Abstract
Previous research has examined the utilisation of musical cues to improve the performance of cardiopulmonary resuscitation (CPR) delivered in training environments. We postulated a musical cue that is both contemporary and transcends cultures may improve CPR performance. Our aim was to establish whether chest compressions are performed with improved rate and depth if a song of a fixed beat (PinkFong’s ‘Baby Shark’ with a tempo of 115 beats per minute (bpm) and 15 beats in each verse) is played to a healthcare professional immediately before undertaking CPR compared to whale noises (a non-metronomic rhythm). 58 Participants of a paediatric conference (majority doctors) were randomly assigned to listen to a minute of Baby Shark (28) or whale song (30) and then undertake a minute of CPR. There was no significant difference in the mean compression rate between the Baby Shark and control groups, with the groups achieving 121 and 125 bpm, respectively (p=0.18). In relation to compression depth within the target zone, the Baby Shark group had more compressions completed within the target zone (55%) than the control group (39%) although this difference was not significant (p=0.08). Listening to Baby Shark prior to undertaking simulated CPR does not improve overall performance, but there is a potential tendency to improve adequate compression depth which may be beneficial in training exercises.
Keywords: Cardiopulmonary Resuscitation, Training, Procedural Skills Training, Education And Evaluation
INTRODUCTION
Early effective cardiopulmonary resuscitation (CPR) is the first link in the Advanced Paediatric Life Support (APLS) chain of survival and requires both a good rate and depth of compression. 1 Bystander initiation of compressions has been shown to lead to a fourfold improvement in survival. 2 This has led to several national campaigns encouraging the public to commence CPR as soon as possible. Current APLS guidelines recommend a rate of 100–120 beats per minute (bpm), with a compression:breath ratio of 15:2. It can be a challenge to maintain an adequate rate without external auditory cues especially as the majority of locations in which a cardiac arrest might occur lack a metronome. Several musical mnemonics have been suggested to facilitate an appropriate compression rate. These tunes range from children’s nursery rhymes like 'Nellie the Elephant' 3 to popular classics such as 'Stayin’ Alive', 4 but many of these suggestions are culturally limited and in the latter case tailored to an audience that can remember the 1970s. While the British Heart Foundation campaign using a famous actor and the 'Stayin' Alive' chorus was very successful (https://www.youtube.com/watch?v=Li9l0lNo7_Q_), we postulated a musical cue that is both contemporary and transcends the boundaries of nations and cultures may continue to improve CPR performance. With over 3 billion hits on YouTube, PinkFong’s Baby Shark (https://www.youtube.com/watch?v=XqZsoesa55w accessed 30 April 2020) is both memorable and features an inherent guideline compliant beat, with a tempo of 115 bpm and 15 beats in each verse, to act as a metronome for CPR (table 1).
Table 1.
Previous research describing music in resuscitation studies
| Song | Artist | Year | bpm | Refs |
|---|---|---|---|---|
| Radetzkymarsch | Johann Strauss Sr | 1848 | 110 | Dold 2014 5 |
| Nellie the Elephant | Ralph Butler and Peter Hart | 1956 | 105 | Rawlins 2009 3 |
| S.O.S. | ABBA | 1975 | 120 | Roehr 2014 6 |
| That’s the Way (I Like It) | KC and the Sunshine Band | 1975 | 109 | Hafner 2015 7 |
| Stayin’ Alive | Bee Gees | 1977 | 104 | Hafner 2015, 7 Matlock 2008 4 |
| Count on Me, Singapore | Clement Chow | 1986 | 112 | Ho 2019 8 |
| Macarena | Los Del Rio | 1993 | 103 | Oulego-Erroz 2011 9 |
| Men are Ships, Women are Ports (Korean) | Shim Su Bong | Unknown | 100 | Honk 2016 10 |
| Baby Shark | PinkFong | 2016 | 115 |
Our aim was to establish whether chest compressions are performed with improved rate and depth if a song of a fixed beat (using 'Baby Shark' as a model song) is played to a healthcare professional immediately before undertaking CPR compared to whale noises. Whale song was chosen as we believed it would add no relevant metronomic beat and act as white noise (as opposed to silence) in an attempt to maintain blinding without introducing an alternative song with an appreciable rhythm. Given the study was undertaken in a noisy environment (without background music) using noise-cancelling headphones to provide the soundtrack, we were not clear that we could have delivered silence in that environment.
