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HLSC122: Evidence for Practice

HLSC122 _ Assessment 3: Critical Appraisal Essay_ © Australian Catholic University 2021 _ Page 1 of 2

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ASSESSMENT INFORMATION

Assessment Title Assessment Task 3: Essay – critical appraisal of evidence

Purpose

The To demonstrate your ability to critically appraise a piece of published evidence in relation to a clinical issue. Using Critical Appraisal Skills Programme (CASP), you will demonstrate the ability to critically appraise the design and methods of a systematic review or randomised controlled trial, highlighting the strengths and weaknesses of the study.

Due Date Monday 17th May

Time Due 0900 hours

Weighting 50%

Length

Essay 1200 words +/- 10% Completed CASP checklist attached as Appendix A to your essay

Assessment Rubric See Unit Outline Appendix A

LOs Assessed 3, 4 & 5

Task

You are required to demonstrate your ability to critically appraise a piece of published. Using an appropriate CASP checklist (e.g., CASP for RCTs or CASP for SRs), you are required to use the checklist to inform your answers.

Target Audience Nursing, midwifery and paramedicine healthcare professionals

Submission

Your essay should be submitted as a Word file via your HLSC122 campus tile Assessment 3 dropbox.

Your essay should include your completed CASP checklist as an Appendix.

FORMATTING Written script

File format .doc or .docx (not .pdf files)

Margins 2.54cm, all sides

Font and size 11-point Calibri or Arial

Spacing Double spacing

Paragraph Aligned to left margin, indent first line of each paragraph 1.27cm

Title Page As per the Individual written script template

Level 1 Heading Centered, bold, capitalize each word (14-point Calibri or Arial)

Level 2 Headings

Optional/ don’t have to be used: Flush left, bold, capitalize each word (12-point Calibri or Arial)

Structure Essay Structure as per the Academic Skills Unit guide: Introduction, body, conclusion, reference list

Direct quotes Quotes from references should not be used for this assessmenthttps://casp-uk.net/casp-tools-checklists/

HLSC122: Evidence for Practice

HLSC122 _ Assessment 3: Critical Appraisal Essay_ © Australian Catholic University 2021 _ Page 2 of 2

Header Page number top right corner (9 point Calibri or Arial)

Footer Name _ Student Number_ Assessment _ Unit _ Year (9 point Calibri or Arial)

REFERENCING

Referencing Style APA 7th

Minimum References Should include at least four (4) credible and relevant references (i.e., peer reviewed journal articles or textbooks).

Age of References

Published in the last 5 years as this area of knowledge is rapidly developing. Note that this excludes seminal (original) works, which have no age limitations.

Reference List Heading

“References” is centered, bold, on a new page. (14 point Calibri or Arial)

Alphabetical Order References are arranged alphabetically by author family name

Hanging Indent Second and subsequent lines of a reference have a hanging indent

DOI Presented as functional hyperlink

Spacing Double spacing the entire reference list, both within and between entries

ADMINISTRATION

Late Penalties

Late penalties will be applied from 9:01am on the 17th of May 2021, incurring 5% penalty of the maximum marks available up to a maximum of 15%. Assessment tasks received more than three calendar days after the due or extended date will not be allocated a mark. Example: An assignment is submitted 12 hours late and is initially marked at 60 out of 100. A 5% penalty is applied (5% of 100 is 5 marks). Therefore, the student receives 55 out of 100 as a final mark. Penalty Timeframe Penalty Marks Deducted 9:01 am Wednesday to 9 am Thursday 5% penalty 5 marks 9:01am Thursday to 9am Friday 10% penalty 10 marks 9:01am Friday to 9am Saturday 15% penalty 15 marks Received after 9:01 Saturday No mark allocated n/a

Return of Marks

Marks will be generally returned in three weeks; if this is not obtainable, you will be notified via your campus LEO forum.

Assessment template project informed by ACU student forums, ACU Librarians and the Academic Skills Unit.

