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C2005 Evidence Evaluation Template - Nov.11 2003 a.HFreq.hh.20Jan05Final.doc


Page 1 of 8

WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS

Worksheet Author:


Taskforce/Subcommittee:

ACLS

Authors Home Resuscitation Council:
AHA

Date Submitted to Subcommittee:
1 Nov 04, Revised 20 Jan 2005


STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.
Existing guideline, practice or training activity, or new guideline:

Existing guideline:
High-Frequency (`Rapid Compression Rate') CPR
High-frequency (.100 compressions per minute) manual CPR has been advocated as a technique for improving
resuscitation from cardiac arrest [20±23]. Studies in some, but not all, laboratories have shown that rapid
compression rates improve cardiac output, aortic and myocardial perfusion pressures, coronary blood fllow, and 24-
hour survival compared with standard CPR [20,21]. Clinical studies on the use of high-frequency CPR are limited.
There is evidence for improved hemodynamics with manual but not mechanical rapid chest compression rates in
patients [22±24]. Thus, high-frequency CPR shows some promise for improving CPR. Outcome studies in humans
are needed to determine the efficacy of this technique in the management
of patients in cardiac arrest (Class Indeterminate).
Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific,
positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific
outcomes (ROSC vs. hospital discharge).

High frequency CPR is a feasible, safe and effective alternative to standard CPR.


Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.
Search in titles and abstracts for the following keywords: High frequency CPR (or Cardiopulmonary Resuscitation); High
impuse CPR (or Cardiopulmonary Resuscitation)

List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register
of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles,
and books.
Medline/ Pubmed databases; personnal collection; ECC master library; No Cochrane database or EMBASE search
performed; 12 articles identified
State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects
> minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)
Inclusion Criteria: Cardiac arrest studies; Comparison of hemodynamics, metabolic parameters, and/or survival of high
frequency-CPR with standard CPR.
Exclusion Criteria: Reviews
Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g.,
Cummins-1).
.
If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library.
5 articles



STEP 2: ASSESS THE QUALITY OF EACH STUDY
Step 2A: Determine the Level of Evidence.
For each article/source from step 1, assign a level of evidencebased on
study design and methodology.

Level of
Evidence
Definitions
(See manuscript for full details)
Level 1
Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Level 2
Randomized clinical trials with smaller or less significant treatment effects
Level 3
Prospective, controlled, non-randomized, cohort studies
Level 4
Historic, non-randomized, cohort or case-control studies
Level 5
Case series: patients compiled in serial fashion, lacking a control group
Level 6
Animal studies or mechanical model studies
Level 7
Extrapolations from existing data collected for other purposes, theoretical analyses
Level 8
Rational conjecture (common sense); common practices accepted before evidence-based guidelines
a.HFreq.hh.20Jan05Final.doc


Page 2 of 8



Step 2B: Critically assess each article/source in terms of research design and methods.
Was the study well executed?

Suggested criteria appear in the table below. Assess design and methods and provide an overall
rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be
excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary
endpoint of each study. For more detailed explanations please see attached assessment form.

Component of
Study and Rating

Excellent

Good

Fair

Poor

Unsatisfactory
Design &



Methods
Highly appropriate
sample or model,
randomized, proper
controls
AND
Outstanding
accuracy,
precision, and data
collection in its
class
Highly appropriate
sample or model,
randomized, proper
controls
OR
Outstanding accuracy,
precision, and data
collection in its class
Adequate,
design, but
possibly biased

OR
Adequate under
the
circumstances
Small or clearly
biased population or
model

OR
Weakly defensible in
its class, limited
data or measures
Anecdotal, no
controls, off
target end-points

OR
Not defensible in
its class,
insufficient data
or measures

A = Return of spontaneous circulation
C = Survival to hospital discharge
E = Other endpoint
B = Survival of event


D = Intact neurological survival

Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

DIRECTION of study
by results & statistics:

SUPPORT the proposal

NEUTRAL

OPPOSE the proposal

Results
Outcome of proposed guideline
superior, to a clinically important
degree, to current approaches
Outcome of proposed guideline
no different from current
approach
Outcome of proposed guideline
inferior to current approach

Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction
(ie, supporting or neutral/
opposing)
; combine and summarize.
Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality
studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/
date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies.
Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. a.HFreq.hh.20Jan05Final.doc


Page 3 of 8


Supporting Evidence

High frequency CPR is a feasible, safe and effective alternative to standard CPR.



Excellent

















Good








Swart 1994 E
(Hemo)
Maier 1984 E
(Hemo)
Kern 1986 E
(Trauma)


Quality of Evidence


Fair






Swensen 1988 E
(Hemodynamics)







1
2
3
4
5
6
7
8


Level of Evidence
A = Return of spontaneous circulation
C = Survival to hospital discharge
E = Other endpoint
B = Survival of event


D = Intact neurological survival a.HFreq.hh.20Jan05Final.doc


Page 4 of 8


Neutral or Opposing Evidence

High frequency CPR is a feasible, safe and effective alternative to standard CPR.



Excellent
















Good








Tucker 1994 E
(Hemo)


Quality of Evidence


Fair













1
2
3
4
5
6
7
8


Level of Evidence
A = Return of spontaneous circulation
C = Survival to hospital discharge
E = Other endpoint
B = Survival of event


D = Intact neurological survival a.HFreq.hh.20Jan05Final.doc


Page 5 of 8



REVIEWERS PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical
specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential
conflicts of interest involving consulting, compensation, or equity positions related to