Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

Thomas Kingston; Nicholas B Tiller; Elle Partington; Mukhtar Ahmed; Gareth Jones; Mark I Johnson; Nigel A Callender

doi:10.1371/journal.pone.0254800

. 2021 Jul 22;16(7):e0254800. doi: 10.1371/journal.pone.0254800

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

Thomas Kingston ^1,^#, Nicholas B Tiller ², Elle Partington ³, Mukhtar Ahmed ⁴, Gareth Jones ⁵, Mark I Johnson ⁵, Nigel A Callender ^5,^6,^*,^#

Editor: Ritesh G Menezes⁷

¹Department of Anaesthesia and Critical Care, Barnsley District General Hospital, Barnsley, South Yorkshire, United Kingdom

²Institute of Respiratory Medicine and Exercise Physiology, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Centre, Torrance, California, United States of America

³Newcastle Medical School, Newcastle University, Newcastle Upon Tyne, Tyne and Wear, United Kingdom

⁴Emergency Medicine Department, Leeds Teaching Hospitals, Leeds, West Yorkshire, United Kingdom

⁵School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, West Yorkshire, United Kingdom

⁶Department of Anaesthesia, Northumbria Specialist Emergency Care Hospital, Cramlington, Northumberland, United Kingdom

⁷Imam Abdulrahman Bin Faisal University, SAUDI ARABIA

Competing Interests: This study received the temporary loan of equipment from Laerdal Medical UK. NAC is the owner of a commercial indoor climbing gymnasium. NBT is funded by a postdoctoral fellowship from the Tobacco-Related Disease Research Program (TRDRP; award no. T31FT1692). MIJ reports grants from Glaxosmithkline and the Neuromodulation Society of the United Kingdom and Ireland (NSUKI) including consultancy fees from TENSCare, outside the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no other conflicts of interest to declare.

^✉

* E-mail: n.callender@leedsbeckett.ac.uk

Contributed equally.

Roles

Thomas Kingston: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing

Nicholas B Tiller: Conceptualization, Methodology, Visualization, Writing – original draft, Writing – review & editing

Elle Partington: Data curation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing

Mukhtar Ahmed: Conceptualization, Methodology, Writing – original draft, Writing – review & editing

Gareth Jones: Conceptualization, Data curation, Investigation, Methodology, Resources, Supervision, Writing – review & editing

Mark I Johnson: Conceptualization, Methodology, Supervision, Writing – review & editing

Nigel A Callender: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft, Writing – review & editing

Ritesh G Menezes: Editor

PMCID: PMC8297772 PMID: 34293018

Abstract

Objectives

Compliant surfaces beneath a casualty diminish the quality of cardiopulmonary resuscitation (CPR) in clinical environments. To examine this issue in a sporting environment, we assessed chest compression quality and rescuer exertion upon compliant sports safety matting.

Methods

Twenty-seven advanced life support providers volunteered (13 male/14 female; mass = 79.0 ± 12.5 kg; stature = 1.77 ± 0.09 m). Participants performed 5 × 2 min, randomized bouts of continuous chest compressions on a mannequin, upon five surfaces: solid floor; low-compliance matting; low-compliance matting with a backboard; high-compliance matting; high-compliance matting with a backboard. Measures included chest compression depth and rate, percentage of adequate compressions, and rescuer heart rate and perceived exertion.

Results

Chest compression depth and rate were significantly lower upon high-compliance matting relative to other surfaces (p<0.05). The percentage of adequate compressions (depth ≥50 mm) was lowest upon high-compliance matting (40 ± 39%) versus low-compliance matting (60 ± 36%) and low-compliance matting with a backboard (59 ± 39%). Perceived exertion was significantly greater upon high-compliance matting versus floor, low-compliance matting, and low-compliance matting with a backboard (p<0.05).

Conclusion

Providers of CPR should be alerted to the detrimental effects of compliant safety matting in a sporting environment and prepare to alter the targeted compression depth and rescuer rotation intervals accordingly.

Introduction

Global survival rates following cardiac arrest are low (2.8–47.4%) [1] and influenced by factors including the quality of cardiopulmonary resuscitation (CPR) and automated defibrillator (AED) access [2]. Although cardiac arrest during exercise is rare, with an estimated incidence of 4.5 per million per year [3, 4], sport and recreation venues have been identified as higher-risk environments [5]. In such venues, however, prompt bystander-delivered CPR and AED deployment are more likely and, therefore, confer a better outcome [6, 7].

