Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study Michael Wagner, MD, a,b Katharina Bibl, MD, a Emilie Hrdliczka, a Philipp Steinbauer, a Maria Stiller, a Peter Gröpel, PhD, c Katharina Goeral, MD, a Ulrike Salzer-Muhar, MD, d Angelika Berger, MD, MBA, a Georg M. Schmölzer, MD, PhD, b,e Monika Olischar, MD a abstract OBJECTIVES: Our aim for this study was to test whether visual and verbal feedback compared with instructor-led feedback improve the quality of pediatric cardiopulmonary resuscitation (CPR). METHODS: There were 653 third-year medical students randomly assigned to practice pediatric CPR on 1 of 2 manikins (infant and adolescent; n = 344 and n = 309, respectively). They were further randomly assigned to 1 of 3 feedback groups: The instructor feedback (IF) group (n = 225) received traditional, instructor-led feedback without any additional feedback device. The device feedback (DF) group (n = 223) received real-time visual feedback from a feedback device. The instructor and device feedback (IDF) group (n = 205) received verbal feedback from an instructor who continuously reviewed the trainees’ performance using the feedback device. After the training, participants’ CPR performance was assessed on the same manikin while no feedback was being provided. RESULTS: For the primary outcome of total compression score, participants in the DF and IDF groups performed similarly, with both groups showing scores significantly (P , .001) better than those of the IF group. The same findings held for correct hand position and the proportion of complete release. For compression rate, the DF group was at the higher end of the guideline for 100 to 120 chest compressions per minute compared with the IF and IDF groups (both P , .001). No effect of feedback on compression depth was found. CONCLUSIONS: Chest compression performance significantly improved with both visual and verbal feedback compared with instructor-led feedback. Feedback devices should be implemented during pediatric resuscitation training to improve resuscitation performance. WHAT’S KNOWN ON THIS SUBJECT: High-quality chest compressions (CCs) require optimal hand position, adequate depth (one-third of the chest ’ s diameter), complete release, and a frequency of 100 to 120 CCs per minute. Feedback devices (visual or verbal) were shown to improve the quality of training, although evidence remains inconclusive. WHAT THIS STUDY ADDS: We provide more evidence to the topic of feedback in resuscitation trainings, including a large number of equally experienced participants, revealing that visual feedback and visual combined with verbal feedback improve CC performance compared with instructor-led training in infant and adolescent manikin settings. To cite: Wagner M, Bibl K, Hrdliczka E, et al. Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study. Pediatrics. 2019;143(2):e20182441 Divisions of a Neonatology, Pediatric Intensive Care, and Neuropediatrics, and d Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria; b Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta Health Services, Edmonton, Canada; c Department of Applied Psychology: Work, Education, and Economy, University of Vienna, Vienna, Austria; and e Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada Drs Wagner, Bibl, and Olischar conceptualized and designed the study, drafted the initial manuscript, analyzed the data, and reviewed and revised the manuscript; Drs Goeral and Gröpel, Ms Stiller, Ms Hrdliczka, and Mr Steinbauer designed the data collection instruments, collected data, conducted the initial analyses, and reviewed and revised the manuscript; Drs Schmölzer, Salzer-Muhar, and Berger conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2018-2441 Accepted for publication Nov 15, 2018 PEDIATRICS Volume 143, number 2, February 2019:e20182441 ARTICLE by guest on September 25, 2020 www.aappublications.org/news Downloaded from
Transcript
Effects of Feedback on ChestCompression Quality: A RandomizedSimulation StudyMichael Wagner, MD,a,b Katharina Bibl, MD,a Emilie Hrdliczka,a Philipp Steinbauer,a Maria Stiller,a Peter Gröpel, PhD,c
Katharina Goeral, MD,a Ulrike Salzer-Muhar, MD,d Angelika Berger, MD, MBA,a Georg M. Schmölzer, MD, PhD,b,e
Monika Olischar, MDa
abstractOBJECTIVES: Our aim for this study was to test whether visual and verbal feedback comparedwith instructor-led feedback improve the quality of pediatric cardiopulmonary resuscitation(CPR).
METHODS: There were 653 third-year medical students randomly assigned to practice pediatricCPR on 1 of 2 manikins (infant and adolescent; n = 344 and n = 309, respectively). They werefurther randomly assigned to 1 of 3 feedback groups: The instructor feedback (IF) group(n = 225) received traditional, instructor-led feedback without any additional feedback device.The device feedback (DF) group (n = 223) received real-time visual feedback from a feedbackdevice. The instructor and device feedback (IDF) group (n = 205) received verbal feedbackfrom an instructor who continuously reviewed the trainees’ performance using the feedbackdevice. After the training, participants’ CPR performance was assessed on the same manikinwhile no feedback was being provided.
