Please cite this article in press as: Talikowska M, et al. Cardiopulmonary resuscitation quality and patient survival outcome in cardiac
arrest: A systematic review and meta-analysis. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.07.036
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Resuscitation
j ourna l h o mepa ge: www.elsevier.com/locate/resuscitation
Review article
Cardiopulmonary resuscitation quality and patient survival outcome
in cardiac arrest: A systematic review and meta-analysis
Milena Talikowska
a,∗
, Hideo Tohira
a
, Judith Finn
a,b,c
Q1
a
Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine,
Curtin University, Bentley, WA, Australia
b
St. John Ambulance, Western Australia, Belmont, WA, Australia
c
School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
a r t i c l e i n f o
Article history:
Received 3 March 2015
Received in revised form 10 July 2015
Accepted 25 July 2015
Keywords:
Cardiac arrest
Cardiopulmonary resuscitation
Quality
Survival
a b s t r a c t
Aim: To conduct a systematic review and meta-analysis to determine whether cardiopulmonary resusci-
tation (CPR) quality, as indicated by parameters such as chest compression depth, compression rate and
compression fraction, is associated with patient survival from cardiac arrest.
Methods: Five databases were searched (MEDLINE, Embase, CINAHL, Scopus and Cochrane) as well as the
grey literature (MedNar). To satisfy inclusion criteria, studies had to document human cases of in- or out-
of hospital cardiac arrest where CPR quality had been recorded using an automated device and linked to
patient survival. Where indicated (I
2
< 75%), meta-analysis was undertaken to examine the relationship
between individual CPR quality parameters and either survival to hospital discharge (STHD) or return of
spontaneous circulation (ROSC).
Results: Database searching yielded 8842 unique citations, resulting in the inclusion of 22 relevant articles.
Thirteen were included in the meta-analysis. Chest compression depth was significantly associated with
STHD (mean difference (MD) between survivors and non-survivors 2.59 mm, 95% CI: 0.71, 4.47); and with
ROSC (MD 0.99 mm, 95% CI: 0.04, 1.93). Within the range of approximately 100–120 cpm, compression
rate was significantly associated with STHD; survivors demonstrated a lower mean compression rate
than non-survivors (MD −1.17 compressions per minute, 95% CI: −2.21, −0.14). Compression fraction
could not be examined by meta-analysis due to high heterogeneity, however a higher fraction appeared
to be associated with survival in cases with a shockable initial rhythm.
Conclusions: Chest compression depth and rate were associated with survival outcomes. More studies
with consistent reporting of data are required for other quality parameters.
© 2015 Published by Elsevier Ireland Ltd.
1. Introduction
Several studies have investigated the link between the quality Q2
of cardiopulmonary resuscitation (CPR) provided to persons expe-
riencing cardiac arrest and subsequent survival outcomes. Quality
is commonly defined in terms of parameters such as chest com-
pression depth, compression rate and compression fraction, along
with others including ventilation rate, ventilation pause duration,
peri-shock pause, duty cycle and incomplete chest release.
A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.07.036.
∗
Corresponding author at: Prehospital, Resuscitation and Emergency Care
Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University,
GPO Box U1987, Perth, WA 6845, Australia.
E-mail address: milena.talikowska@postgrad.curtin.edu.au (M. Talikowska).
Compression depth, rate and fraction are most extensively
described in the literature. A number of papers have reported a
statistically significant relationship between compression depth
and various survival outcomes, for example survival to emergency
department (ED),
1
survival to hospital admission,
2
survival to hos-
pital discharge (STHD)
3,4
and STHD with favourable functional
outcome.
3
European Resuscitation Council (ERC) Guidelines for
Resuscitation 2010 recommended pushing to a depth of between
50 and 60 mm.
5
Compression rate has likewise been linked to
survival.
6,7
ERC Guidelines 2010 recommended a compression rate
in the range of 100–120 compressions per minute (cpm).
5
Papers
3,8
have also linked compression fraction (the proportion of time spent
delivering chest compressions during CPR)
8
to survival outcomes.
ERC 2010 Guidelines advise that rescuers minimise interruptions
to chest compressions.
5
A systematic review investigating the effect of CPR quality on
cardiac arrest outcome was previously undertaken by Wallace
http://dx.doi.org/10.1016/j.resuscitation.2015.07.036
0300-9572/© 2015 Published by Elsevier Ireland Ltd.
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