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Resuscitation 82 (2011) 944–946

Contents lists available at ScienceDirect

Resuscitation

journa l homepage: www.e lsev ier .com/ locate / resusc i ta t ion

hort communication

randomised control trial comparing two techniques for locating chestompression hand position in adult Basic Life Support

ndrew Owena,∗, Philip Harveyb, Laura Kocierzb, Alex Lewisb, Jennifer Waltersb, Jonathan Hulmec

Russell’s Hall Hospital, Dudley DY1 2HQ, United KingdomThe Medical School, University of Birmingham, Birmingham B15 2TT, United KingdomSandwell and West Birmingham Hospitals NHS Trust, Birmingham City Hospital, Dudley Road, Birmingham B18 7QH, United Kingdom

r t i c l e i n f o

rticle history:eceived 16 November 2010eceived in revised form 30 January 2011ccepted 24 February 2011

eywords:asic Life Supportand positiondulthest compression000 guidelines005 guidelines

a b s t r a c t

Introduction: Chest compressions performed correctly have the potential to increase survival post cardiacarrest. The 2005 European Resuscitation Council (ERC) guidelines altered and simplified instructions forhand position placement to increase the number of chest compressions performed. This randomisedcontrolled trial compares chest compression efficacy (hand position and number of effective chestcompressions) after training using the 2005 guidelines or the 2005 guidelines with a hand positionmodification based on 2000 ERC guidelines.Methods: First year healthcare students at the University of Birmingham, United Kingdom, were randomlyallocated to either ‘2005’ or ‘intervention’ group immediately after passing a Basic Life Support (BLS)assessment to ERC standards. The 2005 group performed 2 min of BLS on a SkillReporterTM manikin(Laerdal Medical, Stavanger, Norway). The intervention group received training on hand placement usinglandmark techniques from the 2000 ERC guidelines; emphasising rapid hand positioning. This group also

TM

RCandmark technique

performed 2 min of BLS on a SkillReporter manikin.Results: 82 students were assessed; 41 in the 2005 group and 41 in the intervention group. Averagecompression rate was 102 in the 2005 group and 104 in the intervention group (p = 0.29). Average numberof incorrect hand placements was 24 in the 2005 group and 9 in the intervention group (p = 0.03).Conclusions: The use of landmark measurement techniques in hand placement for external chest com-pressions does not have a detrimental effect on the number of chest compressions performed during BLS

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and increases correct han

. Introduction

Correctly performed chest compressions can increase survivalost cardiac arrest.1 Minimising the time spent not doing chestompressions also improves outcome.2–5

The 2005 ERC guidelines simplified instructions for hand place-ent in an attempt to improve the number of chest compressions

erformed by reducing “hands-off time” (i.e. time in which no chestompressions are performed).

Basic Life Support (BLS) skills are often not acquired adequatelyuring training.6 Simplifying hand positioning instructions was onef six main changes intended to aid learning and memory by reduc-

ng the number of steps in the life support algorithm.7

Subsequent study confirmed that the 2005 guidelines do reduceands-off time compared to previous guidelines.7–9 This reductionas been attributed to a cut in steps in the BLS sequence, the one-

∗ Corresponding author.E-mail address: Andrewowen@nhs.net (A. Owen).

300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.resuscitation.2011.02.038

itioning.© 2011 Elsevier Ireland Ltd. All rights reserved.

versus three-shock strategy, the omitted check for signs of circula-tion after shock delivery and the changed ratio of compression toventilation.9 However, calculations have assessed the new guide-lines globally without specifically investigating the effect of handpositioning technique on either hands-off time or correct handplacement.

Prior to the 2005 guidelines there was insufficient evidenceto support a specific hand position during compressions.7,10,11

Since the change this has been investigated further.12,13 Radi-ological assessment to determine the landmark for optimalchest compressions considered compression of the ster-num to be comparable to that of a hinge: compression ofthe distal sternum results in a reduction in energy expen-diture. Correct sternal landmark identification has beenhighlighted as important to compress both the structuresdirectly below the compression site and adjacent parts of the

heart.12

This randomised controlled trial compares the use of alandmark technique as proposed in the 2000 European Resus-citation Council (ERC) guidelines, with a taught emphasis on

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apidity of hand positioning, compared to the 2005 ERC tech-ique.