Chest compression depth and rate, two primary indices of CPR quality, partly determine outcome in cardiac arrest. Importantly, chest compressions should be performed upon a firm surface, and achieve a depth of 50–60 mm at a rate of 100–120 compressions per minute [2]. Achieving these targets may be influenced by many factors in a sports setting, including the surface present beneath a casualty, a factor which has been found to attenuate chest compression quality in clinical settings [8–10].

Sporting facilities are a non-clinical environment where compliant undersurfaces are frequently encountered (e.g. gymnastics facilities and martial arts gymnasiums). Indeed, some venues such as indoor climbing gymnasiums may feature very large expanses of floor area confluently overlaid with high-compliance matting. In these environments, considerable and/or unacceptable delay may be incurred while relocating a casualty to a firm surface upon which to perform chest compressions. Despite safety matting being commonplace in the sports and leisure industry, the influence of such surfaces on CPR quality has, to our knowledge, not yet been investigated.

To facilitate the development of future guidance on CPR delivery in sporting facilities which feature compliant matting surfaces, the aims of this study were: i) to ascertain the effect of compliant sports safety matting upon markers of chest compression quality and rescuer exertion, and ii) to investigate whether the use of a CPR backboard attenuated any detrimental effects of a more compliant surface.

Methods

Participants

Thirty-two advanced life support (ALS) providers (13 male/19 female; age: 30.1 ± 6.8 y; mass: 75.7 ± 14.1 kg; height: 1.75 ± 0.10 m; mean ± SD) were recruited from local paramedic (n = 10 participants), critical care (n = 6) and emergency medicine (n = 16) departments. Using previous work by Perkins et al. [8] and Tweed et al. [9] a power calculation was performed a-priori (G*Power, Dusseldorf, Germany; α: 0.05, β: 0.8, two-tailed), anticipating a medium effect size for the primary dependent variables (partial eta squared; η²_p = 0.06). Employing a Repeated-Measures Analysis of Variance (ANOVA), n = 26 was estimated as sufficient. Leeds Beckett University ethical review board granted approval, and participants provided written, informed consent. All participants were free from known pre-existing cardiorespiratory illness (medical questionnaire) and medications known to affect the cardiovascular response to exercise. Before testing, participants were asked to abstain from alcohol and caffeine for 24h.

Experimental protocol

The effects of matting compliance on compression quality were assessed using a randomized, single-blind, crossover design at a commercial indoor climbing gymnasium. Participants delivered chest compressions on a training mannequin beneath which were matting surfaces of varying compliance. Measures of chest compression quality and rescuer exertion were recorded throughout.

Procedures

Following 10-min of quiet sitting, baseline telemetered heart rate (HR; Polar T31, Polar Electro, Finland) and rating of perceived exertion (RPE; CR-100 scale; [11]) were recorded. Prior to testing, a single 20 s bout of compressions was performed on the resuscitation mannequin with visual feedback from the software in an attempt to ensure consistent performance among participants. Following a brief rest, participants then performed 5 × 2-min bouts of continuous, compression-only CPR upon various surfaces (Table 1) in a randomized order, each separated by a 5-min seated rest period (Fig 1). Participants were instructed to adhere to the 2015 ERC resuscitation guidelines (Compression rate: 100–120 min^-1; depth: 50–60 mm; [2]).

Table 1. Descriptions of surfaces beneath the mannequin during each compression bout.

Surface	Abbreviation	Description
Floor	Floor	Solid concrete floor.
Low-compliance foam	LC	The foam matting in-situ in the gymnasium (Vitafoam VE38 200, density: 38–40 kg/m³; hardness: 180–220 N).
Low-compliance foam & backboard	LCBB	As for LC but with a rigid backboard (800 mm x 500 mm x 18 mm rigid board) inserted between the manneqin and matting.
High-compliance foam	HC	Foam of higher-compliance used in some sports settings (Vitafoam VE40 400, density 40 kg/m³; hardness: 110–130 N).
High-compliance foam & backboard	HCBB	As for HC but with the rigid backboard.

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All surfaces except for the Floor comprised three 100 mm layers of foam laid to a total depth of 300 mm, as is standard in venues similar to that where testing was undertaken. All surfaces were covered with an opaque sheet to remove visual cues for participants. N = Newtons.

Fig 1 — Bouts of continuous, compression-only CPR (2 min) were performed upon five surfaces in a random order: Floor = Concrete floor; LC = Low-compliance foam; LCBB = Low-compliance foam & backboard; HC = High-compliance foam; HCBB = High-compliance foam & backboard.

Measures

Chest compressions were performed on a commercially available resuscitation training mannequin (Resusci-Anne QCPR; Laerdal Medical, Norway), incorporating an electronically-metered internal depth gauge and recoil spring. To achieve a torso mass equivalent to a 75 kg male phantom (32.6 kg; [12]), lead sachets were secured within the thorax compartment of the mannequin.

