Barriers in the implementation of the Resuscitation Guidelines: European survey of defibrillation techniques

The Resuscitation Guidelines recommend minimizing unnecessary breaks in chest compression delivery [1]. When defibrillation is attempted, the time from cessation of chest compressions to shock delivery should not exceed 5–10 s, which is possible if chest compressions are performed while charging the defibrillator. Despite the fact that guidelines recommend using adhesive pads, the survey results revealed that the use of manual paddles is still common in Europe. There were just 10/27 (37 %) countries declaring use of adhesive pads in both pre- and in-hospital environment in a rate of 76–100 %. The use of adhesive pads was declared by 63 % of the respondents. There are discrepancies in the use of adhesive pads between the countries and the location of the healthcare service (pre- and in-hospital areas). In countries with low adhesive pads usage, we see signs of growing use of adhesive pads in the pre-hospital area, which may be associated with awareness of the guidelines in this group of healthcare providers which changes the former defibrillation practice [11‐13]. In the recently published study from Hungary only 6,5 % of the interviewed senior consultants of the intensive care units and emergency departments from audited 56 hospitals declared the use of adhesive pads routinely at the time of the survey [15].

The 2015 Resuscitation Guidelines recognize a possibility of providing defibrillation with manual paddles in case of lack of adhesive pads [1], however, there is limited number of evidence how frequent it happens and what is the technique of defibrillation performed with manual paddles since the Guidelines do not provide any information regarding this topic. Based on previous reports on this topic we identified the most common techniques of performing defibrillation. The questionnaire contained a field for any other technique, however, no respondent suggested a different approach. In our study three different techniques of manual paddles use were reported. Two of them include charging the defibrillator during chest compression delivery. The difference between them is the location of the paddles – either on the patient’s chest (29 %) or on the defibrillator (43 %). Currently, there is no evidence to determine which technique is better in terms of chest compression quality, safety of the rescuer and pre- and post-shock pauses in chest compressions.

Five of the respondents declared they did not perform chest compressions during charging the defibrillator, which, despite the short time it takes for charging of the modern defibrillator, still generates long pauses in chest compression delivery. The survey was performed 3 months after delivery of the 2015 Guidelines, however, the 2005 technique was still reported as being used, which may reflect current practice in some European countries. There are also differences in performing defibrillation with adhesive pads (charging the defibrillator towards the end of every 2 min cycle of CPR). This is also recognized in the 2015 guidelines by the ALS writing group, however, the benefit from this intervention is unknown [1, 16, 17].

Interestingly, an economic reason for not using adhesive pads, even though high 9/14 (64 %), was not the only reason indicated by respondents. Resistance to using adhesive pads and the tradition of using manual paddles are still important barriers in guideline implementation. The Hungarian study also revealed that the major obstacle for adhesive pads use which were the perceived cost-efficiency concerns declared in 60 % of responds, however, the majority of clinicians (92 %) were aware of the benefits of adhesive pads use [15].

Many of the respondents (47 %) using the manual paddles still use gel or electrode pastes as a coupling medium, despite the fact it is not recommended since 2005 Guidelines release [18]. The reason for that may be low availability of gel pads is some European countries indicated by the respondents.

The use of adhesive pads is the leading technique for initial cardiac arrest rhythm assessment (56 % of respondents), however, the quick-look technique appears to be used at a similar level (22 %) with 19 % of respondents declaring 3-lead ECG use for initial monitoring. The choice of the different approach to initial cardiac rhythm assessment may influence the outcome of resuscitation. One of the key changes in ERC ALS Guidelines since 2010 is keeping the focus on the use of adhesive pads and a defibrillation strategy to minimize the preshock pause [1]. The use of 3-lead ECG monitoring for initial rhythm assessment is definitely inferior to either adhesive pads or “quick look” with paddles [9], however, five of the respondents who declared adhesive pads use chose 3-lead ECG monitoring for that purpose.

There are also different approaches to the technique of defibrillation attempts when shockable rhythm is present during the quick-look assessment technique. Further studies are needed to indicate the optimal approach.

When a low quality signal was detected, 10/27 (37 %) of the survey respondents changed the method of monitoring to 3-lead ECG, 7/27 (26 %) looked for better signal quality with adhesive pads use and 5/27 (19 %) of respondents did not change the method of monitoring. The quality of the ECG signal is vital during cardiac arrest management and may influence therapeutic decisions. Currently, there are no human studies known to the authors of this paper assessing this issue in terms of cardiac arrest management.