RESULTS: For the primary outcome of total compression score, participants in the DF andIDF groups performed similarly, with both groups showing scores significantly (P , .001)better than those of the IF group. The same findings held for correct hand position and theproportion of complete release. For compression rate, the DF group was at the higher end ofthe guideline for 100 to 120 chest compressions per minute compared with the IF and IDFgroups (both P , .001). No effect of feedback on compression depth was found.
CONCLUSIONS: Chest compression performance significantly improved with both visual and verbalfeedback compared with instructor-led feedback. Feedback devices should be implementedduring pediatric resuscitation training to improve resuscitation performance.
WHAT’S KNOWN ON THIS SUBJECT: High-quality chestcompressions (CCs) require optimal hand position, adequatedepth (one-third of the chest’s diameter), complete release, anda frequency of 100 to 120 CCs per minute. Feedback devices(visual or verbal) were shown to improve the quality of training,although evidence remains inconclusive.
WHAT THIS STUDY ADDS: We provide more evidence to the topicof feedback in resuscitation trainings, including a large numberof equally experienced participants, revealing that visualfeedback and visual combined with verbal feedback improveCC performance compared with instructor-led training ininfant and adolescent manikin settings.
To cite: Wagner M, Bibl K, Hrdliczka E, et al. Effects ofFeedback on Chest Compression Quality: A RandomizedSimulation Study. Pediatrics. 2019;143(2):e20182441
Divisions of aNeonatology, Pediatric Intensive Care, and Neuropediatrics, and dPediatric Cardiology, Departmentof Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria; bCentre for the Studiesof Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta HealthServices, Edmonton, Canada; cDepartment of Applied Psychology: Work, Education, and Economy, University ofVienna, Vienna, Austria; and eDivision of Neonatology, Department of Pediatrics, University of Alberta, Edmonton,Canada
Drs Wagner, Bibl, and Olischar conceptualized and designed the study, drafted the initialmanuscript, analyzed the data, and reviewed and revised the manuscript; Drs Goeral and Gröpel,Ms Stiller, Ms Hrdliczka, and Mr Steinbauer designed the data collection instruments, collecteddata, conducted the initial analyses, and reviewed and revised the manuscript; Drs Schmölzer,Salzer-Muhar, and Berger conceptualized and designed the study, coordinated and superviseddata collection, and critically reviewed the manuscript for important intellectual content;and all authors approved the final manuscript as submitted and agree to be accountablefor all aspects of the work.
DOI: https://doi.org/10.1542/peds.2018-2441
Accepted for publication Nov 15, 2018
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The authors of a large multicenterobservational study reportedthat the incidence of pediatriccardiopulmonary resuscitation (CPR)is ∼1.4%.1 Unfortunately, only ∼40%of children receiving CPR survive tohospital discharge, and survival withgood neurologic outcome remainsrare.1–4 These outcomes are partiallyrelated to poor CPR quality, whichcould be improved by providing high-quality CPR supported by regularsimulation-based training in bothpediatric basic and advanced lifesupport.4–7 Therefore, in the 2015European Resuscitation Councilguidelines, it is stated that high-quality chest compressions (CCs)require the following: (1) optimalhand position, (2) compressing thelower part of the sternum by at leastone-third of the anterior-posteriordiameter of the chest (equivalent to4 cm in infants and 5 cm inadolescents), (3) using a compressionrate of 100 to 120 CCs per minute,and (4) allowing for complete chestrecoil between each CC.8
To improve the quality of CPR,various feedback devices, including(1) the SkillReporter Resusci Anne orResusci Baby QCPR,9–11 (2)a computer-based voice advisorymanikin feedback system,12 or (3)palm-sized devices that can be placedbetween the trainee’s hands and themanikin’s or patient’s chest (eg,Philips MRx Q-CPR DefibrillatorManagement and Feedback,13
CPREzy-Pad,14 and Zoll Pocket15),are available. The immediate CPRfeedback is then given visually (viaa monitor) or verbally (eg, “slightlyincrease the frequency ofcompressions”), to either aninstructor or the person providingCPR. Although these feedback devicesseem promising, the evidenceremains inconclusive, with authors ofseveral simulation studies reportinga significant improvement of CPRperformance,16,17 whereas otherswere unable to find any benefit whencompared with traditional, instructor-
led trainings.18–20 We aimed to assesswhether visual or verbal feedback byusing a feedback device comparedwith instructor-led feedback wouldimprove CPR performance andquality in an infant and an adolescentmanikin during CPR training.
