all resuscitation attempts since 2007. The system is a product of ZOLL Medical Corporation, Chelmsford, MA, USA, integrated in the defibrillators AED-pro© and E-Series©. The defibrillation electrode pads (CPR-D-Padz® ZOLL Medical Corporation, Chelmsford, MA, USA) incorporate a motion sensor registering compression depth, recoil and frequency. The questionnaire addressed the following functions of the real-time feedback system. Audio feedback A metronome ticks with a frequency of 100 beats/min in line with guideline recommendations. Visual feedback The chest compression depth in cm is displayed on the monitor as variable bar. Voice prompts The device gives feedback through messages such as ‘push harder’ or ‘good compressions’. Pauses Following a period of more than 10 s of inactivity the device will request continuation of chest compressions by a voice prompt: ‘continue CPR’. Timer functions A clock displayed on the monitor starts upon system activation. The device prompts for EKG analysis every 2 min (CPR cycle). This clocking is continued for the complete mission. Data recording The device saves the complete CPR attempt (EKG, chest compressions, pauses). Data are stored for analysis and debriefing. The survey was conducted on an anonymous and voluntarily basis from June 2011 until January 2012. One of the authors (S.T.) was present while the questionnaires were filled in to answer any comprehension questions. Questionnaires were not issued to staff that did not want to participate in the study or those from the group of unequipped personnel that had previously worked with real-time feedback systems elsewhere. Statistical analysis was done with Microsoft Office EXCEL (Microsoft Corporation, Redmond, WA, USA) and SPSS Version 20 (SPSS Inc., Chicago, IL, USA; 2004). Data were aggregated from a four-level scale to a two-level scale. Relative frequencies of characteristics were calculated and two-sided significance between the groups was compared by Chi-squared test. Significance level was set at P < 0.05 and the confidence intervals were set at 95%. The conduct of this questionnaire comparison was approved by the Ethics Committee of the State Medical Board of Registration for Westphalia–Lippe and the University of Münster based on the registration no. 2006-571-f-S. Informed consent to participate in this survey including data processing and publication was obtained from all participants. Results Overall, 205 persons participated in the survey, 102 equipped personnel from the Münster service and 103 unequipped participants from the Dortmund service. There were no differences in epidemiological data or work experience between the two groups (Table 1). Results of the total sample (equipped and unequipped personnel) and detailed results of both groups are shown in Tables 2 and 3 and Fig. 1. Table 1 Epidemiology of the participants. No significant differences between the two groups (equipped vs. non-equipped personnel) regarding their gender, age, qualification and work experience exist   Equipped personnel  Non-equipped personnel  P-value  Sex  Female  1106  55.2%    Male  898  44.8%    Age (in years)  Average age [standard deviation]  34 [8]  35 [8]  0.772 = n.s.  Maximum age  60  59    Minimum age  21  21    Qualification  Emergency physician  27  26  0.841 = n.s.  Paramedic  75  77    Work experience  Average in years [standard deviation]  9 [7]  8 [8]  0.175 = n.s.    Equipped personnel  Non-equipped personnel  P-value  Sex  Female  1106  55.2%    Male  898  44.8%    Age (in years)  Average age [standard deviation]  34 [8]  35 [8]  0.772 = n.s.  Maximum age  60  59    Minimum age  21  21    Qualification  Emergency physician  27  26  0.841 = n.s.  Paramedic  75  77    Work experience  Average in years [standard deviation]  9 [7]  8 [8]  0.175 = n.s.  