Compression data

Data on each compression were recorded automatically by the mannequin’s proprietary software (SkillReporter PC, V 3.2.0.1; Laerdal Medical, Norway) for exactly 2-min, initiated at the first compression. Maximum and minimum compression depth (mm) was recorded for each compression (compression depth and depth at end of release). Correspondingly, the percentage of compressions attaining the target depth threshold (≥50 mm) were recorded. Mean compression rate (min^-1) was calculated from the inter-compression time interval. Mean compression data were reported as that averaged over the entire 2-min bout, unless specified.

Rescuer exertion

Participant HR was recorded during the 60 seconds prior to each trial (HR_Pre-Task) and in the final 20 seconds of compressions (HR_Peak). Perceived exertion was rated immediately before each compression bout (RPE_Pre-Task) and immediately following the 2-min epoch (RPE_Peak).

Statistical analyses

Raw participant data were exported from the mannequin software to Microsoft Excel (Microsoft Corporation, Washington, USA) and analyzed using SPSS Version 26 (IBM, Chicago, USA). Normality of distribution was assessed using the Shapiro-Wilk test. Compression variables (compression rate, depth and percentage of adequate compressions) were compared among surfaces using a One-Way Repeated-Measures Analysis of Variance (ANOVA). Participant heart rate (HR_Pre-Task vs. HR_Peak) and RPE (RPE_Pre-Task vs. RPE_Peak) were analyzed using a Two-Way Repeated-Measures ANOVA. The Greenhouse-Geisser correction was applied where the assumption of sphericity was violated and all post-hoc analyses were performed with Bonferroni adjustment. Effect size was estimated using the partial eta-squared (η²_p) method and categorized as small = 0.01, medium = 0.06, or large = 0.14 [13]. Data are presented as mean ± SD with critical alpha-level applied as 0.05, and confidence interval of 95%.

Results

Participants

From the 32 participants recruited, five subjects (all female) were excluded from the analysis owing to a failure to deliver chest compressions of the pre-determined cutoff depth (>40 mm; 80% of minimum target depth) on solid floor (mean compression depth: 34.4 ± 3.4 mm). When compared to the remaining female participants (n = 14), those excluded were of a similar age (28.2 ± 3.2 vs. 29.1 ± 4.0 y; p>0.05; η²_p: 0.01), but exhibited a significantly lower body mass (58.0 ± 8.5 vs. 74.4 ± 12.5 kg; p = 0.015, η²_p: 0.30), stature (1.65 ± 0.04 vs. 1.71 ± 0.09 m; p = 0.036, η²_p: 0.24), and BMI (21.5 ± 3.5 vs. 25.3 ± 3.3; p = 0.042, η²_p: 0.22). Accordingly, 27 participants were included in the final analysis (age: 31.5 ± 7.3 y; mass: 79.0 ± 12.5 kg; 1.77 ± 0.09 m; 13 male/14 female).

Compression data

Compression depth

Compression metrics among all surfaces are shown in Table 2 and Fig 2. There was a significant main effect of surface (F[2.83, 73.63] = 5.42, p = 0.002; η²_p: 0.17). Post-hoc analyses showed the compression depth achieved upon the HC surface was significantly lower than that achieved upon the Floor (p = 0.003), LC (p = 0.001), and LCBB (p = 0.039) surfaces. There was no difference in mean compression depth upon the Floor and LC, LCBB or HCBB (all p = 1.000); LC and LCBB or HCBB (both p = 1.000); HCBB and LCBB (p = 0.949); or HC and HCBB (p = 0.786). For percentage of compressions attaining an adequate depth (≥50 mm), there was a significant main effect of surface (F[2.98, 77.59] = 3.53, p = 0.019; η²_p: 0.12). Post-hoc analyses found that the percentage of adequate compressions was lower for the HC compared with the LC and LCBB surfaces (p<0.001 and = 0.033, respectively). No difference in the percentage of adequate compressions was observed between the Floor and LC (p = 0.956), HC (p = 0.767), HCBB or LCBB (both p = 1.000); LC and LCBB or HCBB (both p = 1.000); LCBB and HCBB (p = 1.000); or HC and HCBB (p = 1.000).

Table 2. Compression metrics among surfaces.