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Research Impact of hand dominance on effectiveness of chest compressions in a simulated setting: a randomised, crossover trial Jamie Cross BHSc(Paramedicine), is a paramedic1; Tommy Lam BHSc(Paramedicine), is a paramedic1; Joel Arndell BHSc(Paramedicine), is a paramedic1; John Quach BHSc(Paramedicine), is a paramedic1; Buck Reed MIHM, GradCertHltMgmt, BCA, DipParamedicSci is Associate Lecturer in Paramedicine1; Liz Thyer PhD, BSc(Hons), DipAmbParaStudies, GCTE is Senior Lecturer in Paramedicine1; Paul Simpson PhD, MScM(ClinEpi), GCClinEd, GCPaeds, BEd, BHSc(PrehospCare), AdvDipParaSci, ICP is Senior Lecturer and Director of Academic Program (Paramedicine)1 Affiliations: 1Western Sydney University, New South Wales

https://doi.org/10.33151/ajp.16.672

Abstract Aim External cardiac compressions (ECC) are a critical component in determining the effectiveness of cardiopulmonary resuscitation (CPR). Guidelines prior to the 2010 International Liaison Committee on Resuscitation directed rescuers to place the heel of the dominant hand directly on the chest when performing ECC, however current guidelines are silent on this issue. Existing research is inconsistent in findings, and heterogeneous in design and participants. The aims of this pilot study were to: 1) investigate the impact of hand dominance on effectiveness of ECC; and 2) generate outcome data to inform sample size calculations for a larger future study.

Methods This study utilised a single blinded, prospective randomised crossover trial design. Each participant was allocated to a ‘dominant hand on chest’ (DHOC) or ‘non-dominant hand on chest’ (NDHOC) group. On a simulation manikin, participants in the DHOC group performed 3 minutes of ECC with dominant hand on the chest and non-dominant hand supporting, followed by a ‘rest and recovery’ period and then a second 3-minute period of ECC with the hand reversed such that the non-dominant hand was on the chest. The NDHOC group performed the same series of compressions but in reverse order. The primary outcome measure was effectiveness of ECC, determined by a percentage-based ‘CPR score’ (‘CS’). Secondary outcomes were compression depth, rate and release. The Wilcoxon rank-sum (Mann- Whitney) test was used due to the non-normal distribution of the data. Due to the crossover design, hierarchical linear regression was used to assess for a period or cross over effect.

Results For the primary outcome of this study, we have found no significant difference in CS between DHOC and NDHOC (69.9% (SD=29.9) vs. 69.1% (SD=34.1); p=0.92), respectively. There were no differences in the secondary outcomes of compression rate and depth, though compression release was improved in the DHOC group (53% vs. 42%; p=0.02).

Conclusion In this randomised crossover study conducted in a simulation context there was no difference in ECC effectiveness measured by an overall effectiveness outcome according to placement of the dominant or non-dominant hand on the chest during compressions. A modest improvement in ECC release was seen in the dominant hand on chest group. While the study was underpowered, the results support an approach involving rescuers placing whichever hand they are most comfortable with on the chest irrespective of handedness. Keywords: resuscitation; paramedic; effectiveness; external chest compressions; hand dominance Corresponding Author: Paul Simpson, [email protected]

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Introduction External cardiac compressions (ECC) are a critical component in determining the effectiveness of cardiopulmonary resuscitation (CPR) (1). ECCs provide a vital temporary circulation that may sustain cerebral and myocardial perfusion during sudden cardiac arrest, potentially contributing to reduced cerebral damage and increased likelihood of successful defibrillation.

The role of ECCs in cardiac arrest and its association with improved survival outcomes has become clearer over the past decade, with the 2010 and 2015 International Liaison Committee on Resuscitation placing an increased emphasis on early, high-quality and uninterrupted compressions in both a basic and advanced life support context (1,2). While the guidelines provide explicit recommendations regarding the various components of ECC such as compression rate, depth, recoil and hand position, they are silent on the issue of whether to have the dominant or non-dominant hand placed directly on the chest. Prior to 2010, it was recommended that the heel of the dominant hand be placed on the chest, and the non- dominant on top to support (3).