Table 2 General assessment of the real-time feedback system. Shown are the summed ratings of the answers ‘agree’ and ‘strongly agree’ regarding the given statements in comparison of equipped and non-equipped personnel. The results show a higher acceptance of a real-time feedback system and less doubt about it in the group of equipped personnel when compared to non-equipped personnel Statement  Participants  n  Acceptance  P-value        n  %    ‘Voice prompts promote safety’  Total sample  203  141  69.6    Non-equipped  102  60  58.8  0.001  Equipped  101  81  80.2    ‘I trust the given voice prompts’  Total sample  198  145  73.2    Non-equipped  98  58  59.2  0.001  Equipped  100  87  87.0    ‘Voice prompts disturb me in the field’  Total sample  202  54  26.7    Non-equipped  101  41  40.6  0.001  Equipped  101  13  12.9    ‘Display disturbs me in the field’  Total sample  200  20  10.0    Non-equipped  99  12  12.1  0.322  Equipped  101  8  7.92    ‘I like to work with the RTF-system’  Total sample  198  173  87.4    Non-equipped  96  76  79.2  0.001  Equipped  102  97  95.1    ‘Real-time feedback system is a source of irritation’  Total sample  197  22  11.2    Non-equipped  96  19  19.8  0.001  Equipped  101  3  3.0    Statement  Participants  n  Acceptance  P-value        n  %    ‘Voice prompts promote safety’  Total sample  203  141  69.6    Non-equipped  102  60  58.8  0.001  Equipped  101  81  80.2    ‘I trust the given voice prompts’  Total sample  198  145  73.2    Non-equipped  98  58  59.2  0.001  Equipped  100  87  87.0    ‘Voice prompts disturb me in the field’  Total sample  202  54  26.7    Non-equipped  101  41  40.6  0.001  Equipped  101  13  12.9    ‘Display disturbs me in the field’  Total sample  200  20  10.0    Non-equipped  99  12  12.1  0.322  Equipped  101  8  7.92    ‘I like to work with the RTF-system’  Total sample  198  173  87.4    Non-equipped  96  76  79.2  0.001  Equipped  102  97  95.1    ‘Real-time feedback system is a source of irritation’  Total sample  197  22  11.2    Non-equipped  96  19  19.8  0.001  Equipped  101  3  3.0    Table 3 Assessment of the system’s acceptance in different areas. Shown are the summed ratings of the answers ‘agree’ and ‘strongly agree’ regarding the given statements in comparison of equipped and non-equipped personnel Statement  Participants  n  Acceptance  P-value        n  %    Frequency   ‘Metronome helps to find the correct chest compression rate’  Total sample  200  189  94.5    Non-equipped  102  96  94.1  0.809  Equipped  98  93  94.9     ‘Metronome disturbs me in the field’  Total sample  199  141  29.2    Non-equipped  101  43  42.6  0.001  Equipped  98  15  15.3     ‘I don't need the metronome to find the correct chest compression rate’  Total sample  199  103  51.8    Non-equipped  101  57  56.4  0.18  Equipped  98  46  46.9    Compression depth   ‘Display helps me to achieve correct chest compression depth’  Total sample  202  161  79.7    Non-equipped  101  85  84.2  0.115  Equipped  101  76  75.3     ‘Voice prompt referring to chest compression depth are useful’  Total sample  196  145  74.0    Non-equipped  102  67  65.7  0.006  Equipped  94  78  83.0     ‘Display helps me to achieve full chest recoil’  Total sample  201  134  66.7    Non-equipped  101  77  76.2  0.004  Equipped  100  57  57.0    Timing   ‘Timer function improves temporal orientation’  Total sample  203  179  88.2    Non-equipped  101  94  93.1  0.032  Equipped  102  85  83.3     ‘Timer function improves changeover for rescuers delivering compressions’  Total sample  202  162  80.2    Non-equipped  100  82  82.0  0.525  Equipped  102  80  78.4     ‘I can accomplish temporal orientation in the field without feedback’  Total sample  202  54  26.7    Non-equipped  100  33  33.0  0.046  Equipped  102  21  20.6     ‘Real-time feedback generates unnecessary interruptions in the field’  Total sample  198  110  55.6    Non-equipped  100  65  65.0  0.007  Equipped  98  45  45.9    Quality management   ‘Data concerning the resuscitation quality should be recorded’  Total sample  203  165  81.3    Non-equipped  101  76  75.3  0.028  Equipped  102  89  87.3     ‘Individual performance of team member is controlled’  Total sample  203  139  68.5    Non-equipped  101  69  68.3  0.962  Equipped  102  70  68.6     ‘Debriefing with data analysis should only be conducted with the team’  Total sample  203  165  81.3    Non-equipped  101  78  77.2  0.141  Equipped  102  87  85.3     ‘Quality improvement is achieved through team debriefing’  Total sample  203  183  90.2    Non-equipped  101  96  95.1  0.02  Equipped  102  87  85.3    Statement  Participants  n  Acceptance  P-value        n  %    Frequency   ‘Metronome helps to find the correct chest compression rate’  Total sample  200  189  94.5    Non-equipped  102  96  94.1  0.809  Equipped  98  93  94.9     ‘Metronome disturbs me in the field’  Total sample  199  141  29.2    Non-equipped  101  43  42.6  0.001  Equipped  98  15  15.3     ‘I don't need the