	^(a)Floor			^(b)LC			^(c)LCBB			^(d)HC			^(e)HCBB
Depth (mm)	49.8	±	4.3^d	50.2	±	5.0^d	50.0	±	5.2^d	47.0	±	4.9^a^,^b^,^c	48.6	±	4.9
CI (95%)	48.1	-	51.5	48.2	-	52.1	47.9	-	52.0	45.1	-	49.0	46.6	-	50.5
Rate (min^-1)	127	±	13^d^,^e	125	±	13^d^,^e	125	±	16^d^,^e	119	±	11^a^,^b^,^c	120	±	14^a^,^b^,^c
CI (95%)	121	-	132	120	-	131	119	-	132	115	-	123	115	-	125
Adequate (%)	51	±	38	60	±	36^d	59	±	39^d	40	±	39^b^,^c	49	±	42
CI (95%)	36	-	66	46	-	74	44	-	74	25	-	56	32	-	65

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Data are mean ± SD (n = 27). Floor = concrete floor; LC = low-compliance foam; LCBB = low-compliance foam with backboard; HC = high-compliance foam; HCBB = high compliance foam with backboard. Depth = mean compression depth during 2-min bout; Rate = mean compression rate (.min^-1); Adequate = percentage of compressions achieving ≥50 mm depth during 2-min bout. CI (95%) = 95% confidence interval.

^aSignificantly different versus Floor;

^bSignificantly different versus LC;

^cSignificantly different versus LCBB;

^dSignificantly different versus HC;

^eSignificantly different versus HCBB.

Alpha level = <0.05.

Compression rate

There was a significant main effect of surface (F[4, 104] = 11.47, p<0.001; η²_p: 0.30; Table 2 and Fig 2). Post-hoc testing revealed that the HC and HCBB surfaces resulted in significantly lower compression rates relative to the Floor (p<0.001 and = 0.005, respectively), LC (p = 0.002 and = 0.007, respectively) and LCBB surfaces (p = 0.006 and = 0.005, respectively). No difference was observed between the HC and HCBB surfaces (p = 1.000), or between the Floor, LC and LCBB surfaces (all p = 1.000).

Rescuer exertion

Rating of perceived exertion

Data for RPE following post-hoc analyses are shown in Table 3. There was a significant main effect of time (RPE_Pre-Task vs. RPE_Peak; F[1, 24] = 89.03, p<0.001; η²_p: 0.79) and surface (F[4, 96] = 11.47, p<0.001; η²_p: 0.32), and a significant interaction between the two (F[4, 96] = 13.62, p<0.001; η²_p: 0.36). Post-hoc analyses revealed that the HC and HCBB surfaces elicited a greater RPE_Peak than the Floor (p = 0.002 and = 0.002, respectively) and LC surfaces (p<0.001 and = 0.010, respectively), with the HC surface also significantly different to the LCBB surface (p = 0.001). There was no difference between the HC and HCBB (p = 1.000) surfaces or between the HCBB and LCBB surfaces (p = 0.101).

Table 3. Heart rate and perceived exertion in response to chest compressions.

		^(a)Floor			^(b)LC			^(c)LCBB			^(d)HC			^(e)HCBB
HR	*Pre (bpm)*	79	±	13	78	±	16	80	±	15	80	±	15	77	±	10
	CI (95%)	74	-	85	72	-	84	74	-	86	74	-	86	73	-	81
	*Post (bpm)*	125	±	25 ^#^†	128	±	24	126	±	25 ^#^†	134	±	25	135	±	23
	CI (95%)	114	-	136	119	-	138	116	-	136	124	-	144	126	-	145
	Sig.		< 0.001			< 0.001			< 0.001			< 0.001			< 0.001
RPE	*Pre*	5.9	±	7.9	4.2	±	6.3	4.2	±	5.3	6.2	±	7.8	5.2	±	8.7
	CI (95%)	2.7	-	9.1	1.6	-	6.7	2.0	-	6.3	3.1	-	9.3	1.7	-	8.7
	*Post*	34.3	±	20.7 ^d^,^e ^†	34.6	±	20.1 ^d^,^e	37.4	±	23.3 ^d^,^e ^#^†	50.7	±	27.3 ^a^,^b^,^c	46.3	±	23.1 ^a^,^b^,^c
	CI (95%)	26.0	-	42.7	26.5	-	42.8	28.0	-	46.8	39.5	-	62.0	37.0	-	55.6
	Sig.		< 0.001			< 0.001			< 0.001			< 0.001			< 0.001

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Data are mean ± SD (n = 27). Floor = concrete floor; LC = low-compliance foam; LCBB = low-compliance foam with backboard; HC = high-compliance foam; HCBB = high compliance foam with backboard. HR = Heart rate. bpm = beats per minute; RPE = CR-100 perceived exertion scale. Sig. = significance level pre- versus post-compressions. CI (95%) = 95% confidence interval.

^#Significant interaction with HC.

^†Significant interaction with HCBB.