We hypothesized that both the visualand verbal feedback would improveCPR performance more than theinstructor-led feedback during a CPRtraining.
METHODS
This prospective, randomized,unblinded simulation trial was doneat the Vienna Pediatric SimulationTraining Center at the MedicalUniversity of Vienna and is reportedaccording to the ConsolidatedStandards of Reporting Trialsapproach with the extension forsimulation-based research.21 Thelocal ethics committee approved thestudy, and the local data protectioncommittee approved the studyquestionnaire. Third-year medicalstudents from the Medical Universityof Vienna who were required to dotheir mandatory pediatric CPRtraining were included. Participantssigned an informed consent formbefore participation and were thenrandomly assigned into 2 manikingroups: Group 1 performed CPRtraining using a quality ofcardiopulmonary resuscitation(QCPR) infant manikin (LaerdalMedical GmbH, Stavanger, Norway);group 2 performed QCPR trainingusing a QCPR Resusci Anne (LaerdalMedical GmbH) with a built-incompression spring needing 30 kg ofweight for 5-cm CCs (thereforerepresenting the CPR effort requiredfor an adolescent). Both manikingroups were further randomlyassigned into 3 feedback groups: (1)the instructor feedback (IF) group:participants completed the CPRtraining with feedback from theirinstructor without the assistance ofa feedback device (1 instructor was
assigned to each participant and gaveconstant feedback); (2) the devicefeedback (DF) group: participantsreceived direct visual feedback froma feedback device during CPR trainingbut did not received any feedbackfrom an instructor; and (3) theinstructor and device feedback (IDF)group: participants received directverbal feedback from an instructorwho continuously observed theparticipants’ actual CC quality on thefeedback device. The verbal feedbackin both the IF and IDF groupsincluded positive active coachingfrom the instructor (eg, “continuewith that frequency,” “you are doinggood,” or “keep going”).
Randomization
The study included 3 differentrandomization steps to reducepotential biases. Because thepediatric CPR training was conductedin supervised group sessions,participants were first divided intosmall training groups of 10 to 11persons each by using a computer-generated list of random numbers(Microsoft Excel; Microsoft,Redmond, WA). Second, the smalltraining groups (n = 64) wereassigned (computerized randomnumbers) to either the infant or theadolescent manikin group and 1 ofthe feedback groups. Finally, by usingsealed envelopes, 1 of 5 instructorswas randomly allocated to eachtraining group; each instructor thussupervised 12 to 13 training groupsin total. The allocation was done bya student assistant.
Instructors and Feedback Device
The 5 instructors participating in thestudy were all members of the localsimulation team and were trained inpediatric CPR.22 They had equalteaching experience of .3 years.Before the study, the instructorsreceived an update on CPR withdetailed information about the studyand demonstrated their teachingskills (according to the 4-stagetechnique for skills teaching23) and
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knowledge about the CPR algorithm.The feedback devices included theResusci Baby QCPR manikin or theResusci Anne manikin, which are bothequipped with integrated sensorsmeasuring various CC parameters (eg,CC rate, depth, hand position, andcomplete release), and the SimPadtouchscreen with the SkillReportersoftware (Laerdal), a palm-sized devicethat provides real-time visual feedback.Depending on the group allocation, theSimPad was either visible to theparticipant (DF group), visible to theinstructor only (IDF group), or maskedto both (IF group). Participants in theIF and IDF groups received verbalfeedback from the instructor.
Study Procedure
Before the training, participantsreviewed the current pediatric CPRguidelines8 and watcheda demonstration of the CPR algorithmby an instructor. Participants werethen allocated to their randomlyassigned groups and completed 2distinct phases: a training phasefollowed by an assessment. In thetraining phase, participants practicedCPR with feedback for 2 minutes.Participants worked in teams of 2,whereby only the participantperforming CCs was studied withoutevaluating the other performing theventilations. To standardize the timebetween training and assessment,participants were assigned to theassessment in the same order asduring the training phase, which wasafter ∼45 minutes (this was becauseof the course design). Participantsmoved to the assessment phase andcompleted another 2-minute CPR onthe same manikin. Notably, nofeedback was provided in theassessment phase; the SimPad screenwas hidden and not visible to eitherthe participant or the instructor.