While it seems intuitive that a person preparing to perform ECC would place their dominant hand on the chest, evidence suggests this may not always be the case. In a study of 383 novice rescuers in Korea of whom 99% were right-handed (right dominant), 46% chose to position their non-dominant hand on the chest when given the choice in a simulated setting (4). It is also intuitive to suggest that ECC, as with many other motor skills or tasks, might be more efficiently performed with the dominant hand, given that the dominant side of the body for the majority of people might be perceived to have greater strength, coordination and control.

The current evidence describing the role of the dominant or non-dominant hand on the chest during ECC and impact on effectiveness is inconsistent. Only a single study has explored whether the issue of handedness impacts overall ECC quality (5). Using an objective manual assessment process, no difference was found between the dominant and non- dominant hand position. The remaining studies contributing to the existing body of evidence focussed on individual components of ECC, mainly compression rate, depth and release (recoil) (4,6-9). Comparability of results across this small body of evidence is difficult due marked heterogeneity in setting, design, participant groups and, in particular, the type of ECC being used as the intervention. The durations of ECC performed are highly variable, while some include CPR (compressions and ventilation) performed in pairs or single rescuers.

Against this uncertainty in evidence, further research was justified and hence we conducted a crossover randomised

controlled trial on a population of student paramedics enrolled in an undergraduate paramedicine program at an Australian university. Our study sought to answer the following primary research question: In a simulated setting consisting of a manikin patient, does performing ECC with the dominant hand on the chest, compared to non-dominant hand on chest (NDHOC), increase effectiveness of ECC measured by an accelerometer-based ‘CPR’ primary outcome score?

Methods This study utilised a single blinded, prospective randomised crossover trial methodology and was conducted at Western Sydney University in a simulated setting. Data were collected between June and December 2016.

Participants and recruitment Participants were university students at Western Sydney University. Participants were eligible if they held a valid first-aid certificate and were enrolled in a clinical health science degree (paramedicine, podiatry, physiotherapy, occupational therapy). Recruitment took place via promotion of the study on social media pages, posters at paramedic conferences and public announcements. Participants were asked to participate in a study exploring general CPR performance but were blinded to the specific research question at any stage to reduce the chance of performance bias.

Study outcomes The primary outcome was ‘ECC effectiveness’ determined by a ‘CPR score’ (‘CS’). A more detailed explanation of the CS can be accessed at http://cdn.laerdal.com/downloads-test/ f3784/Att_2_to_00021778.pdf The CS was produced by an accelerometer-based ECC measurement device within a Laerdel Resusci-Anne ALS™ simulation manikin (Laerdal Medical, Stavanger, Norway). The CS is a composite measure of ECC performance that calculates the effectiveness of compression as a percentage figure, based on parameters within the 2010 American Heart Association resuscitation guidelines (11). Using a proprietary algorithm, the CS is calculate by incorporating measurements of the following individual components of ECC: compression depth (% of ECC in which correct depth of compression of at least 5 cm is achieved); rate (% of compressions performed at correct rate between the range of 100-120 per minute); compression release (% of compressions where complete release [recoil] is achieved); hand position (% of compressions where hand position was correct); and number of compressions per cycle (12). Of these, the components of compression depth, compression rate and compression release were considered relevant to the impact of hand dominance and were analysed independently and are presented as secondary outcomes.

Sample size Review of the existing literature investigating the impact of

Cross: Chest compressions: impact of hand dominance Australasian Journal of Paramedicine: 2019;16

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hand dominance on ECC effectiveness found reported differences between groups to be quite variable and insufficient for performing sample size calculations for an appropriately powered larger study. Therefore, this study was conducted as a pilot study, to generate preliminary results data on which a reliable sample size calculation for the future study could be based. As such, no statistical sample size calculation was performed for this present study. A pragmatic enrolment target of 80 participants was set in advance based on funding and logistical considerations associated with this research project.