. Methods

82 first-year healthcare students at the University of Birming-am, UK, were recruited from those on a BLS course during thecademic year 2008/2009. Students were eligible if they passed theLS assessment on their first attempt and were excluded if theyequired retesting, prior to randomisation. Recruitment was car-ied out by course instructors during the final lecture of the courserior to sitting the end of course assessment. Students were given aree choice to opt into this study. Ethical approval was not requiredor this study.

This is a student-led course using more senior healthcare stu-ents to train and assess their peers. The structure and successfulerformance of this course has been described previously.14 Theurriculum uses the most recent ERC guidelines. Instructors usehe 4-stage teaching method within small groups, as recommendedy the ERC.15 Skills in the BLS algorithm are demonstrated andescribed several times. For chest compression hand position, stu-ents are taught to ‘place the heel of their hands in the centre of thehest’. Contemporaneous demonstrations involving hand place-ent in the middle of the lower third of the sternum are performed

y all teachers in small groups. Supervised practice of all skills isndertaken and candidates’ efforts are corrected as required. This isonsistent with recommendations for teaching chest compressionsescribed in Guidelines 2005 and has been our course standardince inception.11

The nature of the study was explained to the students in theenultimate teaching session. Immediately after successful com-letion, at first attempt, of the end of course assessment, studentsere randomised to control and trial groups. Randomisation was

arried out using Microsoft Excel to randomise the list of names.Trial group students were instructed in the use of the landmark

echnique for locating hand position described in the ERC 2000uidelines8:

. With your hand that is nearest to the victim’s feet, locate thelower half of the sternum.

. Using your index and middle fingers, identify the lower ribedge nearest to you. Keeping your fingers together, slide themupwards to the point where the ribs join the sternum. Withyour middle finger on this point, place your index finger on thesternum itself.

. Slide the heel of your other hand down the sternum until itreaches your index finger; this should be the middle of the lowerhalf of the sternum.

. Place the heel of the other hand on top of the first.

. Extend or interlock the fingers of both hands and lift them toensure that pressure is not applied over the victim’s ribs.

The 4-stage approach was used throughout teaching.15 Theechnique was taught by a single experienced instructor in groupsf 3, taking 10 min per group or until all participants felt confi-ent with the technique. All students reported feeling that theyad received adequate training. An emphasis was placed on rapidnd accurate hand position location to minimise ‘no-flow’ time. Thedditional training did not include practice or teaching on otherreas of correct compression performance such as rate and depth.

he time between training and testing was less than 30 min.

Participants in the control group were not given any furtherraining.

All study participants performed 2 min of BLS using the posi-ioning technique appropriate for their group.

n 82 (2011) 944–946 945

Timing started at the first chest compression. Quality wasassessed objectively and subjectively. Laerdal SkillReporterTM

manikins with Laerdal PC SkillReporterTM and Laerdal PCSkillmeterTM VAM software were used for all assessments.

A two tailed t-test was used to assess significance of variablesbetween control and trial groups. Microsoft Excel was used to per-form calculations. Values of p < 0.05 were considered statisticallysignificant.

3. Results

The total number of participants were 82; 41 in both the controland trial group.

The average compression rate in the control group was 102compressions/min and in the trial group 104/min (p = 0.3).

The average compression depth was 33.5 mm for the controlgroup and 35.9 mm for the trial group (p = 0.1).

The average duty cycle was 46.4% in the control group and 46.3%in the trial group (p = 0.76).

There was a significant difference in the average number ofincorrect hand positions: 24 in the control group and 9 in the trialgroup (p = 0.03).

4. Discussion

In this study incorrect hand positioning was significantlyreduced using the 2000 ERC guideline hand positioning techniquecompared to the 2005 method without adversely affecting com-pression depth, rate, average number of compressions or duty cycle.

An aim of the 2005 guidelines was to improve knowledge andskill retention by simplifying the BLS algorithm. However, sim-plifying teaching of CPR hand placement does not improve skillacquisition or retention although it does reduce hands-off timeduring testing 6-weeks later.11

We suggest that use of the simplified method of hand position-ing as part of the 2005 guidelines results in poorer accuracy ofhand placement when measured objectively. Others have foundsignificant deterioration in accuracy after initial teaching usingthe landmark technique. This was after it had been taught as partof the more complicated 2000 guidelines.11 Other studies haveshown that hand position is comparable between groups taughta landmark technique and a simpler ‘hand in the middle of thechest’ technique,16 however this was also as a part of the morecomplicated 2000 ERC guidelines taught to various levels of com-plexity.