The tables on which the manikinswere placed were all at the sameheight (72 cm or 28.36 in) for allgroups. Smaller participants wereprovided with a step stool (24 cm or
9.45 inches in height) to improve theirefficiency of QCPR.24 The number oftrainees who used the step stool wasrecorded. Data collection wasconducted in group sessions, with 10to 11 participants per session.
Outcomes
The primary outcome of the studywas the total compression score,which is a composite score calculatedby the SkillReporter software andconsists of correct hand position,adequate depth, compression rate,and complete release per 2-minutecycle. For these parameters, thetarget measures were chosenaccording to the 2015 EuropeanResuscitation Council guidelines.8
Every participant received 100% foreach variable if the criteria of theguidelines were executed accurately.Any deviation decreased the score toas low as 0% along an S-curvedepending on the amount ofdeviations, with small deviationsreducing the score less than largedeviations. More detailed informationon software scoring can be retrievedon the manufacturer’s Web site.25
Secondary outcomes of the studyinvolved all subcomponents of thetotal compression score, includingcorrect hand position, mean CC depth,CC depth compliance, mean CC rate,CC rate compliance, and theproportion of complete release.
Sample Size
In the sample size calculation, it wasassumed that the main effects of the 3different feedback methods on the CCperformance would compose the 3primary comparisons. Hence,allowing for Bonferroni adjustment,P , .017 was considered statisticallysignificant for each of these 3comparisons. Although the differencebetween the 2 manikin conditionswas not assumed, we checked thisassumption and thus included theinteraction in the sample sizecalculation. Given the inconclusiveevidence of recent research,16–20 weestimated a small-to-middle effect
size for the sample size calculation.The calculation with G*Powersoftware was used to predict thata total sample size of 604 would givesufficient power (95%) to detecta significant difference at the a levelof .017. We estimated that 12% of thegroups would be excluded owing totechnical issues with dataacquisition,26 so we aimed to recruitat least 676 participants in total.
Statistics
All statistical analyses wereperformed with SPSS 24.0 (IBM SPSSStatistics, IBM Corporation, Armonk,NY). To ensure homogeneity of thegroups, a 2 (manikin: infant andadolescent) 3 3 (feedback: IF, DF,and IDF) analysis of variance wasconducted on participants’ age andphysical characteristics (height,weight, and BMI), and a x2 test wasused to compare the distribution ofmen and women and experiencedversus unexperienced participantsacross conditions. To test the studyhypothesis, a 2 3 3 analysis ofvariance was conducted on each ofthe study outcomes. In case ofsignificant main effect of feedback(P , .05, 2-tailed), post hoccomparisons were performed withBonferroni correction (P , .017, 2-tailed) between any 2 pairs offeedback groups while adjusting forthe main effect of manikin. In case ofsignificant interaction, post hoccomparisons were performed byusing the Bonferroni correction (P ,.017, 2-tailed) between any 2 pairs offeedback groups separately for eachmanikin condition. Parameters witha skewed data distribution were logtransformed before analysis.
RESULTS
Between December 2016 and January2017, a total of 681 participants wererecruited; 28 participants wereexcluded (1 declined to participate; 1used a wheelchair, which did notallow for performance of CPR on thetable; and 26 were excluded because
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of technical issues with the feedbackdevices). A total of 653 third-yearmedical students were included asparticipants in the final analysis(Fig 1). No significant difference wasfound in participants’ age andphysical characteristics among thestudy groups (Table 1). Similarly, thedistribution of men and women andexperienced versus unexperiencedparticipants was equal across thegroups.
Total Compression Score
All tested CC parameters arepresented in Table 2, and Fig 2reveals the total CC score across the
groups and phases. During thetraining phase, participants in the DFand IDF groups had a 10- to 13-pointhigher total CC score compared withthe IF group (P , .001 and P , .001,respectively), whereas the DF and IDFgroups had similar total CC scores. Inthe assessment, again, participants inthe IF group performed worse thanparticipants in both the DF (P, .001)and IDF (P , .001) groups, whereasthe 2 latter groups did not differ.
Hand Position
In the training, correct hand positionwas more pronounced in both the DFand IDF groups than in the IF group
(P = .001 and P , .001, respectively),whereas the DF and IDF groups didnot differ. In the assessment, the DFand IDF groups also showed betterhand position than the IF group(P = .006 and P , .001, respectively),whereas the 2 former groups did notdiffer.