METHODS
Participants were self-selected from a group of paediatric emergency medicine nurses, doctors, researchers and paramedics attending a paediatric conference in 2019. Consent was assumed by completion of a short survey to collect demographic data (participants’ specialty, years’ experience in their profession, months since undertaken CPR (either simulated or in clinical practice)) and their APLS status. Participants were then randomly allocated via a block design (process via sealedenvelope.com in blocks of two and four) to either the ‘Baby Shark’ group or a control group. Each participant was read a short introductory statement, which stated that ‘CPR should be performed at 100–120 bpm’ and explained the process they were about to undergo. Each group listened to 30 s of music—Baby Shark (at 115 bpm) for the intervention group and whale music (via YouTube https://www.youtube.com/watch?v=tgkoJFlwKmg) for the control. This was done via headphones so as not to alert waiting for participants of the study objectives. Following this, participants were asked to perform 60 s of compression-only CPR (timed by the investigator) on a Zoll R series defibrillator. This timing was chosen as it would enable more study participants to be tested in the available time while still simulating an appropriate time period of resuscitation. Relevant information as per key elements to report for simulation-based research 11 can be found in table 2. Data including as rate and depth were collected by the defibrillator with participants (and study team) blinded to their performance.
Table 2.
Key reporting elements for simulation-based research as per Cheng et al 11
| Elements | Descriptor |
|---|---|
| Participant orientation | Participants were asked to provide chest compressions as per APLS guidelines to a manikin. |
| Simulator type | The manikins used were laerdal little junior connected to Zoll R compression and rhythm detectors. |
| Simulation environment | A partitioned room with the manikin on the floor in a breakout room at a conference venue. |
| Simulation scenario | Individual undertook 1 min of chest compressions. There was no pilot testing and the faculty supported the administration of testing. |
| Instructional design | There was no education element to the study. |
| Feedback | No feedback was provided to the participants. |
APLS, Advanced Paediatric Life Support.
Previous research 12 has demonstrated a rate of mean compressions per minute (cpm) of 111 (SD 13). To demonstrate that the intervention would adjust the mean to 100 or 120 cpm (ie, a 10 cpm difference) 25 participants per arm would be needed. The study aimed to recruit at least 50 participants.
Data were analysed using Excel (Microsoft) using an independent sample T-test to compare means between the two groups. Under current UK Health Research Authority guidance, this study was deemed exempt from formal ethical approval in England as it did not involve patients or users of health services.
RESULTS
A total of 79 participants were enrolled, and 58 participants were included in the study. The exclusion of participants was due to a technical error which meant that data recordings from one of the study sessions were unable to be retrieved, and this group contained an equal number of participants in both arms. Figure 1 shows the recruitment flow diagram
Figure 1.
Recruitment flow (Consolidated Standards of Reporting Trials).
Demographics of the participants are shown in table 3.
Table 3.
Recruitment Flow (Consolidated Standards of Reporting Trials)
| Total | Baby Shark | Control | |
|---|---|---|---|
| Clinical role | |||
| Advanced clinical practitioner | 2 | 2 | 0 |
| Emergency medicine clinician | 7 | 2 | 5 |
| Nurse | 1 | 0 | 1 |
| PICU fellow | 1 | 1 | 0 |
| Paediatric trainee | 3 | 2 | 1 |
| Trainee AMP | 1 | 0 | 1 |
| Researcher | 1 | 1 | 0 |
| Rural general practitioner | 1 | 0 | 1 |
| PEM consultant | 17 | 6 | 11 |
| Paediatrician | 24 | 14 | 10 |
| Years of experience | |||
| ≤5 | 7 | 4 | 3 |
| 6–10 | 21 | 11 | 10 |
| 11–15 | 16 | 8 | 8 |
| 16–20 | 7 | 3 | 4 |
| 21–30 | 7 | 2 | 5 |
| Last time you performed CPR ? (child or adult/clinical or simulated) | |||
| <1 week ago | 2 | 2 | 0 |
| <2 weeks ago | 8 | 2 | 6 |
| <1 month ago | 11 | 3 | 8 |
| <2 months ago | 9 | 5 | 4 |
| <6 months ago | 18 | 8 | 8 |
| <12 months ago | 5 | 3 | 2 |
| >1 year ago | 5 | 3 | 2 |
| APLS status | |||
| APLS provider | 27 | 14 | 13 |
| APLS instructor | 23 | 12 | 11 |
| Not current | 8 | 2 | 6 |
AMP; APLS, Advanced Paediatric Life Support; CPR, cardiopulmonary resuscitation; GP, general practitioner; PICU, pediatric intensive care unit; PEM, paediatric emergency medicine.
The majority of participants were doctors (91.4%), with two advanced clinical practitioners and one nurse participating. The cohort had good experience, with only seven (12%) having less than 5 years’ experience with CPR and just over half having more than 10 years’ experience with CPR. This is also reflected in that 50 of the participants (86.2%) were locally qualified with AAPLS certification, and of these, almost half (23) were APLS instructors. There were no significant differences between the arms apart from a propensity for emergency clinicians in the control group which occurred by chance.