Study process and data collection After recruitment, participants were required to complete an information form providing demographic details and information on the following potential confounding variables: age (years); gender (M/F); previous ‘real’ ECC experience (having performed ECC in a live clinical setting as a bystander or health professional) (Y/N). Three questions designed to elicit hand dominance without participants being aware that this was an important factor were also included: ‘What hand do you throw with?’; ‘What hand do you hold a tennis racquet with?’; and ‘What hand do you write with?’ As stated previously, participants were blinded to the research question and study outcomes.

Following confirmation of eligibility, participants were allocated randomly to one of two groups: ‘dominant hand on chest’ or ‘non-dominant hand on chest’. Group allocation was determined by a computer-generated randomisation schedule created using Microsoft Excel 2010. Allocation concealment was guaranteed by the use of sequentially numbered sealed opaque envelopes. An envelope for each participant was not opened until after a participant’s enrolment in the study was confirmed. This allocation determined the sequence in which two periods of ECC were performed by each participant.

Participants were asked to approach the manikin from the anatomical left side, and based on the group allocation were instructed which hand to have in contact with the chest as they prepared to commence ECC. Each participant performed two periods of ECC (no ventilations), each of three minutes duration, with a ‘rest and recovery’ period of at least 15 minutes in between. Those allocated to the DHOC group performed the first period of ECC with the dominant hand in contact with the chest and the non-dominant hand supporting on top of it, then reversed that hand position for second ECC period. Those in the NDHOC group performed their two periods of ECC in the opposite sequence, still with a rest and recovery period.

Data analysis Data were analysed by a biostatistician blinded to group allocation. Analysis was performed using Stata© version 13 (StataCorp. 2014. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). Only paired data were

included in the final analysis (that is, when a participant completed both DHOC and NDHOC phases of ECC). Descriptive statistics were generated, and differences between primary and secondary outcomes were assessed using non-parametric tests (two sample Wilcoxon rank-sum (Mann- Whitney)) due to the non-normal distribution of the data. Statistical significance was established at p<0.05.

Due to the crossover design, hierarchical linear regression was used to assess for a ‘period effect’ and a ‘carryover effect’, that being whether the sequence in which the two periods were ECC performed impacted on the results.

Ethical approval Approval to conduct the study was granted by the Western Sydney University Human Research Ethics Committee (approval number HREC 11036). As the trial was a manikin study, it was not registered on a clinical trial register.

Results Seventy-five students agreed to participate in the study. The study flow from recruitment to analysis is illustrated in Figure 1.

Nine students completed only the first period of ECC after being randomised, failing to return and complete the second period for various reasons; these data were not included in the final analysis, resulting in 66 paired ECC measurements being available for analysis. Demographic information for the participating students is presented in Table 1, indicating randomisation created balanced groups.

Table 1. Demographics of participants (overall and by randomised group)

Demographic All participants

(n=75)

DHOC (n=37)

NDHOC (n=38)

Age (years) – mean (SD)

23.4 (4.6) 22.5 (3.1) 24.3 (5.6)

Gender – % female 51 53 47 Previous ‘real ECC’ (% yes)

23 48 52

SD = standard deviation; CPR = cardiopulmonary resuscitation; ‘real CPR’ = previously performed ECC in a live clinical setting as bystander or health professional; DHOC = dominant hand on chest; NDHOC = non-dominant hand on chest

For the primary outcome of this study, we have found no significant difference in CS between DHOC and NDHOC (69.9% (SD 29.9) vs. 69.1% (SD= 34.1); p=0.92), respectively. There were no significant differences in CS according to gender (male CS 65.5% vs. female 73.3%; p=0.2) or previous ‘real-CPR’ experience (previous experience 72.7% vs. no

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Cross: Chest compressions: impact of hand dominance Australasian Journal of Paramedicine: 2019;16 previous experience 68.2%; p=0.8), so no adjustment by these potentially confounding variables was required.

Hierarchical linear regression of CS by period plus an interaction term for period and dominant hand showed no evidence of phase sequence effects. On average, period two had a 0.4% lesser CS than period one, but this was not significantly different. Additionally, no evidence was found of a carryover effect as the interaction between period and dominant hand was not significant.