Compression Depth
Mean CC Depth
There were no significant differencesamong the feedback groups in eitherthe training or the assessment phase.There was only an overall significantdifference between the infant andadolescent manikin groups in both
FIGURE 1Study groups and design.
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phases (P , .001 and P , .001,respectively), merely reflecting thedifferences in required CC depth foradolescents and infants.
CC Depth Compliance
During the training phase,participants in the DF groupperformed 7% to 10% more CCs withadequate depth than participants inboth the IF (P , .001) and the IDF(P , .001) groups but only whenusing the infant manikin. In theassessment, the compliance wasgenerally higher in the DF group thanin the IF group (P = .016), whereasthe DF and IDF groups, and the IF andIDF groups did not differ in CC depthcompliance.
Compression Rate
Mean CC Rate
In the training, there were nosignificant differences among thefeedback groups. During assessment,
the DF group performed ∼5 CCs perminute more compared with the IF(P, .001) and IDF (P, .001) groups,and the IDF group also had a higheroverall mean CC rate than the IFgroup (P = .009).
CC Rate Compliance
During training, participants in the DFgroup performed 14% fewer CCs withadequate rate than participants in theIDF group (P = .006) but only in theadolescent manikin setting. Duringthe assessment, the DF group hada 15% to 20% lower CC ratecompliance than both the IF(P = .001) and IDF (P = .001) groups,whereas the 2 latter groups did notdiffer. These differences were, again,only in the adolescent manikincondition.
Complete Release
In the training, the DF group hadhigher percentages of completerelease than both the IF (P , .001)
and IDF (P = .007) groups, and theIDF group was also better than the IFgroup (P , .001), but only in theadolescent manikin condition. Duringthe assessment, the IF group hada 20% to 30% worse completerelease compared with both the DF(P , .001) and IDF (P = .003) groups,whereas the 2 latter groups did notdiffer in complete release. Again,these differences were only visiblewhen using the adolescent manikin.
DISCUSSION
Authors of several studies reportedthat the use of feedback devices canimprove CPR quality.26–29 With ourstudy, we added that both visualfeedback and verbal feedbackcombined with visual feedbacksignificantly improved CPRperformance in medical studentswhen compared with instructor-based feedback alone. Participantswho received training with a feedback
Experience with any feedback device before thestudy
26 (22) 26 (23) 36 (32) 22 (20) 23 (21) 21 (23)
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device had significantly higher totalcompression scores (Fig 2), bothduring the training and, moreimportantly, in the subsequent
assessment with no feedback provided.This indicates that the training was, atleast, short-term transferred insubsequent performance.
Our results are supported by a studyof simulated adult-life support byBuléon et al26 and Wutzler et al.29
The authors of both studies reportedthat the use of a real-time feedbackdevice improved the quality of CCs,whereas the CPR quality declinedafter 2 minutes of CCs withouta feedback device, as documented byBuléon et al.26 Authors of studies ofsimulated infant CPR reported similarresults. Lee et al30 found that feedbackfrom a smartwatch resulted in highercorrect CC depth during infant CPR.Similarly, Binder et al31 demonstrateda reduction in mask leak and anincrease in tidal volume deliveryduring simulated neonatal CPR whena respiratory function monitor wasvisible. Furthermore, Cheng et al32
showed that compliance withresuscitation guidelines improvedwhen using a feedback device duringtraining and real-life CPRs.
Within the IF group, we observeda relatively poor CPR quality, as
a Indicates a significant difference (Bonferroni test) between the DF group and IF group.b Indicates a significant difference (Bonferroni test) between the IDF group and IF group.c Indicates a significant difference (Bonferroni test) between the IDF group and DF group.
FIGURE 2Total compression score of the study groups. Data are presented as mean 6 SEM.
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indicated by the data from thefeedback device, which is in line withprevious studies.27 Cheng et al7
reported a poor perception of CPRquality among health care providers,which improved when using a real-time visual feedback device. Deakinet al33 showed that the accuracy of CCswithout a feedback device resulted ina poor judgment of accurate depth(64.4% of CCs were out of the targetdepth). Moreover, MacKinnon et al34
described a positive effect ofa feedback device on self-motivatedlearning and CPR performance. Ourdata support that CPR training witha feedback device can help promoteself-motivated learning during dailyclinical routines. However, althoughreal-time feedback devices improvedCPR quality during real-life in-hospitaladult cardiac arrests, the return ofspontaneous circulation or survivalwas similar between studied groups.35
An evaluation of a feedback device inreal pediatric CPR revealed poor ratesfor correct depth (39%) and release(84%).36 Further studies are neededto evaluate the necessity of trainingintervals, long-term impacts, andpatient outcome.