metronome to find the correct chest compression rate’  Total sample  199  103  51.8    Non-equipped  101  57  56.4  0.18  Equipped  98  46  46.9    Compression depth   ‘Display helps me to achieve correct chest compression depth’  Total sample  202  161  79.7    Non-equipped  101  85  84.2  0.115  Equipped  101  76  75.3     ‘Voice prompt referring to chest compression depth are useful’  Total sample  196  145  74.0    Non-equipped  102  67  65.7  0.006  Equipped  94  78  83.0     ‘Display helps me to achieve full chest recoil’  Total sample  201  134  66.7    Non-equipped  101  77  76.2  0.004  Equipped  100  57  57.0    Timing   ‘Timer function improves temporal orientation’  Total sample  203  179  88.2    Non-equipped  101  94  93.1  0.032  Equipped  102  85  83.3     ‘Timer function improves changeover for rescuers delivering compressions’  Total sample  202  162  80.2    Non-equipped  100  82  82.0  0.525  Equipped  102  80  78.4     ‘I can accomplish temporal orientation in the field without feedback’  Total sample  202  54  26.7    Non-equipped  100  33  33.0  0.046  Equipped  102  21  20.6     ‘Real-time feedback generates unnecessary interruptions in the field’  Total sample  198  110  55.6    Non-equipped  100  65  65.0  0.007  Equipped  98  45  45.9    Quality management   ‘Data concerning the resuscitation quality should be recorded’  Total sample  203  165  81.3    Non-equipped  101  76  75.3  0.028  Equipped  102  89  87.3     ‘Individual performance of team member is controlled’  Total sample  203  139  68.5    Non-equipped  101  69  68.3  0.962  Equipped  102  70  68.6     ‘Debriefing with data analysis should only be conducted with the team’  Total sample  203  165  81.3    Non-equipped  101  78  77.2  0.141  Equipped  102  87  85.3     ‘Quality improvement is achieved through team debriefing’  Total sample  203  183  90.2    Non-equipped  101  96  95.1  0.02  Equipped  102  87  85.3    Figure 1 View largeDownload slide Selected items assessing the acceptance of the real-time feedback system. Shown are the summarized proportions of the ratings ‘agree’ and ‘strongly agree’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). Asterisks are indicating statistical significance (P < 0.05). Figure 1 View largeDownload slide Selected items assessing the acceptance of the real-time feedback system. Shown are the summarized proportions of the ratings ‘agree’ and ‘strongly agree’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). Asterisks are indicating statistical significance (P < 0.05). General features Six general questions addressed the usefulness of single feedback components. The total sample rated the functions of the real-time feedback system as useful with a mean of 80.5%. There were significant differences between the groups (equipped 86.7% vs. unequipped personnel 74.9%, P = 0.037). The assessment of the usefulness of the feedback systems single components is shown in Fig. 2. Figure 2 View largeDownload slide Assessment of usefulness of the real-time feedback system’s components. Shown are the summarized proportions of the ratings ‘useful’ and ‘very useful’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). All components are more often rated to be useful by the equipped EMS personnel. Asterisks are indicating statistical significance (P < 0.05). Figure 2 View largeDownload slide Assessment of usefulness of the real-time feedback system’s components. Shown are the summarized proportions of the ratings ‘useful’ and ‘very useful’ in comparison of non-equipped (dark columns) vs. equipped personnel (light columns). All components are more often rated to be useful by the equipped EMS personnel. Asterisks are indicating statistical significance (P < 0.05). In total, 69.4% of all participants agreed that voice prompts promote safety. Agreement to this statement was significantly higher in the group of equipped personnel (80.2 vs. 58.8%, P < 0.001). Overall, 73.2% of all participants agreed that the voice prompts could be trusted. With 87 vs. 59.2% agreement was significantly higher in the group of equipped personnel (P < 0.001). In total, 26.7% of all participants rated voice prompts as disturbing. Unequipped personnel agreed to this statement more often (40.6 vs. 12.9%; P < 0.001). Of all, 29.15% of all participants felt disturbed by the metronome, the group of unequipped personnel agreed significantly more often to