The Journal of Emergency Medicine, Vol. 46, No. 5, pp.

643–649, 2014
Copyright Ó 2014 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2013.08.085

Selected Topics:
Prehospital Care

THE MOST EFFECTIVE RESCUER’S POSITION FOR CARDIOPULMONARY

RESUSCITATION PROVIDED TO PATIENTS ON BEDS: A RANDOMIZED,
CONTROLLED, CROSSOVER MANNEQUIN STUDY

Chong Kun Hong, MD,*†1 Sang O Park, MD,‡1 Han Ho Jeong, PHD,§ Jung Hyun Kim, PHD,§ Na Kyoung Lee, RN,*
Kyoung Yul Lee, PHD,k Younghwan Lee, MD,{ Jun Ho Lee, MD,* and Seong Youn Hwang, MD*
*Department of Emergency Medicine, Sungkyunkwan University School of Medicine, Samsung Changwon Hospital, Changwon, Republic of
Korea, †Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Sungnam, Republic of Korea,
‡Department of Emergency Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea,
§Department of Emergency Medical Technology, Masan University, Changwon, Republic of Korea, kDepartment of Physical Education,
Kyungnam University, Changwon, Republic of Korea, and {Department of Emergency Medicine, Hallym Sacred Heart Hospital, School of
Medicine, Hallym University, Anyang, Republic of Korea
Reprint Address: Seong Youn Hwang, MD, Department of Emergency Medicine, Sungkyunkwan University School of Medicine, Samsung
Changwon Hospital, Changwon 630-522, Republic of Korea

, Abstract—Background: The effectiveness of chest com-
pressions for cardiopulmonary resuscitation (CPR) is affec-
ted by the rescuer’s position with respect to the patient. In
hospitals, chest compressions are typically performed while
standing beside the patient, who is placed on a bed. Study
Objectives: To compare the effectiveness of chest compres-
sions, performed on a bed during 2 min of CPR, among
three different rescuer positions: standing, on a footstool,
or kneeling on the bed. Methods: We performed a crossover
randomized simulation trial. Participants were recruited
from among students in the Department of Paramedics
from July to August 2011. Thirty-eight participants were
enrolled, and they performed chest compressions on a
mannequin for 2 min in each of the three different positions,
with a 1-week interval between each position. Results: The
number of adequate compressions (depth > 50 mm) and
the mean compression depth were significantly greater in
the kneeling and footstool positions than in the standing po-
sition, but there was no significant difference between the
kneeling and footstool positions. There were no significant
differences in the compression rate, the percentage of
1
Chong Kun Hong and Sang O Park are the first authors, who
contributed equally to the study.
correctly released compressions, and the percentage of com-
pressions performed using the correct hand position among
the three rescuer positions. Conclusion: The mean compres-
sion depth and the number of adequate compressions were
greater for both the kneeling and footstool positions than
for the standing position during 2 min of CPR. We recom-
mend kneeling on a bed or standing on a footstool as the
rescuer positions during hospital CPR on a bed. Ó 2014
Elsevier Inc.
, Keywords—cardiopulmonary resuscitation; heart mas-
sage; beds; position; fatigue
INTRODUCTION
Effective chest compressions are essential for providing
blood flow during cardiopulmonary resuscitation
(CPR). For this reason, the 2010 guidelines of the Amer-
ican Heart Association (AHA) for CPR and emergency
cardiovascular care emphasize the ‘‘push hard and push
fast’’ technique, which requires compressions of at least
5 cm in depth at a rate of at least 100 compressions per
minute (1). During CPR, it is common for the quality of

RECEIVED: 14 November 2012; FINAL SUBMISSION RECEIVED: 10 June 2013;

