Introduction place, Baghbaninaghadehi et al. (2016) suggested that





An original research titled “Is
mechanical-assist device better than manual chest compression? A randomized
controlled trial” published by Dove Medical Press Limited showed the
results of a randomized controlled trial (RCT) on whether a mechanical-assist
device, the CPR RsQ Assist Device (CPR RAD) is better than manual chest
compression (Yuksen et al., 2017). This
essay would critique and appraise the research evidence by means of the Joanna Briggs Institute 2017 Critical
Appraisal Checklist for RCT (“checklist”).



Study Design and Conduct


An impact evaluation based
on experimental design was performed and participants were chosen at random
from the eligible population – individuals who are likely to perform CPR such
as medical students, physicians, nurses, emergency medicine technicians and hospital
staff (White et al., 2014). To
determine how the CPR RAD affects the CPR in terms of chest compression quality
in a manikin model, 80 participants were randomly separated into 2 groups – The
experimental (treatment) group of 41 participants using the device and a
control group of 39 participants doing the manual compression using the
six-block randomization. All participants had to perform a maximum of 4 minutes
of hands-only compression with or without a device. This shows that the
research used both random sampling and true random assignment, an essential
characteristic of RCT as suggested by White et
al. (2014), thus satisfying the first checklist.


The randomization method
used sequentially numbered, opaque, sealed envelopes (SNOSE), the standard
method of ensuring allocation concealment and central randomization from which
the centralized assignment protocol does not involve any person associated with
the research trial (Baghbaninaghadehi et al., 2016). This
demonstrates that besides having a randomization process in place, Baghbaninaghadehi et
al. (2016) suggested that a proper allocation procedure was also
done to reduce biases and increase the study’s power, henceforth satiating
the second checklist.


Besides choosing an appropriate sample of the
population to measure the relevant baseline variables, the researchers also adopted
tests of significance that utilize P-value
in determining the statistical significance of the observed baseline difference
in the participants’ characteristics (Egbewale, 2015). This research shows that there were
no statistically significant differences between the groups in terms of age, sex,
CPR experience, and percentage of participants who had completed a CPR course
i.e. P-values of more than 0.05. This
implied that the clinical characteristics of the participants in both groups
are similar at the baseline, which fulfils the third checklist.


The participants were not
blinded to the trial allocation after the random allocation as they were very
aware of the need to perform chest compression on the Resusci Anne®
SkillReporter™ for a maximum of 4 minutes or until fatigued. The manual group
performed standard chest compression, while the device group performed chest
compression using the CPR RAD with a set rate of 100 times/minute. “Blinding”
in randomized trials refers both to the general methodological principle of
withholding information from individuals with the aim of preventing bias and to
a group of procedures used to withhold information from specific groups of
individuals such as patients, treatment providers, or outcome assessors (Hróbjartsson, 2011). Hence, it
was not applicable to achieve the fourth, fifth and sixth checklist.


White et al. (2014) suggested that it is important to check that participants
in the control groups do not suffer from “contamination” through a similar
intervention being carried out in the control areas. The research did not
indicate if there were other exposures or treatments occurring at the same time
with the “cause” that could explain the “effect”. Therefore, it is unclear if
it fulfils the 7th checklist.


The attrition for all
randomly allocated participants remained the same from the initial
randomization process to the end time of the trial i.e. no dropout rates. This
meant that was no loss to follow up between the 2 groups which could severely
compromise the study’s validity (Dettori, 2011). There is also complete knowledge
in terms of measurements. This shows that the follow up was complete, thus the
8th checklist was fulfilled.


All RCT results should be analyzed on an
intention-to-treat (ITT) basis to reduce potential biases. It is a strategy in
the conduct and analysis of RCTs which ensures that all patients allocated to both
groups are analyzed together in the respective groups to which they were
randomized, whether or not they completed the study (Gupta, 2015). There was no
indication in the research paper that the ITT analysis was conducted. For that
reason, it did not justify the 9th checklist.


The results of the study
showed the chest compression results – chest compression rates and depth – between
the manual chest compression group and chest compression with automatic chest
compression device group in a table form. However, it did not specify how the results
were achieved – Is it measured by the same displacement sensor on the manikin? Was the same accelerometer
used by all participants? (Gauna, 2016) Was the measurement procedures the
same for all participants? Therefore, it is not distinct if the outcomes were measured in the same way for both
groups. With that, it is not clear if it satisfies the 10th


It is not clear if the study
satisfies the 11th checklist. The reliability of the measurement was
unclear as the study did not specify the number of raters, training of raters,
the intra-rater reliability, and the inter-raters reliability within the study.
It is important to specify these details in such study as a variation between
raters may jeopardize the integrity of the inquiries, and could potentially
have an impact on the results (Gwet, 2016).



Statistical Analysis and Reporting


In its statistical analysis,
the characteristics of all participants in each group as well as the chest
compression results for both groups were compared by using descriptive
statistics. The STATA software version 14 (StataCorp LP, College Station, TX,
USA) was used to perform the analyses. By adopting descriptive statistics, the data
were summarized in table form  the data
with the purpose of describing the characteristics of the participants and the
compression results. It enabled detection of sample characteristics that may
influence the conclusions (Thompson). This concludes that an appropriate
statistical analysis, which satisfies the 12th checklist.


The research adopted a standard
parallel design which divides the sample population into 2 groups (Spieth et al., 2016) – the experimental
(treatment) group of 41 participants use the device whilst a control group of
39 participants use manual compression (White et al., 2014). This design is appropriate for such study, thus
fulfilling the 13th checklist.





RCT was relatively reliable and appropriate to justify the authors’ conclusion
that the CPR RAD is more effective in chest compression in comparison with the manual
chest compression as using the device led to better outcomes in terms of
fatigue reduction and proper compression rate. It clearly described the planning,
conduct, and analysis of the study. The chest compression results between the
manual chest compression group and the device group were well described and
analyzed by the P-value as depicted
in Table 2. The study results and their interpretation were discussed in detail
and the limitations of the methods used were also described. However, the results
still did not justify the use of the device wholly for chest compressions in
clinical situations and should be critically evaluated further before its
relevance can be considered