this statement (15.3 vs. 42.6%, P < 0.001). A total of 87.4% of all participants agreed to the statement ‘I like working/would like to work with a real-time feedback system’, again there were significant differences between the groups (95.1 vs. 79.2%, P = 0.001). And 11.17% of all participants considered the real-time feedback system as a source of irritation. Equipped personnel agreed in only 3%, where unequipped personnel agreed in 19.8% (P < 0.001). Frequency A total of 94.5% of the total sample agreed to the statement that the metronome helps to find the correct chest compression rate. There were no significant differences between the two groups. Overall, 29.2% of all participants felt disturbed by the metronome in the field; however, equipped personnel agreed less often (15.3 vs. 42.6%, P < 0.001). In total, 51% indicated that they could find the correct compression frequency without any help (56.4 vs. 46.9%, P = 0.18). Chest compression depth A total of 79.7% of all participants found the display helpful to achieve correct compression depth. There was no significant difference between the two groups (75.3 vs. 84.2%, P = 0.115). 74% found voice prompts on compression depth helpful (83.0 vs. 65.7%, P = 0.06). The visual feedback to achieve complete recoil was considered helpful by 66.7% of all participants (57 vs. 76.2%, P = 0.004). Timer function In total, 88.2% of all participants agree that the real-time feedback system improves temporal orientation. In contrast to most other items agreement was higher in the group of unequipped personnel with 93.1% vs. equipped personnel with 83.3% (P = 0.032). 80.2% of all participants agreed that a change of rescuers delivering chest compressions was easier with support of the real-time feedback system (82 vs. 78.4%, n.s.). Asked if temporal orientation in the field was possible without real-time feedback 26.7% of all participants agreed. Agreement was higher in the group of unequipped personnel (33.0 vs. 20.6%; P = 0.046). Overall, 55.6% of all participants agreed that the real-time feedback system generates unnecessary interruptions (65 vs. 45.9%; P < 0.005). Quality management In total, 81.3% of the study sample agreed that data should be recorded and made available for QM. There was significantly higher acceptance in the group of equipped personnel (87.3 vs. 75.3%, P = 0.028). Team debriefings were rated positively by 81.3% (85.3 vs. 77.2%; n.s.) and 90.2% agreed that debriefing will result in quality improvements (95.1 vs. 85.3%; P = 0.02). Discussion Both groups—equipped and unequipped personnel—show homogenous and comparable epidemiological characteristics. Factors potentially influencing the acceptance of technical support such as gender, age, education or work experience are equally distributed in both groups. The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful and more than 95% of equipped personnel enjoy working with it. Only 11% consider it a source of irritation. These results show a positive attitude towards real-time feedback systems. However, this study also revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists. This documents scepticism by unequipped personnel that cannot be confirmed by experienced users—system use in daily routine results in better evaluation than the expectations of unequipped personnel. Participants were asked whether they could adhere to CPR guideline recommendations for frequency and timing without support of a real-time feedback system. Both groups estimate their own capability higher than actual performance that has been documented in studies. More than 50% of participants believe that they are able to deliver chest-compressions at the correct frequency without technical support; a quarter of participants believe that they are able to safely time CPR cycles without help. This is in contrast to Wik et al. [9] who could show that in 176 real-life missions (without real-time feedback) the time without any chest compressions was 48% and the effective chest compression rate was only 64/min [9]. In a study by Stiell et al. the mean compression depth achieved without real-time feedback (37,3 mm) was far below guideline recommendations. Only 8.4% of cases where in adherence with the ERC-guidelines [10]. Thus, the present study documents an unjustified feeling of competence in delivering ‘high-quality chest-compressions’. This is in accordance with studies