^aSignificantly different versus Floor;

^bSignificantly different versus LC;

^cSignificantly different versus LCBB;

^dSignificantly different versus HC;

^eSignificantly different versus HCBB.

Alpha level = <0.05.

Heart rate

Data for HR following post-hoc analyses are shown in Table 3. There was a significant main effect for time HR_Pre-Task vs. HR_Peak; (F[1, 24] = 297.75, p<0.001; η²_p: 0.93) but no significant main effect for surface (F[2.72, 65.31] = 1.90, p = 0.143; η²_p: 0.07). A significant surface × time interaction was also present (F[4, 96] = 87.88, p = 0.018; η²_p: 0.12). Data pertaining to absolute compression decay and chest leaning are presented in S1 File.

Discussion

This study examined the effect of compliant safety matting on chest compression quality in a sporting environment. Our findings show that high-compliance safety matting found in sporting environments significantly reduced chest-compression quality (compression depth and rate), and increased rescuer perceived exertion. Both were partially improved with use of a backboard.

High-compliance safety matting, frequently encountered in sporting venues, significantly reduced mean compression depth by ~3 mm, and attenuated the percentage of adequate compressions by up to 20% when compared to the Floor, LC and LCBB surfaces. The effect of the high-compliance surface was similar to that attributed to air- and foam-filled mattresses in a clinical environment [8, 9, 14]. Although the absolute decrement in chest compression depth with the HC surface may be relatively small, this difference in depth is comparable to that differentiating survival from non-survival during cardiac arrest [15]. It is also similar in magnitude to that conferring improved survival rates to hospital admission [16] and hospital discharge [17], suggesting this decrement might still be clinically meaningful.

Compression rate was also reduced upon both the HC and HCBB surfaces relative to the Floor, LC and LCBB surfaces. This is again consistent with hospital studies which show reduced compression rates on higher-compliance surfaces [18]. Compression depth and rate often show an inverse association [19–21], where the reduction in rate is due to the greater vertical hand-travel required to attain deeper compression depths [10, 22], as may be the case on more compliant sports matting.

Notably, no differences were apparent between the Floor, LC and LCBB surfaces for compression depth or rate, suggesting effective CPR may be delivered at least upon certain lower-compliance matting types found in some sports venues. As the transport of a collapsed casualty to a firmer surface is likely to introduce an unacceptable delay to treatment [23], and in the absence of specific knowledge of the effects of all safety matting varieties, it seems prudent that rescuers performing CPR should anticipate a negative effect from sports matting, and aim to compensate appropriately.

Introducing a backboard partially attenuated the loss of compression quality on the HC surface, resulting in a 9% increase in the percentage of compressions achieving an adequate depth, and an increase in absolute mean compression depth of ~1.6 mm. Although these measures did not attain statistical significance, research within hospital environments has shown reductions in mattress displacement, and associated rescuer workload, when backboards were used upon compliant hospital beds [10, 22]. No difference in compression depth or the percentage of adequate compressions occurred when a backboard was used upon the low-compliance surface, and similarly no effects were observed on any surface for compression rate. Notwithstanding the above, the use of a backboard upon complaint sports surfaces needs further consideration, and where high-compliance undersurfaces are present, we would advocate backboard use if placement does not delay CPR.

Rescuer exertion is an important factor in the delivery of high-quality CPR. Relative to pre-task values, heart rate and perceived exertion increased during all 2-min bouts of chest compressions (Table 3), with the HC and HCBB surfaces eliciting values for perceived exertion that were significantly higher than the remaining firmer surfaces. Previous work has described a rating of ~35 on the CR-100 scale to correspond with the anaerobic threshold in active young adults [24]. Importantly, the HC and HCBB surfaces, elicited levels of effort closer to the “Heavy” threshold (rating of 50 on the CR-100 scale; [11]). This higher exertion might be attributed to greater mechanical work associated with increased total vertical hand movement, as suggested by Noordergraaf et al. [10], and the elevated muscular effort required to stabilize the lower body on a compliant surface [9]. Our findings suggest that chest compressions upon high-compliance sports matting, may be associated with considerable physiological strain, limiting the duration for which effective CPR can be sustained, even by experienced providers. Such a scenario may, therefore, require more frequent rescuer changeovers during CPR.

Finally, five participants were excluded from the analysis owing to a failure to attain the pre-defined mean compression depth on a solid floor. All were female and of a significantly lower body mass, height, and BMI compared to the remaining female participants (n = 14). Previous work has shown a positive relationship between body mass and stature in CPR efficacy [25]. What remains unclear is whether a more complaint surface may exacerbate this interaction between anthropometry and chest compression quality and warrants future investigation. It may be worth noting that inclusion of these participants in the analysis on an intention-to-treat basis did not alter our conclusions.