The results for the secondary outcome that contribute to the overall CS, those being the individual ECC components deemed relevant to the impact of hand dominance, are shown in Table 2. Only compression release, or the proportion of compressions in which complete recoil was achieved, differed significantly between the groups.

Table 2. Secondary outcomes: ECC individual components ECC component DHOC %

(SD) NDHOC % (SD)

p-value

Compression depth 70 (38) 73 (35) 0.57 Compression release 53 (39) 42 (37) 0.02 Compression rate 59 (40) 57 (40) 0.85

ECC = external chest compression; SD = standard deviation p = probability; DHOC = dominant hand on chest; NDHOC = non- dominant hand on chest

With regard to the second aim, that being the generation of outcome data for use in determining the sample size calculation of a larger appropriately powered trial, a calculation was performed based on the difference of 0.8% shown in this study. Assuming a power of 80% and an alpha value of 0.05, the sample size required to detect a difference of 0.8% without risk of type 2 error in a larger trial would be 16,913.

Discussion In this manikin-based, crossover randomised controlled trial there was no difference in ECC effectiveness as measured by CS between ECC performed with the dominant hand in contact with the chest when compared to the non-dominant hand. ECC rate and depth of compression were not significantly different, though compression release improved with the dominant hand in contact with the chest. Hand dominance, or ‘handedness’, when performing ECC has been the subject of a small body of simulation-based research over the past 17 years. Comparison across these studies is difficult due to differences in study design and participant population, however there is substantial heterogeneity in results. The majority of these studies have explored ECC effectiveness by investigating the various components of ECC performance with a focus primarily on ECC depth, rate and release. The present study adds to the existing body by taking a new outcome approach using the overall compression score as the primary composite outcome,

Figure 1. Consort participant flow diagram (n=75 randomised, n=66 analysed)

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thus adding new knowledge. The finding of no difference in CS according to handedness has not been described elsewhere using an algorithm-derived outcome. A similar finding of no difference in overall ECC ‘score’ was reported by Jiang et al in a 2015 non-randomised manikin study (5). Adopting a non- randomised design, they used an Objective Structured Clinical Assessment (OSCE) manual assessment process to determine a percentage score, with both groups achieving a mean overall CPR score of 88%. If one were basing a position on overall measures of effectiveness alone, it is suggested that the current body of evidence, limited as it may be, would suggest handedness is not important when performing ECC and that the performer should choose which ever hand on the chest they deem to be most comfortable.

However overall ECC effectiveness scores have their limitations and with this in mind, the components of ECC that constitute such overall measures must also be added to the equation. The present study investigated individual components of the overall ECC performance, those being ECC depth, ECC rate and ECC release (recoil). With regard to handedness and ECC depth, the present study’s result of no difference is consistent with the majority of existing data (4-6, 9), but in contrast to Wang et al and Kundra et al who found more optimal depth being achieved when the dominant hand was on the chest (7,8).

With regard to handedness and ECC rate, the present study finding of no difference challenges results from three earlier simulation studies that both reported significant differences favouring dominant hand on the chest evidenced by higher mean compression rates (4-6). While DHOC resulted in significantly higher mean rates, the rates of both groups in each study were comfortably within the recommended guideline parameters for effective ECC raising the question of whether the reported differences would be clinically significant.

With regard to handedness and ECC release (recoil), the present study found a significant increase in the proportion of ECCs in which appropriate release was achieved (DHOC 53% vs. NDHOC 47%). This finding is in contrast to the existing simulation research suggesting no difference. In a study of Chinese medical students using a randomised trial design, Jiang et al reported a greater proportion of ECCs with appropriate chest release when the non-dominant hand was on the chest (5). An older 2000 study of 19 anaesthetics medical residents by Kundra et al also showed no difference in release (8). Again, while statistically significant, the low proportion of ECC with correct release in both groups is alarming given the importance of adequate chest release in ensuring optimal venous return and subsequent myocardial perfusion (12). Irrespective of handedness, inadequate recoil has been shown to be common, often due to the rescuer leaning on the chest during ECC (13,14).