ACCEPTED: 16 August 2013

643
644
chest compressions to decline over time due to rescuer fa-
tigue (2). Onset of rescuer fatigue can vary by rescuer
characteristics such as gender, age, and body mass index
(3,4). However, nonrescuer factors can also significantly
influence onset of rescuer fatigue. Difference of CPR
method (30:2 CPR vs. compression-only CPR) or rescuer
position at the site of arrest can affect the level of rescuer
fatigue and the quality of chest compressions (3,5–7).
Cardiac arrest patients in out-of-hospital situations
almost always undergo CPR while lying on a floor, but
in the case of in-hospital cardiac arrest (IHCA), chest
compressions are typically performed with the patient
lying on a bed (1). However, the depth of chest compres-
sions when performed on a bed has been found to be
significantly shallower than that in CPR performed on
the floor (6,7). Even though the standing position is
the fundamental position for CPR in cases of IHCA,
footstools and kneeling positions are also available in
hospital settings. Numerous reports have highlighted
the inefficiency of the standing position compared to
the kneeling or footstool position (8–10). However, in
previous reports, rescuers performed CPR according to
the 2005 AHA guidelines, which recommended a depth
of 38–50 mm. The guidance for chest compression
depth changed in the 2010 CPR guidelines, and it is not
clear which position is most effective for maximizing
chest compression force for cardiac arrest patients who
are placed on a bed in the IHCA setting under the 2010
CPR guidelines.
We performed a randomized, controlled, crossover
trial to determine the ideal rescuer position when the pa-
tient is lying on a bed, according to the 2010 AHA CPR
guidelines. We tested the hypothesis that there are differ-
ences in the total number of adequate chest compressions
completed during 2 minutes of CPR in 3 different posi-
tions, and also precisely evaluated any time-dependent
deterioration in compression depth among the three posi-
tions during 2 min of uninterrupted compressions.
MATERIALS AND METHODS
We conducted a randomized, controlled, crossover study
to compare the performance of three different rescuer po-
sitions: standing beside the bed, standing on a footstool,
and kneeling on the bed. This study was approved by
the Institutional Review Board (IRB) at our hospital.
Written informed consent was obtained from each partic-
ipant, and this study conformed to the principles outlined
in the Declaration of Helsinki (IRB No. 2011-SCMC-
067-01).
As the number of adequate chest compressions per-
formed was the primary end point of the study, it was
problematic to determine the minimum number of partic-
ipants required to test our hypothesis prior to study initi-
C. K. Hong et al.
ation. Therefore, before participants were recruited, we
conducted a pilot test with 10 students to calculate the
sample size required. These students were excluded
from participating in the subsequent study. We hypothe-
sized that there is a difference in the total number of
adequate chest compressions performed during 2 min of
CPR in the three positions; a difference was defined as
a difference > 10 adequate chest compressions. In the pi-
lot study, the standard deviation of the differences in the
adequate number of compressions among the three posi-
tions was 53.76. With an a level of 0.05 and a power of
80%, a sample size of 38 participants was determined
to be sufficient for evaluating the hypothesis. Given an
anticipated dropout rate of 10%, we enrolled 42 partici-
pants on a first-come, first-served basis. Participants
were recruited through announcements at the Department
of Paramedics and Nursing at Masan University, Repub-
lic of Korea from July 15 to August 30, 2011. Eligible
participants were either nursing or paramedic students
who were Basic Life Support providers certified by the
Korean Association of CPR within the past 2 years. Those
who had a previous cardiac or respiratory disease and
were unable to perform chest compressions for 2 min
were excluded.
After being given a description of the study methods,
the participants were allowed to practice chest compres-
sions on a mannequin (Resusci AnneÒ SkillReporterÔ;
Laerdal Medical Corporation, Stavanger, Norway) in
each of the three different positions. While performing
chest compressions, the participants received feedback
via a laptop running the Laerdal PC Skill Reporting Sys-
tem software (Laerdal Medical Corporation) regarding
the depth of the compressions and the positioning and
releasing of their hands. After the practice session, the
procedure was performed three times, once for each test
position, with 1-week intervals between each position
to minimize any carry-over effect. We used shuffling
cards to randomize the order of the three positions. To
establish the order that the three positions were tested
in for each participant, the six different possible test se-
quences were marked on the backs of cards. On the
back of each card was a description of the order, desig-
nated using letters from A to F, with each letter represent-
ing one of the three possible test positions. At the first
session after the practice session, participants pulled their
card from an envelope. Participants could see the symbols
(A to F), whereas the researcher could only see the
matched code representing the sequences. Because the
participants were blinded to the sequence they were as-
signed, for every session except for the last, the partici-
pants were unaware of their chest compression position
until the sequence began. The participants performed un-
interrupted chest compressions on the same manne-
quin with an advanced airway inserted for 2 min, thus
Rescuer’s Position for CPR on Beds
mimicking an IHCA situation. The mannequin was
placed on an 80-cm-high hospital bed that did not have
a foam-filled mattress. The mannequin was connected
to a laptop computer running the Laerdal PC Skill Report-
ing System software to record the quality of the chest
compressions. For the standing position, participants
stood beside the bed to compress the mannequin. For
the footstool position, participants compressed the
mannequin while standing on a 20-cm-high footstool.
For the kneeling position, participants kneeled on the
bed beside the mannequin. The study was conducted in
an isolated room without a clock, and to minimize bias,
the participants were not allowed to watch the laptop
screen. During and after the chest compressions, the
researcher did not give any advice to the participants
about their compression depth or rate, or the positioning
of their hands. Chest compressions were performed by
the participants according to the current 2010 AHA
CPR guidelines (a rate of > 100 compressions per minute
at a depth of > 5 cm) (1). At the 2-min mark, the
researcher said, ‘‘Stop the compressions, right now.’’ Af-
ter each session, participants recorded their levels of fa-
tigue subjectively on a survey with a numerical rating
scale from 0 to 10.
The primary outcome was the total number of adequate
chest compressions performed during the 2-min period.
Adequate chest compressions were defined as compres-
sions deeper than 5 cm. Because an upper compression
rate limit is not included in the AHA guidelines, the num-
ber of compressions performed during the 2 min differed
among participants, that is, ranging from 200 at a rate of
100/min to 240 at 120/min. The number of adequate chest
compressions is considered an important determinant of
the return of spontaneous circulation and neurological
survival (11,12). Hence, we used the total number of
adequate compressions performed during the 2 min as