Sporting environments are considered higher-risk locations for cardiac arrest [5]. Yet the probability of early recognition of such an event, instigation of high-quality, bystander-delivered CPR, and greater defibrillator access all likely contribute to the superior outcomes observed following cardiac arrest in sporting venues [4, 6, 7]. Our findings highlight additional factors that may be modified or prepared for in order to improve the quality of CPR delivery in such environments. Although further research is required, particularly examining a broader range of matting compliance levels, future guidance should consider the influence of compliant safety matting upon chest compression depth and rescuer fatigue. Where appropriate, these effects should be acknowledged by medical personnel and also addressed during site-specific CPR training courses for sports venue staff.

Limitations

Firstly, we tested safety matting comprised of only two compliance levels and thus are unlikely to represent the entire range of sports protection surfaces. Nevertheless, the two matting types assessed were felt to be representative of those commonly encountered in most venues by the research team, participants and gymnasium staff. Moreover, the use of backboards gave our study an additional level of insight as to the effects of surface compliance on chest compression quality.

Secondly, while every effort was made to blind our participants to the surfaces encountered, it is probable that most were able to detect some difference between at least matting, if not backboard conditions. In any event, if our participants were not effectively blinded, it may be that the magnitude of the decline in compression quality was underestimated.

Finally, we recruited a relatively homogenous group of highly-trained and experienced participants as an attempt to control for influences outside of the matting characteristics alone. The addition of data relating to trained bystanders or gymnasium staff may have been beneficial, particularly as these groups are likely to deliver the initial response to a collapsed patient while awaiting trained medical assistance.

Conclusions

We report a detrimental influence of high-compliance safety matting upon chest compression quality and rescuer exertion during simulated CPR in a sporting environment. This information may be used to guide improved CPR quality upon similar surfaces and may be particularly relevant within venues featuring large areas of compliant matting. These effects should be highlighted to first responders, medical staff and those working within sporting environments. Future research should aim to evaluate the clinical relevance of the decrement imposed by high-compliance matting and the influences of a broader range of surfaces. Moreover, the influence of a CPR backboard and the interactions among surface-type, rescuer training and experience level warrant further investigation.

Supporting information

S1 File. Compression decay and degree of chest leaning.

Additional results relating to magnitude of compression decay and chest leaning present upon each surface.

(DOCX)

Click here for additional data file.^{(20.4KB, docx)}

S1 Table. Individual participant descriptives.

Participant descriptive data for all included and excluded participants.

(DOCX)

Click here for additional data file.^{(19.8KB, docx)}

S1 Data

(XLSX)

Click here for additional data file.^{(49.8KB, xlsx)}

Acknowledgments

We wish to thank Richard Davies and Mark Cook at Laerdal Medical for their help and technical support, and Laerdal Medical UK for the loan of equipment. We are also grateful to Climb Newcastle Ltd. for the use of their venue, and participants from the North East Ambulance Service and NHS Hospital Trusts for giving their time to participate.

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

No financial support was received in relation to this study. Temporary loan of equipment was received from Laerdal Medical UK.

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11.Borg G, Borg E. A new generation of scaling methods: Level-anchored ratio scaling. Psychologica. 2001;28(1):15–45. [Google Scholar]
12.De Leva P. Adjustments to Zatsiorsky-Seluyanov’s segment inertia parameters. J Biomech. 1996;29(9):1223–30. doi: 10.1016/0021-9290(95)00178-6 [DOI] [PubMed] [Google Scholar]
13.Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863. doi: 10.3389/fpsyg.2013.00863 [DOI] [PMC free article] [PubMed] [Google Scholar]
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15.Talikowska M, Tohira H, Finn J. Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2015;96:66–77. doi: 10.1016/j.resuscitation.2015.07.036 [DOI] [PubMed] [Google Scholar]
16.Kramer-Johansen J, Myklebust H, Wik L, Fellows B, Svensson L, Sørebø H, et al. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation. 2006;71(3):283–92. doi: 10.1016/j.resuscitation.2006.05.011 [DOI] [PubMed] [Google Scholar]
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20.Monsieurs KG, De Regge M, Vansteelandt K, De Smet J, Annaert E, Lemoyne S, et al. Excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest. Resuscitation. 2012;83(11):1319–23. doi: 10.1016/j.resuscitation.2012.07.015 [DOI] [PubMed] [Google Scholar]
21.Smereka J, Iskrzycki Ł, Makomaska-Szaroszyk E, Bielski K, Frass M, Robak O, et al. The effect of chest compression frequency on the quality of resuscitation by lifeguards. A prospective randomized crossover multicenter simulation trial. Cardiol J. 2018; 26:769–776. doi: 10.5603/CJ.a2018.0121 [DOI] [PMC free article] [PubMed] [Google Scholar]
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23.Bircher NG, Chan PS, Xu Y. Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiol J Am Soc Anesthesiol. 2019;130(3):414–22. [DOI] [PubMed] [Google Scholar]
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PLoS One. doi: 10.1371/journal.pone.0254800.r001

