CRITICAL CARE MEDICINE SECTION
Overcoming Obstacles to Bystander CPR Cara Gardner, MS* and David H. Gordon, MD†
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ystander cardiopulmonary resuscitation (CPR) initiated in out-of-hospital cardiac arrest (OHCA) has shown to have tremendous benefits to neurologic function and survival. Bystander intervention with high quality chest compressions in the field have increased survival to hospital admission rates from 14.1% to 23%.1 Moreover, the number of patients who retained good neurologic function at hospital discharge following a OHCA nearly doubled from 8.7% to 16.8% with bystander CPR.1 This evidence supports the notion that bystander intervention plays a crucial role in successful resuscitation. Additionally, in a study comparing OHCA outcomes to those receiving mechanical circulatory support and those that did not, several patients survived neurologically intact with up to 120 minutes of low flow time when they were also put on ECMO.2 Roughly 75% of OHCA occur at home, compared to 25% in public. A recent analysis of the Cardiac Arrest Registry to Enhance Survival (CARES) database showed that 47.1% of arrests had CPR initiated by a lay person.3 The barriers to bystander CPR can be divided into patient level and rescuer level obstacles. First in regards to patient level obstacles, it was shown that patients who identified as Black and Hispanic were less likely than Caucasians patients to receive Bystander CPR.3 Other frequently reported barriers include patient being female sex, low socioeconomic status, and difficulty repositioning the patient.4 In regards to the rescuer level obstacles point of view, one main concern is the traumatizing experience bystanders endure during cardiac arrest— whether it be a loved one, neighbor, or stranger. Panic and hysteria are reported as one of the largest barriers for a bystander starting resuscitation efforts according to a study interviewing bystanders following a call to EMS dispatch. Results of another study showed 81.3% of bystanders delayed initiation of resuscitative efforts due to a perceived lack of knowledge and familiarity with how to perform CPR, including still believing that mouth to mouth is necessary.5 The average time for a bystander to confirm that there were no breaths during dispatcher-assisted CPR was 59 seconds shown by one study, which again may reflect bystander uncertainty
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over who needs CPR.5 When seconds matter, the ability to recognize cardiac arrest and the confidence of the bystander in their ability to initiate resuscitation will save lives. With greater education we can overcome several of these barriers. The International Liaison Committee on Resuscitation (ILCOR) has set a goal of 50% of cardiac arrests should get bystander CPR, as a result the world restart a heart day trained over 5.4 million people, but only 7900 of them in the U.S.6 Traditionally CPR has been taught in four hour Basic Life Support Classes. The time commitment itself can stop people from getting CPR education. However, hands only CPR and AED education can be only a minute away. The AHA and Red Cross have one to three minute long videos online for learning hands-only CPR and use of an AED.7,8,9 The American Heart Association (AHA) created an ultra-brief video lasting one minute that teaches hands-only CPR which was shown to participants in a research study. Individuals were significantly more likely to intervene as a bystander performing CPR immediately following the video, as well as individuals faced with simulated cardiac arrest two months later.10 These videos often do not go into and mollify the barriers to providing bystander CPR. Frequent exposures can mitigate the lack of familiarity that occurs as length of time from training increases. Use of brief repetitive educational CPR training videos in schools, workplaces, gas stations, airports, and even in the ED can break the above obstacles and barriers. These small changes will make a profound difference in the lives of our communities we save.
The barriers to bystander CPR can be divided into patient level and rescuer level obstacles.
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