the primary outcome, rather than the proportion of
adequate compressions. The secondary outcomes were
1) total number of chest compressions, 2) mean
compression depth, 3) compression rate (compressions
per min), 4) percentage of compressions at the correct
compression rate (more than 100 compressions per
min), 5) percentage of correctly released compressions,
6) percentage of compressions performed using the
correct hand position (defined as hand position on the
lower half of the sternum), and 7) the subjective severity
of fatigue (1). For evaluation of the time-dependent dete-
rioration of compression depth for the three positions, the
values of the mean compression depths were separated
into 20 consecutive 6-s sectors. The data were calculated
manually from the Laerdal PC Skill Reporting software
by two different medical abstractors who were blinded
to the study hypotheses. The medical abstractors
measured the depth of each chest compression in milli-
645
meters and recorded the data in a Microsoft Office Excel
spreadsheet. If there were any discrepancies between the
abstractors’ reports, the first author intervened. Incom-
plete release and poor positioning were also recorded. A
compression was defined as a compression depth of at
least 10 mm. Other chest compression data were obtained
from the result sheets of the Laerdal PC Skill Reporting
System software.
Statistical analyses were performed by a statistician
who did not participate in the trial and was blinded to
the sequence order and CPR position (presented as a
numbered code). The number of adequate chest compres-
sions, compression rate, total number of compressions,
and the mean compression depth in each position were
analyzed using repeated-measures data analysis with a
mixed model. Mean compression depth was also
analyzed using repeated-measures analysis of variance
to compare the deterioration in compression depth among
the three positions. The percentage of compressions per-
formed at the correct compression rate, the percentage of
correctly released compressions, and the percentage of
compressions performed using the correct hand position
were analyzed using the c2 test. The subjective severity
of fatigue was analyzed using the Kruskal-Wallis test,
and a post hoc analysis with Bonferroni correction was
conducted. We considered a p-value of < 0.05 to be sig-
nificant. Statistical analysis was performed using PASW
18.0 (SPSS Inc., Chicago, IL).
RESULTS
A total of 42 participants were enrolled and randomized
into the six possible sequence scenarios for the three
test positions. The mean age of the study participants
was 23.8 6 1.6 years, and there were 23 men (54.8%).
The mean body height and weight were 171.1 6
8.4 cm and 63.6 6 10.7 kg, respectively (Table 1). Of
the 42 participants enrolled, 4 who did not attend one
of the subsequent sessions were excluded from the anal-
ysis, leaving 38 participants available for analysis
(Figure 1). There were significant differences in baseline
characteristics between the enrolled group and the
dropout group (Table 1).
The total number of adequate compressions was
significantly greater for the kneeling and footstool posi-
tions than for the standing position, but there was no sig-
nificant difference for this measure between the kneeling
and footstool positions. Mean compression depth was
deeper for the kneeling and footstool positions than for
the standing position, but again there was no significant
difference between the kneeling and footstool positions
(Table 2).
However, there were no significant differences in
compression rate and the percentage of compressions
646
Table 1. Demographics of Study Participants
Overall n = 42
Male sex, n (%) 23 (54.8)
Age, mean 6 SD (years) 23.8 6 1.6
Weight, mean 6 SD (kg) 63.6 6 10.7
Height, mean 6 SD (cm) 171.1 6 8.4
Body mass index, mean 6 SD (kg/m2) 21.6 6 2.6
SD = standard deviation.
performed at the correct compression rate among the
three positions. Furthermore, there were no significant
differences in the percentage of correctly released com-
pressions or the percentage of compressions performed
using the correct hand position among the three positions.
The severity of fatigue was lower for the footstool and
kneeling positions than for the standing position, but
there were no significant differences between the foot-
stool and kneeling positions for this measure (Table 2).
There were no significant differences in time-dependent
changes over the 2-min period among the three positions;
however, during the first minute of compressions, com-
pressions performed in the kneeling and footstool positions
were more often of adequate depth than those performed in
the standing position (Figure 2).
DISCUSSION
To the best of our knowledge, this study was the first to
compare three rescuer positions on a bed for in-hospital
CPR using the 2010 AHA guidelines. This study also
achieved precise evaluation of CPR effectiveness by
utilizing a time-dependent analysis (6-s intervals) for
Figure 1. Flow diagram of the study.
C. K. Hong et al.
Participants n = 38 Dropouts n = 4 p-Value
19 (50) 4 (100) 0.079
23.6 6 1.6 25.2 6 0.5 0.068
63.3 6 10.9 66.9 6 8.9 0.522
170.4 6 8.5 177.3 6 4.2 0.120
21.6 6 2.6 21.2 6 1.8 0.733
compression depth using three in-hospital rescuer posi-
tions during 2 min of uninterrupted compressions. This
mannequin study demonstrated that the total adequate
number of compressions performed during 2 min was
higher when compressions were performed in either the
kneeling or the footstool positions than in the standing
position.
High-quality CPR is an important component in the
chain of survival, and is an important determinant of
the return of spontaneous circulation (1). It is affected
by the position of the rescuer with respect to the patient.
Unlike out-of-hospital cardiac arrest situations, in-
hospital chest compressions are typically performed
with the patient placed on a bed. The depth of chest com-
pressions is significantly shallower when performed on a
bed than when the patient is on the floor (7). Kneeling or
standing on a footstool has the potential advantage that
the CPR provider can apply greater compression force
by positioning his or her shoulders directly above the pa-
tient’s chest. Some previous reports have found that
rescuer position did not affect the quality of the chest
compressions (7,13,14). However, Foo et al. reported
that the kneeling position yielded better performance
than the standing position after 5 min of compressions
(8). Rescuer fatigue typically results in a decreased qual-
ity of compressions, and therefore, in the hospital setting,
rescuers switch roles every 2 min to prevent fatigue (1). In
our study, we found an effect of rescuer fatigue within the
2-min window recommended by the AHA guidelines.
Cho et al. also reported that the maximal mean compres-
sion depth was achieved when the bed height was at the
level of the rescuer’s knees (9).
The number of compressions and the compression rate
were not significantly different among the three positions.
This finding suggests that the position affects only the
compression depth. Hightower et al. demonstrated that
although the compression rate was maintained over
time, chest compression quality decreased significantly
(2). Despite time-dependent deterioration, the depth of
the compressions did not differ among the three posi-
tions. However, during the first minute of compressions,
compressions performed in the kneeling and footstool po-
sitions were more often of adequate depth than those per-
formed in the standing position. Participants in all three
positions achieved depths of > 38 mm throughout the
Rescuer’s Position for CPR on Beds 647

Kneeling vs. Footstool

1.000

0.542

0.323
Standing vs. Footstool
Post Hoc Analysis

< 0.001†

< 0.001†

0.004§
Standing vs. Kneeling

Figure 2. Graph of the time-dependent analysis of mean

compression depth for the three different positions (per 6
0.003†

< 0.001†

< 0.001§

s). The upper horizontal dotted line (.) located at 50 mm in

the graph of ‘‘mean compression depth’’ indicates the mini-
mum adequate compression depth according to the 2010
guidelines. The lower horizontal dashed line (—) located at
38 mm in the graph of ‘‘mean compression depth’’ indicates
the minimum adequate compression depth according to
the 2005 guidelines.
< 0.001‡
< 0.001*

< 0.001*
p-Value

0.489
0.185

0.696

0.196
0.244
Table 2. Comparisons of the Number of Adequate Compressions among the Three Positions

2 min. Participants in this study were educated and

* p-Value with statistical significance after repeated measures data analysis with a mixed model.

trained to perform chest compressions with a mannequin,

which may have influenced the results. However, the re-
144.6 6 98.3
243.6 6 36.0
121.8 6 18.0

§ p-Value with statistical significance after post hoc analysis using Bonferroni correction.
49.0 6 8.0

5.1 6 2.2
Footstool

sults indicate that the two alternative positions (footstool

99.3
89.5

86.3

and kneeling) help the rescuer to perform high-quality

chest compressions as compared to the standing position.
Adequate chest recoil is another important component
for chest compressions (1). In our study, the percentage of
138.6 6 103.9
238.6 6 32.4
119.3 6 16.2

49.4 6 8.0

4.5 6 1.8
Kneeling

compressions with adequate chest recoil was not signifi-

97.5
94.7

84.3

cantly different among the three positions. Lewinsohn

‡ p-Value with statistical significance after the Kruskal-Wallis test.

et al. used intrathoracic pressure, which reflects chest

recoil, as a marker for compression quality, and reported
that the most effective position was that in which the pa-
† p-Value with statistical significance between groups.
97.0 6 98.0
230.4 6 24.4
115.2 6 12.2

43.9 6 11.5

7.8 6 2.5

tient’s chest was in line with the rescuer’s mid-thigh (10).

Standing

99.8
92.1

80.8

We believe his to be a valid conclusion, despite our

Data are given as mean 6 SD or percentage.

study’s inability to demonstrate a statistical difference

among the three positions examined. The severity of fa-
tigue was lower when using the kneeling and footstool
Compression rate (compressions per

Correctly released compressions (%)

Correct compression rate (> 100 per

positions than when using the standing position. Foo

Number of adequate compressions

et al. also reported that the severity of back pain after

Mean compression depth (mm)
Total number of compressions

1 day of chest compressions was lower after CPR was

Correct hand position (%)

performed in the kneeling and footstool positions (8).

Limitations
Severity of fatigue

This study has several limitations. First, the elastic com-

min) (%)
minute)

pressions of the mannequin’s chest wall may not accu-

rately mimic chest wall compressions in humans. This
has the potential to affect the external validity of the
648
study. However, our mannequin served as a standardized
model for all study participants, and the crossover design
diminished the interparticipant variance. Therefore, the
comparisons should be valid. Secondly, our primary
outcome was the number of effective chest compressions;
the relationship of this outcome to clinical measures such
as coronary perfusion pressure or patient outcome was
not analyzed. Thirdly, bed height was fixed at 80 cm,
which was based on the apparatus used at our hospital.
However, some hospital beds are adjustable in height,
and adjusting the height of the bed could be helpful for
maximizing compression force. If we had adjusted the
height of the bed for each participant, the results may
have been somewhat different. However, adjusting the
height of the bed is not a simple task in a real-life CPR
situation. Because rescuers change their compressor
role every 2 min to prevent fatigue, the bed height would
have to be adjusted after each rescuer rotation, leading to
a potentially chaotic situation. We doubt that adjusting
bed height is practical when rescuers rotate in the
compressor role every 2 min.
CONCLUSION
The total number of adequate compressions was higher
for both the kneeling and footstool positions than the
standing position during 2 min of CPR. We recommend
the kneeling and footstool positions as the rescuer posi-
tions of choice for the ‘‘push hard’’ technique used for
IHCA situations.
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port: 2010 American Heart Association Guidelines for Cardiopul-
C. K. Hong et al.
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Circulation 2010;122:S685–705.
2. Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in
quality of closed-chest compressions over time. Ann Emerg Med
1995;26:300–3.
3. Hong DY, Park SO, Lee KR, Baek KJ, Shin DH. A different
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considers rescuer factors: a randomised cross-over simulation
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Rescuer’s Position for CPR on Beds 649

ARTICLE SUMMARY
1. Why is this topic important?
Cardiac arrest patients in out-of-hospital situations
almost always undergo cardiopulmonary resuscitation
(CPR) while lying on a floor. Cardiac arrest patients in
out-of-hospital situations almost always undergo cardio-
pulmonary resuscitation (CPR) while lying on a floor,
but in cases of in-hospital cardiac arrest, chest compres-
sions are typically performed with the patient lying on a
bed. The quality of chest compressions is affected by
the rescuer position with respect to the patient.
2. What does this study attempt to show?
This study explores the effect of rescuer position on the
quality of chest compressions provided for cardiac arrest
patients who are on a bed. This study explores the effect of
rescuer position on the quality of chest compressions pro-
vided for cardiac arrest patients who are on a bed.
3. What are the key findings?
A greater number of adequate chest compressions was
achieved during 2 min of CPR when the rescuer was using
a footstool or when in a kneeling position than when the
rescuer was standing. A greater number of adequate chest
compressions was achieved during 2 min of CPR when
the rescuer was using a footstool or when in a kneeling po-
sition than when the rescuer was standing.
4. How is patient care impacted?
We recommend the kneeling or footstool position as the
rescuer position of choice for the ‘‘push hard’’ technique
for in-hospital cardiac arrest situations. We recommend
the kneeling or footstool position as the rescuer position
of choice for the ‘‘push hard’’ technique for in-hospital
cardiac arrest situations.