Decision Letter 0

Ritesh G Menezes

25 Mar 2021

PONE-D-21-04446

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

PLOS ONE

Dear Dr. Callender,

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Academic Editor

PLOS ONE

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'This study received the temporary loan of equipment from Laerdal Medical UK. NAC is

the owner of a commercial indoor climbing gymnasium. NBT is funded by a

postdoctoral fellowship from the Tobacco-Related Disease Research Program

(TRDRP; award no. T31FT1692). MIJ reports grants from Glaxosmithkline and the

Neuromodulation Society of the United Kingdom and Ireland (NSUKI) including

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

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Reviewer #1: Mutliple objectives has been reported in the study, however the abstract doesnt mention about CPR preparedness

There is no limitation mentioned in the manuscript

Study has multiple objectives and includes a combination of research and survey. I would recommend reporting survey as separate manuscript and keeping objective simple

The survey portion of the study is definitely worth reporting but may be as research letter rather than original investigation.

Reviewer #2: I would like to thank the authors on their work to put this study and manuscript together. I enjoyed reading the manuscript. The topic and discussion of CPR surfaces is needed and specifically for environments such as sports venues. Below you can find my comments:

1- Overall challenge in the manuscript is it seems there are two main questions/themes the authors are trying to answer , which might confuse the flow and objective of the manuscript.

a. First one is the matting (fold 1 and 2) in the introduction section.

b. Level of CPR preparedness among commercial indoor climbing gymnasiums.

this caused a little bit of a confusion in the sample as it seems both samples are not the same…. In which it is almost having two studies. Have the authors considered having this manuscript focused on only one part, possibly aim 1 and 2? And have #3 separate paper (although may require more sample)?

2- The authors used the term Advanced Life Support (ALS), is this only CPR course (Basic Life Support by American Heart Association)? Or Advanced Cardiac Life Support). ? is ALS by ERC similar to BLS in AHA or ACLS?. If it was ALS=ACLS, what was the rationale behind selecting ACLS and not BLS/CPR ?

a. Not to mention that in the second study (survey on preparedness), the authors used the term BLS training instead of ALS. using one consistent term would be better.

3- Have the authors thought about using indoor venue staff as subjects instead of recruiting medical personnel , such as critical care, EM, etc? what

4- The study design is a crossover design, meaning subjects did multiple rounds of compressions on various surfaces , wouldn’t that cause some sort of fatigue? Even though they got some rest?

Suggestions:

1- Adding a descriptive table of the subjects characteristics.

2- Adding a study figure that shows exactly what subjects went through and how many were in each group etc. Figure would make it easier to visualize study design to the reader. Procedure section.

Reviewer #3: 1. In my opinion Figure 1 is not strictly required and should be removed from the publication.

2. Actual non-significant p values should be specified, rather than being provided as p>0.05

3. Was re-training attempted in the 5 females excluded from study. One would potentially hypothesize that their technique was inadequate and that re-training may have allowed participation in the study.

4. Interesting that Table 2 describes statistically significant differences. However the 95th % CI overlap for those described as different. Additionally, the means of all parameters described are within 1 SD of the remaining parameters defined. The raw data and statistics should be carefully re-checked.

5. Consider adding the 5 females excluded as an "intention to treat" analysis. Did this make any difference to your reported study findings. (I note that this data has been collected as per the attachment in your ofline data file providd

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2021 Jul 22;16(7):e0254800. doi: 10.1371/journal.pone.0254800.r002

Author response to Decision Letter 0

12 Apr 2021

Please see attached Word document: Responses to reviewer comments

Attachment

Submitted filename: Authors responses to review comments CPR PLoS1.docx

Click here for additional data file.^{(36.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0254800.r003

Decision Letter 1

Ritesh G Menezes

29 Jun 2021

PONE-D-21-04446R1

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

PLOS ONE

Dear Dr. Callender,

Please submit your revised manuscript by 06-July-2021. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #1: My previous concern about multiple objectives in a paper (including survey and research data together) has been resolved by the authors. However the opening line in the discussion section still mentions about "also describe current levels of preparedness for CPR delivery among 222 indoor climbing gymnasiums" Please change this to accurately reflect the current objective of the paper.

