01 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...

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01
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/ XXXXXXXXXX/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, XXXXXXXXXX
02
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_ XXXXXXXXXXpdf 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 XXXXXXXXXXper 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
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Australasian Journal of Paramedicine: 2019;16
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Australasian Journal of Paramedicine: 2019;16
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 XXXXXXXXXXStata 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 XXXXXXXXXXAs 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)
XXXXXXXXXX XXXXXXXXXX)
Gender - % female XXXXXXXXXX
Previous ‘real ECC’
(% yes)
XXXXXXXXXX
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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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 XXXXXXXXXX57
Compression release XXXXXXXXXX02
Compression rate XXXXXXXXXX85
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 XXXXXXXXXXWhile 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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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
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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.
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position improves the quality of external chest compression:
a manikin study based on 2010 CPR guidelines. J Emerg
Med 2015;48:436-44.
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position during chest compression by novice rescuers:
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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
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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
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11. Travers AH, Rea TD, Bobrow BJ, et al. Part 4:
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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
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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
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Answered Same DayMay 15, 2021HLSC122Australian Catholic University

Solution

Vidya answered on May 16 2021
23 Votes

ESSAY - CRITICAL APPRAISAL
IMPACT OF HAND DOMINANCE ON EFFECTIVENESS OF CHEST COMPRESSIONS IN A SIMULATED SETTING: A RANDOMISED, CROSSOVER TRIAL
Introduction:
External Cardiac Compressions...

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