In summary the findings from this simulation-based crossover randomised controlled trial suggest that hand dominance might not be important in the performance of effective ECC. The difference in chest release favouring the dominant hand on the chest while significant, may not produce clinically meaningful improvement in overall effectiveness, particularly given the low rates of release across both groups. When viewed in context of the existing body of research to which this study contributes, it would be most appropriate to suggest that either hand on the chest is acceptable when performing ECC, and that performer comfort should dictate choice of hand position.

Limitations There are several limitations in light of which the data presented herein should be considered. The participants were students predominantly enrolled in an undergraduate paramedicine degree, with little or no real clinical ECC experience. This limits the generalisability of the findings beyond the simulated context, but no less so than the extant literature that currently constitutes the body of evidence on this specific aspect of resuscitation.

The design of the study did not allow for investigation of the relationship between hand dominance and ‘side of approach’. In a small simulation study in which 12 anaesthetists performed ECC on a simulation pressure pad, force distribution across the palm of the hand suggested side of approach should influence which hand is placed on the chest rather than ‘handedness’; that is, the right hand should be on the chest if performing ECC from the right side of the patient (15). This was incorporated into a study by You et al who similarly concluded that hand on the chest matching the side of approach represented the optimal approach (16). In contrast, Jones et al counter that selection of a ‘best’ side of approach is not necessary and could lead to delays in commencement of ECC (17). Future research incorporating ‘side of approach’ may serve to further illuminate the optimal approach amidst the relatively small and inconsistent body of research to which this present study contributes.

Importantly it must be emphasised that this was a manikin- based study conducted in a simulated environment, so there are limitations in the transferability of these findings to resuscitation on real patients during real emergency resuscitation. However, as there is no existing study involving human subjects presenting findings relating to the impact of hand dominance on performance of ECC, the data presented herein constitute meaningful evidence that in the absence of non-simulated research should not be ignored.

Finally, the small sample size of this study means that it is statistically underpowered and therefore susceptible to type 2

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Cross: Chest compressions: impact of hand dominance Australasian Journal of Paramedicine: 2019;16

error, or the chance that a difference might actually exist but has gone undetected in this small sample. The study was conducted as a pilot study to inform feasibility of a larger appropriately powered study, and while this study might be underpowered, the results still warrant presentation as they contribute to the existing evidence-base in the interim.

Conclusion In this randomised crossover study conducted in a simulation context, there was no difference in ECC effectiveness measured by an overall effectiveness outcome according to placement of the dominant or non-dominant hand on the chest during compressions. A modest improvement in ECC release was seen in the DHOC group. While the study was underpowered, the results support an approach involving rescuers placing whichever hand they are most comfortable with on the chest irrespective of handedness.

Acknowledgements This study was funded by a grant from the School of Science and Health at Western Sydney University. The study was primarily designed and implemented by a team of undergraduate paramedicine students participating in the Undergraduate Paramedic Student Research Engagement Academy (‘UPSTREAM’). The authors would like to acknowledge the students of Western Sydney University for participating in this study, and Mr Francios Fouche for providing biostatistical support and data analysis.

Conflict of interest The authors report no conflicts of interest. Each author of this paper has completed the ICMJE conflict of interest statement.

References 1. Kleinman ME, Brennan EE, Goldberger ZD, et al.

Part 5: adult basic life support and cardiopulmonary resuscitation quality. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132(18Suppl2):S414-35.

2. Berg R, Hemphill R, Abella B, et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. ibid. 2010;122:S685-705.

3. International Liaison Committee on Resuscitation. Part 2: adult basic life support. Resuscitation 2005;67:187-201.

4. Cho GC, Kang GH, Oh DJ, Rhee JE, Song GJ. Personal

preference and role of dominant hand position during external chest compression by novice rescuers. ibid. 2010;1:S47.

5. Jiang C, Jiang S, Zhao Y, Xu B, Zhou XL. Dominant hand position improves the quality of external chest compression: a manikin study based on 2010 CPR guidelines. J Emerg Med 2015;48:436-44.