documenting limited guideline adherence [11, 12]. Acceptance of real-time feedback systems was high, could however be raised even further if insufficient CPR-quality without the use of such systems was demonstrated more often. Frequency The Resuscitation Outcomes Consortium looked at 3098 patients in 2012 and could show a correlation of chest-compression frequency and the probability of a return of spontaneous circulation (ROSC). The probability for ROSC was the highest at chest-compression frequencies around 125 min−1 [13]. Real-life data often document frequencies that are higher or lower. Frequencies that are too high result in a significant reduction of compression depth [14–17]. Both equipped and unequipped personnel rated metronome support as helpful to achieve recommended compression frequencies. In total, 42% of unequipped personnel imagined the metronome to be disturbing, while only 15% of equipped personnel find it disturbing under real-life conditions. This is a good example of unjustified concerns by unequipped personnel. Chest compression depth Chest compression depth is an important target in CPR efforts, a strong relationship between chest compression depth and survival has been shown [10, 18, 19]. Wutzler et al. [20] proved that the use of audiovisual feedback resulted in significantly improved chest compressions in a manikin study. In our survey, 84% of unequipped personnel in our study believed that an index on the display could help find the correct compression depth, 75% of equipped personnel agreed. The value of the display regarding chest recoil was rated similarly. Answers regarding the voice prompts were contrary. Overall, 66% of unequipped personnel found voice prompts helpful while 83% of equipped personnel felt supported by voice prompts. This is in contrast to a study that found no benefits of voice prompts [21]. One explanation might be the design of the tested defibrillators. The AED Pro has a monochrome display and is hard to notice during chest compressions. The device has primarily been designed for audio feedback. This might explain the lower acceptance by equipped personnel. Again this is in contrast to the results for voice prompts where unequipped personnel assume less support while equipped personnel appreciate this support. This might reflect an alternative strategy due to the limited display of the system. Another reason might be reduced attention in stressful situations. Resuscitation attempts require complex performance and lead to limited attention [22–24]. Voice prompts and a metronome in the ‘background’ are easier to note and follow than a visual frequency indicator. The importance of deep chest compressions and the perceived support from the real-time feedback system by the majority of participants are important arguments for the use of such devices. Negative evaluations of the display show options for future improvements; newer models have larger displays and offer a better visual support. Another option for improvement could be an acoustic feedback on compression depth. This could be achieved by modulating the pitch of the metronome like in pulse oximeters. Timer The timer function of the real-time feedback system receives an overall good evaluation. Unequipped personnel are more likely to agree that interruptions by the device could be inaccurate in certain situations than equipped personnel. Actual use leads to higher confidence and acceptance of the system. Equipped personnel rate the ‘need’ for timing significantly higher than unequipped personnel. An explanation might be that timing and temporal orientation are not a core function of the device but are found beneficial by users. The awareness for correct timing may also be intensified by repeated use. The time without chest compressions was 48% in Wik et al.'s study, median chest compression fraction was 65% in the study by Stiell et al. [9, 11]. The chest compression fraction is an independent factor of survival [4, 25]. The fact that equipped personnel rate the timer functions positively could be a sign that CPR cycles are timed more precisely and no-flow times are limited. A meta-analysis by Kirkbright et al. demonstrated better chest-compression depth and frequencies with less no-flow times in study groups with audiovisual feedback [26]. Quality management Resuscitation quality still often is inadequate leaving room for improvement. Many