Literature Review: Feedback, Debriefing Effects on CPR

     Dine CJ, Gersh RE, Leary M, et al. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med Aug 28, 2008 [Epub ahead of print].


     Objective—Delivery of high-quality cardiopulmonary resuscitation increases survival from cardiac arrest, yet studies have shown that cardiopulmonary resuscitation quality is often poor. Furthermore, recent work has shown that audiovisual feedback during cardiopulmonary resuscitation only modestly improves performance. [Authors] hypothesized that a multimodal training method comprising audiovisual feedback and immediate debriefing would improve cardiopulmonary resuscitation performance.

     Design—Prospective randomized interventional study.

     Setting—Simulated cardiac arrests at an academic medical center.

     Subjects—A total of 80 nurses were randomized to two groups.

     Intervention—Each group underwent three trials of simulated cardiac arrest. The feedback group received real-time audiovisual feedback during the second and third trials, whereas the debriefing-only group performed cardiopulmonary resuscitation without feedback. Both groups received short individual debriefings after the second trial.

     Measurements—Cardiopulmonary resuscitation quality was recorded using a cardiopulmonary resuscitation-sensing defibrillator that measured chest compression rate/depth and could deliver audiovisual feedback messages for both groups during the three trials. An adequate compression rate was defined as 90 to 110 compressions/min. and an adequate depth as 38 to 51 mm.

     Main results—In the debriefing-only group, the percentage of participants providing compressions of adequate depth increased after debriefing from 38% to 68% (p = 0.015). In the feedback group, depth compliance improved from 19% to 58% (p = 0.002). Compression rate did not improve significantly with either intervention alone. The combination of feedback and debriefing improved compression rate compliance from 45% to 84% (p = 0.001) and resulted in a doubling of participants providing compressions of both adequate rate and depth, 29% vs. 64% (p = 0.005).

     Conclusions—Significant cardiopulmonary resuscitation quality deficits exist among healthcare providers. Debriefing or feedback alone improved cardiopulmonary resuscitation quality, but the combination led to marked performance improvements. Cardiopulmonary resuscitation feedback and debriefing may serve as a powerful tool to improve rescuer training and care for cardiac arrest patients.


     We have learned from the last five years of resuscitation research that good CPR and prompt defibrillation are the two critically important treatments to improve the likelihood of survival for victims of sudden cardiac arrest. However, we also know from the last 30 years of research that the current methods of CPR training are seriously deficient, and that the consequence is that inadequate CPR is being performed—meaning patients are less likely to survive.

     It is widely believed that CPR is a relatively simple skill to learn. But the overwhelming majority of studies have documented that both laypersons and healthcare providers learn CPR poorly and forget it rapidly, with little to none of the skills retained after 6 to 12 months. And, despite changes in training methods such as the use of video-based instruction, training remains largely ineffective. Studies continue to point out that CPR is performed poorly, with inadequate compressions and ventilations and long pauses in compressions. The fact is, we have not properly learned how to do effective CPR, and our EMS patients get poorer care as a result.

     This study attempted to find a solution for this widespread deficiency. The authors showed that healthcare professionals could perform much better CPR after a brief manikin training session that combined immediate visual feedback on the adequacy of each chest compression followed by a five-minute counseling/debriefing session.

     Generations of healthcare providers have been poorly trained by listening to lectures, practicing without adequate feedback, and being tested by observers who couldn't accurately measure rate, depth or full chest recoil. We have accepted this as adequate, but it is not. EMS systems should look at increasing their focus and upgrading their CPR training and oversight--and measure the improvement in patient survival that results.

     Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies.