Impact of the 2010 resuscitation guidelines training on layperson chest compressions

Audrey L. Blewer, David G. Buckler, Jiaqi Li, Marion Leary,4, Lance B. Becker, Judy A. Shea, Peter W. Groeneveld, Mary E. Putt, Benjamin S. Abella

1Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA 19104, USA

2Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA

3Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104, USA

4School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA

Impact of the 2010 resuscitation guidelines training on layperson chest compressions

Audrey L. Blewer1, David G. Buckler1, Jiaqi Li1, Marion Leary1,4, Lance B. Becker1, Judy A. Shea2, Peter W. Groeneveld2, Mary E. Putt3, Benjamin S. Abella1

1Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA 19104, USA

2Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA

3Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104, USA

4School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA

BACKGROUND:Survival from cardiac arrest is sensitive to the quality of delivered CPR. In 2010, updated international resuscitation guidelines emphasized deeper chest compressions and faster rates, yet it is unknown whether training laypersons using updated guidelines resulted in changed CPR performance. We hypothesized that laypersons taught CPR using the 2010 guidelines performed deeper and faster compressions than those taught using the 2005 materials.

METHODS:This work represents a secondary analysis of a study conducted at eight hospitals where family members of hospitalized cardiac patients were trained in CPR. An initial cohort was trained using the 2005 guidelines, and a subsequent cohort was trained using the 2010 guideline materials. Post training, CPR skills were quantif ed using a recording manikin.

RESULTS:Between May 2009 to August 2013, 338 subjects completed the assessment. Among the subjects, 176 received 2005 training and 162 underwent 2010 training. The mean compression rate in the 2005 cohort was 87 (95%CI83–90) per minute, and in the 2010 cohort was 86 (95%CI83–90) per minute (P=ns), while the mean compression depth was 34 (95%CI32–35) mm in the 2005 cohort and 46 (95%CI44–47) mm in the 2010 cohort (P＜0.01).

CONCLUSIONS:Training with the 2010 CPR guidelines resulted in a statistically significant increase in trainees' compression depth but there was no change in compression rate. Nevertheless, the majority of CPR performed by trainees in both cohorts was below the guideline recommendation, highlighting an important gap between training goals and trainee performance.

Cardiopulmonary resuscitation; Cardiac arrest; Sudden death; Education; Guidelines

INTRODUCTION

Performance of high quality cardiopulmonary resuscitation (CPR) by members of the lay public before arrival of emergency medical services is a key factor in improving cardiac arrest survival. A number of observational clinical studies have demonstrated a positive correlation between CPR quality and survival from cardiac arrest.[1–5]Additionally, a recent meta-analysis of CPR performance investigations demonstrated that deeper chest compressions and rates closer to 85 to 100 compressions per minute were associated with improved survival from cardiac arrest.[6]

Taking into account the body of evidence supporting the importance of high quality CPR, the InternationalLiaison Committee on Resuscitation (ILCOR) updated CPR guidelines recommendations in 2010. These updated guidelines recommended deeper chest compressions (＞50 mm) and a faster compression rate (＞100 per min).[7]Observational studies subsequent to these changes have demonstrated that incorporation of the updated guidelines is associated with improved cardiac arrest outcomes,[8,9]while other investigations have suggested that implementation of new CPR guidelines do not result in improved outcomes.[2,10,11]In addition to these conflicting findings among professional providers, little evidence exists to address whether lay bystanders trained in CPR following the 2010 CPR guidelines actually perform deeper or faster compressions.

As a secondary analysis of a prospective multicenter trial of CPR educational strategies, using an existing hospital-based family member CPR training program, conducted in collaboration with nursing personnel, we assessed the skills of subjects who learned CPR under the two most recent guidelines.[12,13]We hypothesized that subjects taught CPR using the 2010 ILCOR guidelines would perform deeper and faster chest compressions than those taught with the 2005 guidelines.

METHODS

Study population and setting

3 Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009; 120: 1241–1247.

CPR instruction was offered by nurses and premedical students to family members of hospitalized patients at each study site. Subjects were considered potential candidates for enrollment if they met the following criteria: 1) the family member or friend to be enrolled was physically present with the patient on the floor or unit; 2) the patient had an admission diagnosis related to coronary disease or signif cant cardiovascular risk factors; 3) the patient was in a stable condition; 4) the family member was over 18 years of age; and 5) the family member felt fit and able to perform moderate physical activity at the time of enrollment. Interested subjects who satisf ed the inclusion criteria were enrolled using a standard written consent form, and completed a pre-training demographics survey.

Each subject viewed the VSI training and received either the 2005 or 2010 CPR guidelines training kit materials, depending on the time of enrollment in the study. Upon completion of the training, the subjects completed a post-training survey assessing their selfefficacy using their newly acquired CPR skills and perspectives on the training experience. Data from these surveys have been reported elsewhere.[13]

CPR training approach

2 Stiell IG, Brown SP, Christenson J, Cheskes S, Nichol G, Powell J, et al. What is the role of chest compression depth during outof-hospital cardiac arrest resuscitation? Crit Care Med 2012; 40: 1192–1198.

Study design

作為黑龍江流域腹地細(xì)石器文化最早的發(fā)現(xiàn)地點(diǎn)，昂昂溪文化的核心是嫩江下游，直接輻射區(qū)是整個(gè)嫩江流域，所以周邊其他原始文化或多或少都受到了昂昂溪文化的影響，形成了一定的地域性美術(shù)特征。但與周邊其他地區(qū)相比，昂昂溪及整個(gè)嫩江下游地區(qū)多為以精細(xì)壓制法加工的的細(xì)石器且體量較小，特征是小巧精致、便于攜帶且種類繁多，數(shù)量可觀。嫩江上流的石器大多數(shù)的加工都比較粗糙，精巧的壓制石器占比例較小而打制石器相對(duì)比例較高且優(yōu)質(zhì)瑪瑙玉髓等石材比例相對(duì)較少。

Post-training CPR quality evaluation

本研究選擇武漢市洪山區(qū)光谷地區(qū)部分城鄉(xiāng)結(jié)合部2006年、2009年、2011年3年的遙感影像(3期遙感影像購買自中國遙感數(shù)據(jù)網(wǎng)，都為6月份的數(shù)據(jù))作為初始數(shù)據(jù)，空間分辨率分別為2.4 m、2.4 m和2.0 m.為了滿足本研究需要，把研究區(qū)用地簡(jiǎn)單分為城市用地和非城市用地，具體詳見表1，土地利用類型分類參考參考文獻(xiàn)[1]中的分類標(biāo)準(zhǔn).

The post-training CPR quality evaluation protocolsvaried between cohorts due to a change in the study design outcome measure. Specifically, the second protocol was part of a large implementation project where immediate testing was not feasible. Since our hypothesis was that the change in guidelines improved CPR quality, immediate testing following training should yield better CPR quality than testing at six months as seen in the literature.[14]Subjects taught with the 2005 guidelines were asked by investigative staff to complete a two-minute skills assessment immediately following the in-hospital training and completion of the post-survey questionnaire. Subjects taught with the 2010 guidelines were contacted at six months post-initial enrollment and asked to complete a brief in-person interview. Once they completed the interview, the subject was asked to perform a two-minute skills test. Subjects who completed the skills assessment six months post-initial training were given $50 compensation for travel and their time.

Data from the CPR skills test in both groups were captured on a CPR recording manikin (Skillreporter ResusciAnne, Laerdal Medical) without direct audiovisual feedback to subjects or any interaction from study staff. CPR performance data were extracted from the recording software and imported into the study database for subsequent quantitative analysis.

Statistical approach and analysis

學(xué)業(yè)基礎(chǔ)不扎實(shí)是職高學(xué)生的一個(gè)通病，一來他們?cè)鹊膶W(xué)習(xí)基礎(chǔ)不理想，二來自我約束能力不足，同時(shí)又缺乏學(xué)習(xí)興趣和積極性。

All data were compiled in a secure, internet-based database application (REDCap Software Version 5.5.21, Vanderbilt University, Nashville, TN) and analyzed using a statistical software package (STATA 13, Statacorp, College Station, TX). Nine subjects were excluded from the 2010 cohort and seven subjects were removed from the 2005 cohort due to missing covariates. Demographic data were examined using the chi-square test for categorical variables, whereas Student's t test was applied to continuous variables. Resuscitation performance data (compression rate and depth) were assessed for approximate normality and Student's t test was used due to the large sample size. We used ordered logistic regression and multiple linear regression to further assess resuscitation performance while controlling potentially confounding covariates. Additionally, we adjusted center-level confounding by adding site in the regression as a fixed-effect. We further analyzed resuscitation performance by classifying these data into three categories based on the ILCOR guidelines. We defined "excellent" rate as greater than 100 per minute, "good" rate between 80 to100 per minute, and "poor" rate as less than 80 per minute. Additionally, we def ned "excellent" depth as above 50 mm, whereas "good" between 38 to 49 mm, and "poor" as less than 37 mm.

RESULTS

Demographics

From May 2009 to August 2013, 402 subjects were trained in CPR at the eight study hospitals. Among the subjects, 176 received training with the 2005 guidelines and 226 underwent training with the 2010 guidelines. From this target group, 176/176 (100%) of the 2005 cohort and 162/226 (72%) from the 2010 cohort completed the skills assessment. Descriptive characteristics and demographics of the study population who completed the skills assessment are detailed in Table 1. Overall, the mean age of subjects was 52±15 years, and 250/338 (74%) of the subjects were female. The majority of subjects were white 196/338 (58%) or black 124/338 (37%), and 259/338 (77%) reported being the patient's spouse or immediate family member. Of the subjects, 175/338 (52%) had never received CPR training, and an additional 91/338 (27%) had not been trained in more than 10 years. While there were statistically significant differences in terms of previous CPR training, there were no variations between studycohorts in regard to age, gender, race, subject's relationship to the patient, and highest level of education attained.

Figure 1. Distribution of subject chest compression rate (A) and depth (B) within both the 2005 and 2010 guidelines training cohorts. Skills data were quantif ed on a CPR-recording manikin.

Table 2. CPR skills assessment after training

CPR skills assessment

After training, subjects were asked to complete a two-minute skills assessment on a CPR recording manikin. Three hundred and thirty-eight subjects completed this assessment and the results of the skills assessment are detailed in Table 2. The mean chest compression rate in the 2005 cohort was 87 (95%CI 83–90) per minute and in the 2010 group was 86 (95%CI 83–90) per minute (P=ns), whereas the mean chest compression depth in the 2005 cohort was 34 (95%CI 32–35) mm and in the 2010 cohort was 46 (95%CI 44–47) mm (P＜0.01). These data are shown in Figure 1.

Figure 2. Proportion of subjects with poor, good, and excellent chest compression rate and depth within both the 2005 and 2010 guidelines training cohorts. P-value represents statistical significance between the 2005 and 2010 guidelines cohorts.

We further analyzed these data categorically to examine the prevalence of poor, good, and excellent rate and depth within study cohorts (see Statistical Approachfor detailed description). Adequacy of rate performance did not vary signif cantly between the cohorts (P=0.14), but adequacy of depth performance was found to be significantly different (P＜0.01) (Figure 2). Of the 2005 cohort, 104/176 (59%) had "poor" depth compared with 42/162 (25%) of the 2010 cohort (P＜0.01), and 59/176 (34%) of the 2005 cohort had "good" depth compared with 56/162 (35%) of the 2010 cohort (P＞0.05). Additionally, 13/176 (7%) of the 2005 cohort had "excellent" depth compared with 64/162 (40%) of the 2010 cohort (P＜0.01).

Limitations

This study was structured as a retrospective analysis evaluating the impact of guideline changes on CPR training and skill retention using data collected from two multi-center prospective hospital-based CPR training dissemination trials. Subjects enrolled from May 2009 to May 2010 were taught CPR using the 2005 guidelines training materials, whereas those enrolled from February 2012 to August 2013 were trained using the 2010 guidelines curriculum.

We used a multiple linear regression model to adjust for age, gender, education, prior training, and relationship to patient as potential confounders on the effect of guidelines training (2005 vs. 2010) on CPR performance. The adjusted P values from this multiple regression are detailed in Table 1. When controlling confounders, training with the 2005 or 2010 guidelines was not significantly associated with a change in rate. Increasing educational attainment was associated with deeper compression depth; even after adjustment for this potential confounder, subjects trained with the 2010 guidelines had mean levels of compression depth that were 12.46 mm (95%CI 15.3–9.58) deeper than those subjects trained with the 2005 guidelines (P＜0.01).

Additionally, we used ordered logistic regression to analyze the categorically grouped compression data's relationship with guidelines training while adjusting for education and prior training. When controlling for potential confounding, guidelines training was not found to be signif cantly related to compression rate. Compared to the 2010 guidelines, subjects trained with the 2005 guidelines have an 85% decreased likelihood of being in a higher depth category, while controlling for education and prior CPR training (P＜0.01).

DISCUSSION

In the current work, we found that implementation of the 2010 CPR guidelines training materials resulted in a statistically significant increase in lay bystander's performance of chest compression depth, while controlling other variables. However, despite this increase, mean depth was still less than the 50 mm threshold recommended by international resuscitation guidelines, highlighting the difficulty of achieving this quality goal.

圖3列出了各編碼算法對(duì)部分?jǐn)?shù)據(jù)集的分類錯(cuò)誤率和矩陣大小，Bautista為文獻(xiàn)[6]中采用的編碼方法.

The impact of CPR guidelines on training

Several studies have compared 2005 to 2010 guidelines training of healthcare providers and the subsequent impact on CPR quality during arrest simulations. Mayer et al[17]trained nurses and physicians using both guidelines recommendations and demonstrated improved CPR performance with the 2010 guidelines. Additionally, Jones et al[18]studied the impact of the 2010 guidelines on medical student CPR performance and found that subjects exhibited a faster rate when trained under the 2010 guidelines. In both studies, the subjects were taught using the standard CPR approach (i.e. 30 compressions: 2 ventilations).

There are limited data on the training of lay providers and the effect of guideline changes on educational effectiveness. A recent Chinese study randomized 88 undergraduate student volunteers to the 2005 or 2010 guidelines training using compressionsonly CPR and found that the quality of CPR (both rate and depth) improved among the 2010 cohort.[19]Our study utilized an existing hospital-based layperson CPR training infrastructure, in which the subject cohort was older (mean age=52±15) and participants were tested six months after initial training. We found that the difference in chest compression rate was not statistically signif cant (P=0.84), which may be due to the guideline instructions for chest compression rate remaining similar from 2005 to 2010. Additionally, we demonstrated improved performance of chest compression depth within the 2010 cohort six months after initial training.

地下開采過程中巖石物理力學(xué)性質(zhì)的測(cè)量通常是比較困難的，而對(duì)巖石物理力學(xué)性質(zhì)的影響因素又多種多樣，容易造成結(jié)果的不確定性，因此對(duì)巖石物理力學(xué)性質(zhì)的研究，采用較多的是巖石彈性波速測(cè)量及聲發(fā)射觀測(cè)等聲學(xué)方法，主要分為2種[8]：

Despite guidelines, lay bystander CPR varies

Since there is growing evidence that training alone may not be suff cient to ensure adequate layperson CPR performance, there may be potential value in considering other innovative approaches.[20,21]Recent investigations have suggested that dispatcher-assisted CPR instructions may provide a useful complement to CPR training for laypersons.[22]A recent study[23]found that dispatcherassisted instructions with compressions-only CPR resulted in a trend towards better outcomes in clinical subgroups. Other investigations have explored the use of cell phone audio guidance for lay bystanders and found that audio guidance improved CPR quality in simulated settings.[24]Despite this, there may be situations where dispatcher assisted CPR or cell phone guidance are not readily available, thus other novel methods to increase CPR retention should be examined. Investigators may consider evaluating processes to encourage trainees to practice their skills more regularly such as through brief email reminders, SMS texts, or phone calls that prompt subjects to consider refreshing their skills. Additionally, it is reasonable to consider whether more testing or feedback is necessary during the training process to increase the rate of competent providers. These novel methods may be an attractive avenue for future investigations.

Rea et al[20]examined the CPR quality of 26 cases of cardiac arrest patients treated by trained layperson provider CPR as a sub-analysis from the public access defibrillation trial. In this retrospective cohort study, CPR quality varied and often did not reach guideline recommended quality targets. Similarly, in a simulation study assessing trained laypersons, Aufderheide et al[21]demonstrated that less than a third of subjects performed adequate compression depth. Our study found similar,poor CPR performance with less than a third of the subjects demonstrating excellent rate and depth.

Methods to improve layperson CPR

While our data suggest an improvement in chest compression depth with the new guidelines implementation, it is important to note that there was wide variation in the quality of CPR performance among our trained lay subjects. This finding is consistent with the larger body of work that has highlighted the difficulty of achieving high-quality layperson CPR during both simulated and presumably actual resuscitation events as well.

Adjustment for confounding

20世紀(jì)80年代，斯特里克蘭和穆魯解決了激光器的啁啾脈沖放大問題。這個(gè)過程始于短脈沖，該脈沖通過一對(duì)光柵反射使其變長。光柵的作用類似于棱鏡，致使不同顏色的光通過不同長度的路徑。由于功率只是隨著時(shí)間而傳遞的能量，因此把光拉長會(huì)降低其功率，這樣就能夠在不損壞激光介質(zhì)的情況下實(shí)現(xiàn)放大。最終，放大的脈沖通過一臺(tái)壓縮器，將其擠壓成較短的脈沖——這是一種更具威力的脈沖。該方法使研究人員能夠獲得可以放在桌面的強(qiáng)大激光脈沖，并且能夠使像BELLA這樣的高功率激光脈沖工具更具可行性。

This study has several limitations. First, subjects were selected as part of a larger ongoing multicenter study investigating various hospital-based CPR training dissemination strategies. Subjects were enrolled using a similar inclusion criteria and CPR training curriculum, but there were variations in the CPR skills test protocol. Specifically, those in the 2005 cohort were subjected to a CPR skills test immediately after the training, whereas subjects in the 2010 cohort were given a six-month post-initial training for skill assessment. Despite the lag in follow-up assessment among those trained using 2010 guidelines, compression depth was significantly deeper in this group, supporting the finding that the change was related to the guidelines training curriculum. Furthermore, the six-month skills test was integrated into an in-person follow-up interview where subjects were not notif ed beforehand that they were being asked to complete a skills check (i.e., the skills check was a "surprise"). This method made it more probable that the subject did not practice immediately before the followup assessment, thus supporting the likelihood that the improvement in chest compression depth was related to the guidelines training curriculum. Despite this, it is worth noting that the potential bias introduced by different follow-up periods may actually mask the true difference between cohorts. Future studies may consider re-examining the relationship between CPR performance and guidelines change with similar follow-up periods.

據(jù)此，在輕罪與重罪的劃分上采取“法定刑標(biāo)準(zhǔn)說”是較為合理的。也就是說，應(yīng)當(dāng)以某種罪行所對(duì)應(yīng)的法定刑高低為標(biāo)準(zhǔn)來劃定其屬于輕罪還是重罪。在實(shí)際操作中，一般就是通過設(shè)置某種法定的刑期(或刑罰)標(biāo)準(zhǔn)來進(jìn)行劃分，低于這一標(biāo)準(zhǔn)的為輕罪，高于這一標(biāo)準(zhǔn)的為重罪。

In conclusion, we have shown that implementation of the 2010 CPR guidelines for layperson training resulted in a statistically signif cant increase in the performance of chest compression depth six months after initial training, compared with the training using the 2005 guidelines materials. Despite the improvement, mean chest compression depth was still below the 50 mm threshold recommended by ILCOR guidelines. These findings have important implications for future development of CPR training materials. Additionally, these findings demonstrate the impact of guideline training on laypersons simulated performance of CPR skills.

ACKNOWLEDGEMENTS

We thank the participants in Cardiopulmonary Resuscitation Hospital-based Implementation Project (CHIP) Research Group and collaborators to the work reported in this publication including: Gail Delfin, MSN, RN, Marisa Cinousis, Madalyn Karamooz, Linda Hoke, PhD, RN, Jim Kurtz, MPH, BSN, RN, Ryan Dos Reis, BSN, RN, Laura Solano, BSN, RN, Maria Rupp, BSN, RN, Patty Baroni, BSN, RN, Jackie Copeland, BSN, RN, Kenneth Deitch, DO, Kathia Damiron, Manish Goyal, MD, Kimberly Dehnkamp, BSN, RN, Kathy Lehman, RN, Judy Lieberman, MA, Donna Taylor, BSN, RN, Janice Baker, BSN, RN, Sharon Delany, MSN, RN, and Julie Hartman, MPH.

將以上3種材料分別按相對(duì)底面斜度為0°，15°，30°，45°，60°，90°進(jìn)行加工，加工后對(duì)其表面進(jìn)行清洗、烘干，備用.

Funding:This work was supported by a grant from the National Institutes of Health (R18HL107217).

Ethical approval:This work was approved by the Institutional Review Board at the University of Pennsylvania and was presented as an abstract at American Heart Association's Resuscitation Science Symposium in Dallas, TX, November 16, 2013.

Conflicts of interest:Ms. Blewer has equity in Resuscor LLC, a resuscitation education company. Ms. Leary serves on the advisory committee of the American Heart Association's Emergency Cardiovascular Care Committee and has equity in Resuscor LLC. Ms. Leary has received research funding from the American Heart Association. Dr. Becker has received research funding from Philips Healthcare and PhysioControl, as well as the Medtronic Foundation. Dr. Abella has received research funding and honoraria from Philips Healthcare, in-kind research support from Laerdal Medical Corporation and research funding fromMedtronic Foundation. Dr. Abella has equity in Resuscor LLC.

Contributors:Blewer AL proposed and wrote the study. All authors contributed to the design and interpretation of the study, and approved the f nal manuscript.

1 Hostler D, Everson-Stewart S, Rea TD, Stiell IG, Callaway CW, Kudenchuk PJ, et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster-randomised trial. Brit Med J 2011; 342: d512.

We used a commercially available CPR video selfinstruction (VSI) program (Family and Friends CPR Anytime, American Heart Association, Dallas, TX and Laerdal Medical Corporation, Stavanger, Norway), which has been validated in previous investigations.[14–16]This educational tool is packaged in a self-contained kit that includes an inflatable head/torso manikin and instructional DVD. The 2005 guidelines version of the DVD teaches compression depth performance at 38–50 mm and a rate of 100 compressions per minute. The inflatable head/torso manikin was engineered to give audio feedback (chest wall "click") when an individual compressed at least 38 mm. The updated 2010 version of the instructional DVD teaches CPR performance with a depth of ＞50 mm at a rate of ＞100 compressions per minute. In this iteration, the manikin was engineered to click at 50 mm of compression depth. For simplicity of study design and analysis, all subjects were instructed in compression-only CPR (without ventilations). Manikins with the audio feedback were only used for the training phase and not subsequent testing.

Our multicenter cohort study was approved by the Institutional Review Boards with jurisdiction over the study sites (University of Pennsylvania, Crozer-Keystone Health System, Albert Einstein Healthcare Network, Temple University, and the Chester County Hospital and Health System). Enrollment was conducted using a standard written informed consent process at eight hospitals aff liated to these health systems. Adult family members or friends of hospitalized patients on cardiology service lines, telemetry wards, step down units, and observation units were eligible for participation, with active enrollment conducted between May 2009 and August 2013.

4 Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O'Hearn N, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. J Amer Med Assoc 2005; 293: 305–310.

5 Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS, et al. Improving in-hospital cardiac arrest process and outcomes with performance debrief ng. Arch Intern Med 2008; 168: 1063–1069.

語言與文化，不可分割。文化可定義為“知識(shí)+嫻熟+認(rèn)識(shí)的統(tǒng)稱”(Snell-Hornby,1988:40)。原文文本通常被看做是“提供信息”。翻譯過程中，譯者會(huì)選擇他們認(rèn)為有趣、有用的信息。譯文中，譯者根據(jù)翻譯目的，選用相應(yīng)方式，提供信息(Reiss and Vermeer,1984:76)。由于譯者翻譯角度不同，對(duì)原文把握理解難免有所不同。盡管都是通過譯文來“提供信息”，由于翻譯目的不同，對(duì)原文信息處理、篩選不同。由于翻譯側(cè)重點(diǎn)不同，譯文中“提供的信息”千差萬別。原文“信息”，有直譯，保持原文色彩；有意譯，方便譯語讀者；也有省略不譯。

實(shí)施案例教學(xué)時(shí)，應(yīng)將案例提前一周發(fā)放給學(xué)生，以便學(xué)生查閱資料，開展課前的小組討論、分析。課堂上教師引導(dǎo)學(xué)生圍繞相關(guān)案例進(jìn)行討論后，根據(jù)案例對(duì)操作目的、步驟要點(diǎn)、注意事項(xiàng)等進(jìn)行示教；學(xué)生根據(jù)案例進(jìn)行模擬操作，如操作前對(duì)病人、環(huán)境等進(jìn)行評(píng)估，對(duì)病人或其家屬進(jìn)行相關(guān)解釋說明，對(duì)實(shí)驗(yàn)用物、環(huán)境進(jìn)行準(zhǔn)備，根據(jù)案例情景就解決問題的技術(shù)進(jìn)行訓(xùn)練，操作過程中注意人文關(guān)懷，操作完畢進(jìn)行健康教育；最后教師進(jìn)行歸納、總結(jié)。

6 Wallace SK, Abella BS, Becker LB. Quantifying the effect of cardiopulmonary resuscitation quality on cardiac arrest outcome: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2013; 6: 148–156.

7 Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010; 122: S676–684.

8 Sayre MR, Cantrell SA, White LJ, Hiestand BC, Keseg DP, Koser S. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care 2009; 13: 469–477.

9 Salmen M, Ewy GA, Sasson C. Use of cardiocerebral resuscitation or AHA/ERC 2005 Guidelines is associated with improved survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. BMJ Open. 2012 Oct 3; 2 (5). pii: e001273. doi: 10.1136/bmjopen-2012-001273. Print 2012.

分析：這一段話是校長為學(xué)生們寫評(píng)語的一個(gè)比喻，將其評(píng)語比喻為墓志銘般只可姑妄讀之，不可信以為真。原文這句話中“good”出現(xiàn)了五次，榮如德將其簡(jiǎn)單且統(tǒng)一地譯為“好”，而楊必翻譯出來的每一個(gè)詞不僅都含有“good”的意思，而且還與其后面的名詞做了中文含義上的對(duì)應(yīng)，即“虔誠的教徒，慈愛的父母，孝順的兒女，賢良的妻子，盡職的丈夫”。（p.35）這樣的翻譯使每一個(gè)名詞都富有了情感，使讀者感受到了譯文的美感與文學(xué)性，而這正是由于楊必的敏感細(xì)膩的女性特征所發(fā)揮出來的譯者主體性的完美體現(xiàn)。

10 Deasy C, Bray JE, Smith K, Wolfe R, Harriss LR, Bernard SA, et al. Cardiac arrest outcomes before and after the 2005 resuscitation guidelines implementation: evidence of improvement? Resuscitation 2011; 82: 984–988.

11 Bigham BL, Koprowicz K, Rea T, Dorian P, Aufderheide TP, Davis DP, et al. Cardiac arrest survival did not increase in the Resuscitation Outcomes Consortium after implementation of the 2005 AHA CPR and ECC guidelines. Resuscitation 2011; 82: 979–983.

12 Blewer AL, Leary M, Decker CS, Andersen JC, Fredericks AC, Bobrow BJ, et al. Cardiopulmonary resuscitation training of family members before hospital discharge using video selfinstruction: A feasibility trial. J Hosp Med 2011; 6: 428–432.

13 Blewer AL, Leary M, Esposito EC, Gonzalez M, Riegel B, Bobrow BJ, et al. Continuous chest compression cardiopulmonary resuscitation training promotes rescuer selfconfidence and increased secondary training: a hospital-based randomized controlled trial*. Crit Care Med 2012; 40: 787–792.

古典粉彩人物瓷畫，從形成開始就已經(jīng)是人物體裁陶瓷史上的高峰。康熙年間已經(jīng)出現(xiàn)最早的粉彩瓷，康熙時(shí)期的粉彩瓷最主要的體裁還是花鳥類的，一直到之后的雍正時(shí)期才真正出現(xiàn)了人物體裁的粉彩作品，雍正時(shí)期的粉彩作品已經(jīng)較之于康熙時(shí)期更加純熟。無論是人物刻畫之細(xì)膩、構(gòu)圖布局之舒朗、設(shè)色用筆之清麗都在歷史當(dāng)中處于巔峰狀態(tài)。而之后的乾隆時(shí)期，粉彩技法上得到進(jìn)一步提升。裝飾手法由于受到乾隆皇帝的審美影響，當(dāng)時(shí)的粉彩人物瓷畫富麗堂皇，盡顯奢華富貴之氣。雍正和乾隆時(shí)期的粉彩人物瓷畫是古典粉彩人物瓷畫的高峰時(shí)期，分別代表著兩種不一樣的繪畫風(fēng)格。

14 Einspruch EL, Lynch B, Aufderheide TP, Nichol G, Becker L. Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30-min video self-training: a controlled randomized study. Resuscitation 2007; 74: 476–486.

15 Isbye DL, Rasmussen LS, Lippert FK, Rudolph SF, Ringsted CV. Laypersons may learn basic life support in 24min using a personal resuscitation manikin. Resuscitation 2006; 69: 435–442.

16 Lynch B, Einspruch EL, Nichol G, Becker LB, Aufderheide TP, Idris A. Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation 2005; 67: 31–43.

17 Mayer V, Schulz CM, Kreuzer M, Wagner KJ, Schneider G, Kochs EF. Cardiopulmonary resuscitation performance during simulator-based trainings: a comparative retrospective analysis of adherence to 2005 and 2010 guidelines. Minerva Anestesiol 2013; 79: 264–273.

18 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.

全面預(yù)算管理需與企業(yè)績效評(píng)價(jià)體系相輔相成、相互促進(jìn)。在強(qiáng)化預(yù)算約束力的前提下，健全和完善房地產(chǎn)企業(yè)業(yè)績?cè)u(píng)價(jià)體系，并與全面預(yù)算管理有效融合。預(yù)算考核不僅要依據(jù)財(cái)務(wù)指標(biāo)，還要依據(jù)非財(cái)務(wù)指標(biāo)，同時(shí)定量評(píng)價(jià)和定性評(píng)價(jià)相結(jié)合，綜合評(píng)價(jià)與動(dòng)態(tài)評(píng)價(jià)相結(jié)合，從而建立起完善的預(yù)算考核機(jī)制。

19 Yang Z, Li H, Yu T, Chen C, Xu J, Chu Y, et al. Quality of chest compressions during compression-only CPR: a comparative analysis following the 2005 and 2010 American Heart Association guidelines. Am J Emerg Med 2014; 32: 50–54.

20 Rea TD, Stickney RE, Doherty A, Lank P. Performance of chest compressions by laypersons during the Public Access Def brillation Trial. Resuscitation 2010; 81: 293–296.

21 Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C, Sparks CW, et al. Incomplete chest wall decompression: a clinical evaluation of CPR performance by trained laypersons and an assessment of alternative manual chest compression-decompression techniques. Resuscitation 2006; 71: 341–351.

22 Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcherassisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation 2001; 104: 2513–2516.

23 Rea TD, Fahrenbruch C, Culley L, Donohoe RT, Hambly C, Innes J, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med 2010; 363: 423–433.

24 Merchant RM, Abella BS, Abotsi EJ, Smith TM, Long JA, Trudeau ME, et al. Cell phone cardiopulmonary resuscitation: audio instructions when needed by lay rescuers: a randomized, controlled trial. Ann Emerg Med 2010; 55: 538–543 e531.

Received March 20, 2015

Accepted after revision August 10, 2015

Benjamin S. Abella, Email: Benjamin.abella@uphs.upenn.edu

World J Emerg Med 2015;6(4):272–278

10.5847/wjem.j.1920–8642.2015.04.004