In terms of recent CPR performance (real or simulated), 48 participants (83%) had performed within the last 6 months, with 5 participants performing CPR in the 6–12 months and >1 year brackets, respectively.
The compression rate and depth averages in the two groups are shown in table 4 with the spread of cpm shown via a box and whisker plot in figure 2.
Table 4.
Comparison of the Baby Shark and control groups
| Baby Shark (SD) | Control (SD) | P value (one-tailed) | |
|---|---|---|---|
| Mean rate | 121.29 bpm (13.97) | 124.94 bpm (15.74) | 0.18 |
| % Compressions in target zone | 54.95% (42.95) | 39.18% (41.51) | 0.08 |
| % Compressions above target zone | 43.97% (43.40) | 58.19% (43.75) | 0.11 |
| % Compressions below target zone | 1.08% (1.60) | 2.55% (6.27) | 0.11 |
| Target depth or greater depth | 98.9% | 97.4% | >0.5 |
Figure 2.
Box and whisker plot of compressions per minute.
There was no significant difference in the mean compression rate between the Baby Shark and control groups, with the groups achieving 121 and 125 bpm, respectively (p=0.18). Looking at the percentage of compression within the target zone, the Baby Shark group had more compressions completed within the target zone (55%) than the control group (39%) although this difference was not significant (p=0.08). There was also no significant improvement for those in the Baby Shark arm in achieving within or above the required depth of chest compressions (98.9% vs 97.4%, p>0.5).
DISCUSSION
In this opportunistic study of healthcare professionals, there was no significant difference in rate, or compression depth, if a song with relevant metronomic rate was played compared to a control song. There was a tendency towards a greater proportion of chest compressions at the appropriate depth. This may be a result of greater concentration if a rhythm is being followed and the professional does not have to think about rate and compression depth simultaneously. Given listening to music is unlikely to cause harm, our study highlights why it has been repeatedly used by those training in paediatric CPR. While it would be entirely inappropriate to hum or use music during an actual arrest prior to attending a resuscitation event (simulation or otherwise), clinical teams may wish to hum or sing music of an appropriate metronomic quality in their head. We believe our findings are more useful for public engagement and training than perhaps real-life resuscitation. The ‘mental metronome’ concept coined by Matlock et al 4 and using the Stayin' Alive chorus was developed for training environments. New defibrillator models often included a metronome to aid the provider with chest compression rate, but prior ‘priming’ as to rate can only aid engagement and is very unlikely to distract from it. Of note, adult studies have found no association with compression rate and survival 13 (although there was an improvement in spontaneous circulation) while recently specific rates and depths have been described. 14 This infers there may be a certain trade-off between rate and depth (going faster may make you compress less deeply, for example), and enable staff to concentrate on just one element (not needing to concentrate on the other) in training, which may aid patient outcomes.
There are many limitations to our study. We used conference participants who may not be representative of typical clinicians, we did not have a third arm of no music and while the accuracy of CPR was measured quantitatively, there is no means of determining what outcome this would have on real patients. These data add to the increasing body of evidence that demonstrates CPR performance can be influenced by using audiovisual cues. A systematic review has not yet been performed, so our group has started this piece of work as it is possible that aggregated findings, as per the studies in table one, may mean a formal Randomised Control Trial (RCT) is warranted.
Our work supports previous evidence that even trained APLS providers including instructors do not deliver CPR at the recommended rate and compression depth. This backs up the notion that CPR ‘competency’ as currently measured in most organisations is inadequate. While our proposed intervention may not be palatable, we have demonstrated a training deficit remains in this important area of clinical practice. Future studies should explore whether there is an impact on the effect of the intervention in groups of experienced and less experienced participants as we did not power the study to examine this. Given our findings, a future strand of enquiry may wish to determine whether targeted feedback on the depth of compressions may be of more benefit than music, in particular to those who are more experienced.
Listening to Baby Shark prior to undertaking simulated CPR does not improve overall performance, but there is a potential tendency to improve adequate compression depth which may be beneficial in training exercises.
Acknowledgments
We would like to gratefully thank all the conference participants who gave up their part of their breaks during the conference to participate in this study.
Twitter: Damian Rol @damian_roland.
Contributors: GL, TD, BL, HG, AT, RF and DR designed the study. BL lead delivery of the study. DR wrote the first draft and all authors contributed to subsequent revisions lead by RS. All authors approved the final version.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data availability statement: Data availability is not applicable as no data sets were generated and/or analysed for this study.
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