6. Jo CH, Ahn JH, Shon YD, Cho GC. Role of dominant hand position during chest compression by novice rescuers: an observational simulation study. Hong Kong Journal of Emergency Medicine 2014;21:382-6.

7. Wang J, Tang C, Zhang L, et al. Compressing with dominant hand improves quality of manual chest compressions for rescuers who performed suboptimal CPR in manikins. Am J Emerg Med 2015;33:931-6.

8. Kundra P, Dey S, Ravishankar M. Role of dominant hand position during external cardiac compression. Br J Anaesth 2000;84:491-3.

9. Nikandish R, Shahbazi S, Golabi S, Beygi N. Role of dominant versus non-dominant hand position during uninterrupted chest compression CPR by novice rescuers: a randomized double-blind crossover study. Resuscitation 2008;76:256-60.

10. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Med 2010;8:18.

11. Travers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR overview. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(18Suppl3):S676-84.

12. Zuercher M, Hilwig RW, Ranger-Moore J, et al. Leaning during chest compressions impairs cardiac output and left ventricular myocardial blood flow in piglet cardiac arrest. Crit Care Med 2010;38:1141.

13. Fried DA, Leary M, Smith DA, et al. The prevalence of chest compression leaning during in-hospital cardiopulmonary resuscitation. Resuscitation 2011;82:1019-24.

14. Niles DE, Sutton RM, Nadkarni VM, et al. Prevalence and hemodynamic effects of leaning during CPR. ibid. 2011;82:S23-6.

15. Baubin M, Kollmitzer J, Pomaroli A, et al. Force distribution across the heel of the hand during simulated manual chest compression. ibid. 1997;35:259-63.

16. You JS, Kim H, Park JS, et al. Relative effectiveness of dominant versus non-dominant hand position for rescuer’s side of approach during chest compressions between right-handed and left-handed novice rescuers. Emerg Med J 2015;32:184-8.

17. Jones CM, Thorne CJ, Hulme J. Effect of a rescuer’s side of approach on their performance of conventional cardiopulmonary resuscitation. Resuscitation 2012;83:e235.

CASP Randomised Controlled Trial Standard Checklist: 11 questions to help you make sense of a randomised controlled trial (RCT)

Main issues for consideration: Several aspects need to be considered when appraising a randomised controlled trial:

Is the basic study design valid for a randomised controlled trial? (Section A)

Was the study methodologically sound? (Section B) What are the results? (Section C) Will the results help locally? (Section D)

The 11 questions in the checklist are designed to help you think about these aspects systematically.

How to use this appraisal tool: The first three questions (Section A) are screening questions about the validity of the basic study design and can be answered quickly. If, in light of your responses to Section A, you think the study design is valid, continue to Section B to assess whether the study was methodologically sound and if it is worth continuing with the appraisal by answering the remaining questions in Sections C and D.

Record ‘Yes’, ‘No’ or ‘Can’t tell’ in response to the questions. Prompts below all but one of the questions highlight the issues it is important to consider. Record the reasons for your answers in the space provided. As CASP checklists were designed to be used as educational/teaching tools in a workshop setting, we do not recommend using a scoring system.

About CASP Checklists: The CASP RCT checklist was originally based on JAMA Users’ guides to the medical literature 1994 (adapted from Guyatt GH, Sackett DL and Cook DJ), and piloted with healthcare practitioners. This version has been updated taking into account the CONSORT 2010 guideline (http://www.consort-statement.org/consort-2010, accessed 16 September 2020).

Citation: CASP recommends using the Harvard style, i.e. Critical Appraisal Skills Programme (2020). CASP (insert name of checklist i.e. Randomised Controlled Trial) Checklist. [online] Available at: insert URL. Accessed: insert date accessed.

©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial- Share A like. To view a copy of this licence, visit https://creativecommons.org/licenses/by-sa/4.0/

Critical Appraisal Skills Programme (CASP) part of Oxford Centre for Triple Value Healthcare Ltd www.casp-uk.net

2

Study and citation: …………………………………………………………………………………………………………

Section A: Is the basic study design valid for a randomised controlled trial?