The above effect of feedback deviceson self-motivated learning deservesmention. In the current study, the DFgroup outperformed the IF group inalmost all relevant CC parametersexcept the CC rate compliance, whichmay also be a consequence ofenhanced motivation. As indicated bythe mean CC rate, the DF group was atthe higher end of an adequate CC rate,which presumably resulted inexceeding the 120 CCs per minutelimit more frequently, therebydecreasing the CC rate compliance.We may assume that this “over-increased” rate was due to increased
motivation when working with thefeedback device. However, this “over-motivation” effect was eliminatedwhen the visual feedback and theverbal feedback from the instructorwere combined (the IDF group).
In our study, the training andassessment phases were performedon the same day, with the trainingphase revealing a positive effect onthe assessment later on. A possibleimplication for hospital bedsidesettings might be that completinga short CPR training session at thestart of the day would pay off laterthat day if there were actual clinicalCPR events. Whether the trainingeffect would last for a longer timeperiod could not be tested with thepresent data.
With our study, we confirmed thatfeedback device–only training isfeasible and associated withimproved CPR quality. Consideringthe above over-motivation effect,although some CPR parameters weresignificantly improved in the DFgroup compared with the IDF group,we strongly recommend regularinstructor-led resuscitation trainings,including feedback devices, toprovide feedback on all aspects ofCPR performance.
The large number of participants andthe randomization to 6 differentgroups are strengths of our study.Furthermore, the recruitment of onlythird-year medical studentsdecreased the potential bias ofexperience or expertise but, at thesame time, limited the generalizationof the findings to a broader clinicianpopulation. Blinding of study subjectsand instructors was not feasible andmight have influenced our results.However, the outcome assessor was
blinded to group allocation duringanalysis. Finally, we solely focused onCCs without measuring ventilationquality, which is an important aspectof CPR in pediatric patients.
CONCLUSIONS
Direct visual feedback to providers orverbal feedback provided via aninstructor who observed the visualfeedback from the manikinsignificantly improves CCperformance in third-year medicalstudents during simulated pediatricresuscitation when compared withtraditional, instructor-based feedbackalone. Feedback devices should beintegrated into pediatric resuscitationtraining to improve resuscitationperformance.
ACKNOWLEDGMENTS
We thank our instructors andpediatricians for their help inimplementing and continuing thisproject. A special thank you toProfessor Manfred Marx, ProfessorGudrun Burda, Professor AdamCheng, and the NetzwerkKindersimulation, who helped withtheir special knowledge and criticaldiscussion on this important topic tostart and finalize this project.
ABBREVIATIONS
CC: chest compressionCPR: cardiopulmonary
resuscitationDF: device feedbackIDF: instructor and device
feedbackIF: instructor feedbackQCPR: quality of cardiopulmonary
resuscitation
Address correspondence to Michael Wagner, MD, Division of Neonatology, Pediatric Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent
Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria. E-mail: [email protected]
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose, other than the declared funding.
FUNDING: Dr Schmölzer is a recipient of the Heart and Stroke Foundation and University of Alberta Professorship of Neonatal Resuscitation, a National New
Investigator of the Heart and Stroke Foundation of Canada, and an Alberta New Investigator of the Heart and Stroke Foundation, Alberta. We thank the public for
donating to these funding agencies. We acknowledge funding from the Laerdal Foundation for Acute Medicine for this research project. None of the funders had any
role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 143, number 2, February 2019 9 by guest on September 25, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2018-2441 originally published online January 30, 2019; 2019;143;Pediatrics
Schmölzer and Monika OlischarPeter Gröpel, Katharina Goeral, Ulrike Salzer-Muhar, Angelika Berger, Georg M.
Michael Wagner, Katharina Bibl, Emilie Hrdliczka, Philipp Steinbauer, Maria Stiller,Study
Effects of Feedback on Chest Compression Quality: A Randomized Simulation
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Referenceshttp://pediatrics.aappublications.org/content/143/2/e20182441#BIBLThis article cites 35 articles, 4 of which you can access for free at:
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