key: cord-0894081-4hrm3reu authors: Sahu, Ankit Kumar; Suresh, Soorya; Mathew, Roshan; Aggarwal, Praveen; Nayer, Jamshed title: Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis date: 2020-10-01 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2020.09.058 sha: 9162317a0fcc20984a5bed43313655d41e276aed doc_id: 894081 cord_uid: 4hrm3reu BACKGROUND AND OBJECTIVES: To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study. METHODS: This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model. RESULTS: Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: −0.47 to −0.10) and CC depth (SMD: -0.26, 95%CI: −0.44 to −0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78). CONCLUSION: The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031). (CC) parameters during CPR. The primary objective was to summarise the changes in mean CC rate and CC depth, in study arms (no-PPE arm versus PPE arm). The secondary objectives were to summarise the proportion of adequate CC rate and depth provided and compare this in both the study arms. This study was prospectively registered in PROSPERO (CRD42020192031). (Sahu, n.d.) J o u r n a l P r e -p r o o f This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA guidelines). (Moher, 2009 ) Databases including PubMed, EMBASE and Web of Science were searched from inception to June-6, 2020. Two independent investigators (AK, RM) searched the databases using search terms like "chest compression", "cardiopulmonary resuscitation", "CPR", "personal protective equipment", "PPE" and "N95 mask" (search query available in Supplementary Table -S1. There were no restrictions in terms of country, publication language or publication date. Reference lists of all relevant articles and "related citation" search tool of PubMed was checked for any additional publications. Study selection was performed by two independent investigators (AK, SS). We included studies that reported the data on the comparison of the effectiveness of CC in terms of either CC rate, CC depth, the proportion of adequate CC rate, proportion of adequate CC depth or proportion of adequate recoil; in study arms with (PPE group) or without PPE (no-PPE group). Case J o u r n a l P r e -p r o o f reports, duplicate publications and reviews were excluded. Discrepancies between reviewers were resolved in the presence of a third reviewer (RM). Data collected included study characteristics such as authors, publication date, study design, information about both study arms (PPE versus no-PPE group) like sample size, type of PPE used and different CC parameters. The CC parameters collected were mean CC rate (per minute), mean CC depth (in millimetres), the proportion of adequate CC rate provided, the proportion of adequate CC depth provided, proportion of time adequate chest recoil was allowed and duration of CC provided along with the definitions used for appropriate CC rate and depth. The proportion of the parameters mentioned above was defined as the ratio of the duration of correct CC (rate, depth or recoil) to the total duration for which CC was provided. Qualitative assessment of rescuer"s fatigue was also extracted from the included studies. The change (no-PPE versus PPE group) in the continuous variables like mean CC rate and mean CC depth were summarised in terms of standardised mean difference (SMD) by Cohen"s method using generic inverse variance method (Cooper and Hedges, 1993) . The proportion of adequate CC rate, CC depth and CC recoil were pooled separately in both the arms (no-PPE versus PPE group) and were compared using Chi-square statistics (p-value < 0.05 was considered statistically significant), as described by Campbell (Campbell, 2007) and Richardson et al (Richardson, 2011) . Fixed effects pooling was used for meta-analysis. To assess the heterogeneity among studies, inconsistency statistics (I2) were calculated. Significant heterogeneity was considered to be present when I2 was greater than 50% (Higgins et al., 2003) . Publication bias was assessed visually by constructing funnel plots and calculating Egger"s regression equation. The p-value for Egger"s regression coefficient less than 0.10 was considered as significant publication bias (Egger et al., 1997) . A total of five studies, consisting of 456 observations (228 in each of no-PPE and PPE arms), were selected for this meta-analysis (Table -1 and Supplementary Table - Table - Results of the quality assessment of the included studies are summarised in Table - 8, Table - 9, Figure -S1, S2, S3 and S4 (Supplement) 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers). Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias). Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 14 FUNDING this information is to be used in any data synthesis. 13 State the principal summary measures (e.g., risk ratio, difference in means). Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis. J o u r n a l P r e -p r o o f World Health Organisation. COVID-19 situation reports Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations n Novel coronavirus: A capsule review for primary care and acute care physicians Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review COVID-19 in health care workers -A systematic review and meta-analysis COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine Which intravascular access should we use in patients with suspected/confirmed COVID-19? Chest Compression With Personal Protective Equipment During Cardiopulmonary Resuscitation: A Randomised Crossover Simulation Study Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance Adult Advanced Cardiovascular Life Support Impact of personal protective equipment on the effectiveness of chest compression -a systematic review and meta-analysis: PROTOCOL Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement RoB 2: A revised Cochrane risk-of-bias tool for randomized trials n.d. /bias/resources/rob-2-revised-cochrane-risk-bias-tool-randomized-trials ROBINS-I tool n.d. /methods-cochrane/robins-i-tool Parametric measure of effect sizes, The Handbook of Research Synthesis. Russell Sage Foundation Chi-squared and Fisher-Irwin tests of two-by-two tables with small sample recommendations The analysis of 2 × 2 contingency tables-Yet again Measuring inconsistency in meta-analyses Bias in meta-analysis detected by a simple, graphical test Effect of wearing personal protective equipment on cardiopulmonary resuscitation : Focusing on 119 emergency medical technicians Influence of personal protective equipment on the performance of life-saving interventions by emergency medical service personnel Wearing a N95 mask increases rescuer"s fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. The authors did not receive any financial support and have no conflicts of interest.J o u r n a l P r e -p r o o f