1. Did the study address a clearly focused research question? CONSIDER: Was the study designed to assess the outcomes of an intervention? Is the research question ‘focused’ in terms of: • Population studied • Intervention given • Comparator chosen • Outcomes measured?

Yes No Can’t tell o o

2. Was the assignment of participants to interventions randomised? CONSIDER: • How was randomisation carried out? Was

the method appropriate? • Was randomisation sufficient to eliminate

systematic bias? • Was the allocation sequence concealed

from investigators and participants?

Yes No Can’t tell o o o

3. Were all participants who entered the study accounted for at its conclusion? CONSIDER: • Were losses to follow-up and exclusions

after randomisation accounted for? • Were participants analysed in the study

groups to which they were randomised (intention-to-treat analysis)?

• Was the study stopped early? If so, what was the reason?

Yes No Can’t tell o o o

Section B: Was the study methodologically sound?

4. • Were the participants ‘blind’ to

intervention they were given? • Were the investigators ‘blind’ to the

intervention they were giving to participants?

• Were the people assessing/analysing outcome/s ‘blinded’?

Yes No Can’t tell

o o o o o

o o o

5. Were the study groups similar at the start of the randomised controlled trial? CONSIDER: • Were the baseline characteristics of each

study group (e.g. age, sex, socio-economic group) clearly set out?

• Were there any differences between the study groups that could affect the outcome/s?

Yes No Can’t tell o o o

3

6. Apart from the experimental intervention, did each study group receive the same level of care (that is, were they treated equally)?

CONSIDER: • Was there a clearly defined study protocol? • If any additional interventions were given

(e.g. tests or treatments), were they similar between the study groups?

• Were the follow-up intervals the same for each study group?

Yes No Can’t tell o o o

Section C: What are the results?

7. Were the effects of intervention reported comprehensively?

CONSIDER:

• • What outcomes were measured, and were

they clearly specified? • How were the results expressed? For

binary outcomes, were relative and absolute effects reported?

• Were the results reported for each outcome in each study group at each follow-up interval?

• Was there any missing or incomplete data? • Was there differential drop-out between the

study groups that could affect the results? • Were potential sources of bias identified? • Which statistical tests were used? • Were p values reported?

Yes No Can’t tell o o o

8. Was the precision of the estimate of the intervention or treatment effect reported?

CONSIDER: • Were confidence intervals (CIs) reported?

Yes No Can’t tell o o o

9. Do the benefits of the experimental intervention outweigh the harms and costs?

CONSIDER: • What was the size of the intervention or

treatment effect? • Were harms or unintended effects

reported for each study group? • Was a cost-effectiveness analysis

undertaken? (Cost-effectiveness analysis allows a comparison to be made between different interventions used in the care of the same condition or problem.)

Yes No Can’t tell o o o

Was a power calculation undertaken?

4

Section D: Will the results help locally?

10. Can the results be applied to your local population/in your context?

CONSIDER: • Are the study participants similar to the

people in your care? • Would any differences between your

population and the study participants alter the outcomes reported in the study?

• Are the outcomes important to your population?

• Are there any outcomes you would have wanted information on that have not been studied or reported?

• Are there any limitations of the study that would affect your decision?

Yes No Can’t tell o o o

11. Would the experimental intervention provide greater value to the people in your care than any of the existing interventions?

CONSIDER: • What resources are needed to introduce

this intervention taking into account time, finances, and skills development or training needs?

• Are you able to disinvest resources in one or more existing interventions in order to be able to re-invest in the new intervention?

Yes No Can’t tell o o o

APPRAISAL SUMMARY: Record key points from your critical appraisal in this box. What is your conclusion about the paper? Would you use it to change your practice or to recommend changes to care/interventions used by your organisation? Could you judiciously implement this intervention without delay?

  1. Study and citation:
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  43. APPRAISAL SUMMARY:

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