studies without the use of real-time feedback systems in different settings documented that chest compression rates and frequencies in real life are insufficient and not in line with current guidelines and many pauses occur [9, 27–29]. This has also been documented in well trained staff. One option to improve CPR quality is team debriefings. Data from real-time feedback systems can be used to illustrate (low) quality. Edelson et al. [30] could show that debriefings supported by data improve compression depth and ROSC rates. In a study by Lukas et al. [6], the use of a real-time feedback system and team debriefings including CPR quality data led to higher ROSC rates than predicted by a prognostication score. To our knowledge there have been no studies on the acceptance of data recording and team debriefings. In our experience recording scene data even for QM is a sensitive issue. Staff may easily feel monitored and controlled. Our results however show a high acceptance of data recording. We also noticed that equipped personnel are less sceptical than unequipped personnel. Prejudices and concerns decrease with the use of a real-time feedback system. Data recording of real-time feedback systems can only register a team effort and is unable to document individual performance. However, fear of individual monitoring does not decrease in equipped personnel. Our study did not address whether this is experienced negatively. More participants in the equipped group consider data recording beneficial than in the control group. This might indicate a shift from fear of being monitored to a more positive understanding of the possibilities for quality improvement. Ambulance services can support a higher acceptance level by ensuring that team debriefings are committed confidentially and that any deviations from guideline recommendations are followed-up with the intention of system-wide improvements and not sanctions towards individual team members. Limitations This study looks at one specific real-time feedback system used in one ambulance service. The results might not be transferable to other services. It is hard to measure acceptance of or prejudices against medical devices. Ratings are subjective and can easily be influenced by recent positive or negative experiences. The control group of unequipped personnel could answer the questions only based on imaginative use of the device according to their individual expectations. Reasons for limited acceptance are often not given. Only few participants used the option of further free text feedback. Therefore, the reason for concerns and reduced acceptance of real-time feedback systems in unequipped personnel cannot be determined by this survey. Further research needs to be conducted to understand the reasons for limited acceptance in the unequipped group. Conclusions In our survey, real-time feedback systems receive overall positive ratings. Over 95% of equipped personnel like to work with the system and 79.2% of unequipped personnel would like to use such systems. Furthermore, the system is perceived less irritating in actual use than imagined by unequipped personnel. Prejudices and concerns seem to decrease with continued use of the system. Users appreciate the benefits and added safety. At present only few sites in Germany use real-time feedback systems. The fact that actual use will reduce fears and concerns should be another reason for implementation. Acknowledgements We would like to thank psychologists Liv Harding and Monika Rammert for helping with the design of the questionnaire. We also thank the Münster Fire Brigade and the Dortmund Fire Brigade for supporting the study. Furthermore, we thank all emergency physicians and paramedics of both brigades for their active support and participation in the study. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1 Nolan JP. Optimizing outcome after cardiac arrest. Curr Opin Crit Care  2011; 17: 520– 6. Google Scholar CrossRef Search ADS PubMed  2 Perkins GD, Brace SJ, Smythe M et al.  . Out-of-hospital cardiac arrest: recent advances in resuscitation and effects on outcome. Heart  2012; 98: 529– 35. Google Scholar CrossRef Search ADS PubMed  3 Callaway CW, Soar J, Aibiki M et al.  . 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All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Mar 1, 2018

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