There are some limitations to this study. Our cohort of individ-uals represents a highly motivated and intelligent section of thepopulation, although they are lay responders, not clinicians, as theyhave not undertaken clinical attachments. Whether our results aresustained when extended to all those taught Basic Life Supportrequires further study.

It was not deemed fair for in the interests of student education,to give the trial group different initial BLS training compared to thecontrol group. This is why all students were trained in BLS as per theERC guidelines prior to undertaking the study. Pre-test assessmentusing a Skillmeter manikin was not introduced to either group asthis would have potential to cause bias.

The candidates in the trial group of this study did receive 10 minof extra training and it could be argued that this influenced results.This training was carefully monitored and only involved the loca-

tion technique, not other aspects of the BLS algorithm or techniqueof chest compressions. The control group was aware that the studyintended to assess hand positioning.

An unacceptable hand position was determined by the manikinand software. The degree of deviation from the accepted correct

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osition has not been recorded and so the degree of improvementnd whether it may have clinical significance is unknown.

Our study was not intended to investigate knowledge reten-ion. Further investigation is needed to see if a landmark technique,ithin simplified 2005 guidelines, sustains improvements in com-ression quality without increased hands-off time.

. Conclusions

A landmark technique for locating chest compression handosition within the [simplified] 2005 ERC BLS guidelines leads to

mproved hand position with no detriment to the quality of resus-itation or the amount of ‘hands off’ time during simulated lifeupport on a manikin.

The clinical significance of this objective improvement andnowledge retention of student’s being taught a landmark tech-ique needs further investigation.

onflict of interest statement

None.

eferences

1. Wik L. Rediscovering the importance of chest compressions to

improve the outcome from cardiac arrest. Resuscitation 2003;58:267–9.

2. Berg RA, Sanders AB, Kern KB, et al. Adverse haemodynamic effects ofinterrupting chest compressions for rescue breathing during cardiopul-monary resuscitation for ventricular fibrillation cardiac arrest. Circulation2001;104:2465–70.

1

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n 82 (2011) 944–946

3. Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopul-monary resuscitation and survival following out of hospital cardiac arrest. JAMA1995;274:1922–5.

4. Kramer-Johansen J, Edelson DP, Losert H, Kohler K, Abella BS. Uniform report-ing of measured quality of cardiopulmonary resuscitation (CPR). Resuscitation2007;74:406–17.

5. Steen S, Liao Q, Pierre L, Paskevicius A, Sjoberg T. The critical importance ofminimal delay between chest compressions and subsequent defibrillation: ahaemodynamic explanation. Resuscitation 2003;58:249–58.

6. Batcheller AM, Brennan RT, Braslow A, Urrutia A, Kaye W. Cardiopulmonaryresuscitation performance of subjects over forty is better following half-hourvideo self-instruction compared to traditional four-hour classroom training.Resuscitation 2000;43:101–6.

7. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L. Euro-pean Resuscitation Council Guidelines for Resuscitation 2005. Section 2. Adultbasic life support and use of automated external defibrillators. Resuscitation2005;67S1:S7–23.

8. Handley AJ, Monsieurs KG, Bossaert LL. European Resuscitation Council Guide-lines 2000 for adult basic life support. Resuscitation 2001;48:199–205.

9. Roessler B, Fleichhackl R, Losert H, et al. Reduced hands-off-time and timeto first shock in CPR according to the ERC Guidelines 2005. Resuscitation2009;80:104–8.

0. Kouwenhoven WB, Jude WR, Knickerbocker GG. Closed-chest cardiac massage.JAMA 1960;173:1064–7.

1. Handley AJ. Teaching hand placement for chest compression – a simpler tech-nique. Resuscitation 2002;53:29–36.

2. Pickard A, Darby M, Soar J. Radiological assessment of the adult chest: implica-tions for chest compressions. Resuscitation 2006;71:387–90.

3. Shin J, Rhee JE, Kim K. Is the inter-nipple line the correct hand position for effec-tive chest compression in adult cardiopulmonary resuscitation? Resuscitation2007;75:305–10.

4. Perkins GD, Hulme J, Shore H, Bion JF. Basic life support training for health care

students. Resuscitation 1999;41:19–23.

5. Mackway-Jones K, Walker M, editors. Pocket guide to teaching for medicalinstructors. London: BMJ Books; 1999.

6. Assar D, Chamberlin D, Colguhoun M, et al. Randomised controlled trials ofstaged teaching for basic life support: 1. Skill acquisition at bronze stage. Resus-citation 2000;45:7–15.