Reviewer #2: (No Response)

Reviewer #3: Thank you for addressing my previous comments. I do not have further questions or comments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

PLoS One. 2021 Jul 22;16(7):e0254800. doi: 10.1371/journal.pone.0254800.r004

Author response to Decision Letter 1

29 Jun 2021

Thank you again to the Reviewers for their time, comments and suggestions in relation to our paper. Specific responses below.

Reviewer 1: My previous concern about multiple objectives in a paper (including survey and research data together) has been resolved by the authors. However the opening line in the discussion section still mentions about "also describe current levels of preparedness for CPR delivery among 222 indoor climbing gymnasiums" Please change this to accurately reflect the current objective of the paper.

Response: Thank you for highlighting this errant line within the manuscript (Line 221). It has now been removed and the manuscript re-checked for any further outstanding issues. Thank you also for your time reviewing our work.

Reviewer 2: No comments.

Response: Thank you for your time and previous comments relating to our manuscript.

Reviewer 3: Thank you for addressing my previous comments. I do not have further questions or comments.

Response: Thank you for your time and help in improving our manuscript.

Attachment

Submitted filename: Authors responses to review comments 29-6-21.docx

Click here for additional data file.^{(26.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0254800.r005

Decision Letter 2

Ritesh G Menezes

5 Jul 2021

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

PONE-D-21-04446R2

Dear Dr. Callender,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

PLoS One. doi: 10.1371/journal.pone.0254800.r006

Acceptance letter

Ritesh G Menezes

13 Jul 2021

PONE-D-21-04446R2

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

Dear Dr. Callender:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. Ritesh G. Menezes

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Compression decay and degree of chest leaning.

Additional results relating to magnitude of compression decay and chest leaning present upon each surface.

(DOCX)

Click here for additional data file.^{(20.4KB, docx)}

S1 Table. Individual participant descriptives.

Participant descriptive data for all included and excluded participants.

(DOCX)

Click here for additional data file.^{(19.8KB, docx)}

S1 Data

(XLSX)

Click here for additional data file.^{(49.8KB, xlsx)}

Attachment

Submitted filename: Authors responses to review comments CPR PLoS1.docx

Click here for additional data file.^{(36.7KB, docx)}

Attachment

Submitted filename: Authors responses to review comments 29-6-21.docx

Click here for additional data file.^{(26.8KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting information files.

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[pone.0254800.ref010] 10.Noordergraaf GJ, Paulussen IWF, Venema A, van Berkom PFJ, Woerlee PH, Scheffer GJ, et al. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation. 2009;80(5):546–52. doi: 10.1016/j.resuscitation.2009.03.023 [DOI] [PubMed] [Google Scholar]

[pone.0254800.ref011] 11.Borg G, Borg E. A new generation of scaling methods: Level-anchored ratio scaling. Psychologica. 2001;28(1):15–45. [Google Scholar]

[pone.0254800.ref012] 12.De Leva P. Adjustments to Zatsiorsky-Seluyanov’s segment inertia parameters. J Biomech. 1996;29(9):1223–30. doi: 10.1016/0021-9290(95)00178-6 [DOI] [PubMed] [Google Scholar]

[pone.0254800.ref013] 13.Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863. doi: 10.3389/fpsyg.2013.00863 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0254800.ref014] 14.Nishisaki A, Nysaether J, Sutton R, Maltese M, Niles D, Donoghue A, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation. 2009;80(5):540–5. doi: 10.1016/j.resuscitation.2009.02.006 [DOI] [PubMed] [Google Scholar]

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PERMALINK

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion

Thomas Kingston

Nicholas B Tiller

Elle Partington

Mukhtar Ahmed

Gareth Jones

Mark I Johnson

Nigel A Callender

Roles

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Methods

Participants

Experimental protocol

Procedures

Table 1. Descriptions of surfaces beneath the mannequin during each compression bout.

Fig 1. Schematic of experimental protocol.

Measures

Compression data

Rescuer exertion

Statistical analyses

Results

Participants

Compression data

Compression depth

Table 2. Compression metrics among surfaces.

Fig 2. Influences of matting composition on chest compression parameters.

Compression rate

Rescuer exertion

Rating of perceived exertion

Table 3. Heart rate and perceived exertion in response to chest compressions.

Heart rate

Discussion

Limitations

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Ritesh G Menezes

Roles

Author response to Decision Letter 0

Decision Letter 1

Ritesh G Menezes

Roles

Author response to Decision Letter 1

Decision Letter 2

Ritesh G Menezes

Roles

Acceptance letter

Ritesh G Menezes

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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