Allan Braslow

Randomized, controlled trial of video self-instruction versus traditional CPR training

STUDY OBJECTIVE We conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would yield comparable or better CPR performance than the current community standard, the American Heart Association Heartsaver course. METHODS Incoming freshman medical students were randomly assigned to VSI or the Heartsaver CPR course. Two to 6 months after training, we tested subjects to determine their ability to perform CPR in a simulated cardiac arrest setting. Blinded observers used explicit criteria to assess our primary outcome, CPR performance skill. In addition, we assessed secondary outcomes including sequential performance of individual skills, ventilation and chest compression characteristics, and written tests of CPR-related knowledge and attitudes. RESULTS VSI trainees displayed superior overall performance compared with traditional trainees. Twenty of 47 traditional trainees (43%) were judged not competent in their performance of CPR, compared with only 8 of 42 VSI trainees (19%; absolute difference, 24%; 95% confidence interval, 5% to 42%). CONCLUSION In a group of incoming freshman medical students, we found that a half-hour of VSI resulted in superior overall CPR performance compared with that in traditional trainees. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population.

A reliable and valid method for evaluating cardiopulmonary resuscitation training outcomes

In order to compare the quality of CPR performance after various training methods, training outcome assessment must provide meaningful data and do it in a way that is reliable. Few studies have provided details of their assessment procedures, and even fewer report on whether the measures to evaluate performance are reliable (yielding information consistently over multiple trials), or valid (measuring the outcome intended). Few studies have attempted to replicate assessment methods used by other authors. Conventional skill sheets have not been shown to assess compressions and ventilations reliably and validly. When using an instrumented manikin, skill checklists can be simplified by eliminating qualitative assessment of compressions and ventilations. Using a sample of 171 CPR trainees rated by trained evaluators, we provide details of agreement between two evaluators and use an established statistic (Cronbachs alpha) to assess the reliability of a 14-item simplified CPR checklist. The level of agreement between two raters was high (Pearson product-moment correlation = 0.87) as was the reliability estimate obtained by Cronbachs alpha (0.89). As criterion-related evidence of the validity of the CPR checklist to assess CPR performance, a correlation with a five-point subjective overall rating of CPR was estimated (Spearman correlation = 0.92). We urge standardized reporting of CPR training outcomes in order to achieve comparability across studies.

Are we training the right people yet?: A survey of participants in public cardiopulmonary resuscitation classes

It has long been argued that cardiopulmonary resuscitation (CPR) training should be targeted at those most likely to be on the scene when a cardiac arrest occurs. Since cardiac arrest occurs in the home about three-quarters of the time, the persons most likely to be on hand are family members. We surveyed 244 participants in public (i.e. not offered in a workplace) CPR classes to determine the make up of the population. In contrast to the family members of cardiac patients, who average 55 years of age, CPR class participants are young (mean 30.8 years). The majority (66.8%) of participants are in their twenties and thirties; only 6.6% are aged 50 or older. A minority (18.5%) indicate living with someone at high risk for a heart attack. In at least one respect, CPR class participants do resemble family members of cardiac patients, they are overwhelmingly (69.4%) female. Even in public classes, the majority (78.5%) of persons taking CPR are fulfilling a job requirement. Most (62.0%) have had prior CPR training; about half (49.2%) have had recent (i.e. within three years) training. Targeting of CPR training to the individuals most likely to be at the scene of a cardiac arrest has long been advocated, but the reality is that training does not reach the right people. More research is needed to determine how better to reach these persons.

Skill mastery in public CPR classes

Effectiveness of CPR performance on a manikin was evaluated immediately after training in public CPR classes by trained independent observers using validated measures and procedures. An instrumented manikin was used to assess critical skills thought to be related to survival following out-of-hospital cardiac arrest (compressions and ventilations), applying standards of the American Heart Association. The 226 subjects were enrolled in CPR classes offered to the public by the American Red Cross and the American Heart Association. Fifty percent of subjects performed 2% or fewer compressions correctly (the most common error being insufficient depth), and 50% performed 10% or fewer of ventilations correctly (the most common error being insufficient volume). Sixty-five percent failed to achieve a compression rate of 80 to 100/min. Forty-five percent of subjects failed to open the airway prior to a breathing check, 50% failed to adequately assess breathing, and 53% did not perform an adequate pulse check. Nearly half of all subjects made at least four errors in assessment and sequencing of skills. According to published criteria, trainee performance of CPR is poor. Failure in critical skills may contribute to poor survival rate following out-of-hospital cardiac arrest. CPR training programs must be developed with attention to learner outcomes.

A peer-training model for instruction of basic cardiac life support

This study evaluates a peer-training model for cardiopulmonary resuscitation (CPR) instruction for laypersons. Forty-one Norwegian factory employees were trained in CPR and given instructor training. These first trainees then trained 311 co-workers. These employees then trained 873 family members and associates at home. The reference group consists of employees in a Massachusetts commercial hotel trained in seven American Red Cross (ARC): Adult CPR classes. The Norwegian home trainees learned CPR using a cardboard training manikin and were trained by Norwegian factory employees who had learned CPR from co-workers. Trainees were evaluated using skill sheets and a Laerdal Skillmeter manikin. The performance of the Norwegians trained at home by peers did not differ from that of the ARC: Adult CPR trainees in six skills of the initial sequence of CPR. The home trainees outperformed the ARC: Adult CPR trainees in the proportion of compressions delivered correctly (P = 0.032) and ventilations delivered correctly (P = 0.015). Peer training may provide CPR instruction comparable to training in CPR classes at lower cost and with potential to reach new population segments.

Future directions for resuscitation research. III. External cardiopulmonary resuscitation advanced life support

This discussion about advanced cardiac life support (ACLS) reflects disappointment with the over 50% of out-of-hospital cardiopulmonary resuscitation (CPR) attempts that fail to achieve restoration of spontaneous circulation (ROSC). Hospital discharge rates are equally poor for in-hospital CPR attempts outside special care units. Early bystander CPR and early defibrillation (manual, semi-automatic or automatic) are the most effective methods for achieving ROSC from ventricular fibrillation (VF). Automated external defibrillation (AED), which is effective in the hands of first responders in the out-of-hospital setting, should also be used and evaluated in hospitals, inside and outside of special care units. The first countershock is most important. Biphasic waveforms seem to have advantages over monophasic ones. Tracheal intubation has obvious efficacy when the airway is threatened. Scientific documentation of specific types, doses, and timing of drug treatments (epinephrine, bicarbonate, lidocaine, bretylium) are weak. Clinical trials have failed so far to document anything statistically but a breakthrough effect. Interactions between catecholamines and buffers need further exploration. A major cause of unsuccessful attempts at ROSC is the underlying disease, which present ACLS guidelines do not consider adequately. Early thrombolysis and early coronary revascularization procedures should also be considered for selected victims of sudden cardiac death. Emergency cardiopulmonary bypass (CPB) could be a breakthrough measure, but cannot be initiated rapidly enough in the field due to technical limitations. Open-chest CPR by ambulance physicians deserves further trials. In searches for causes of VF, neurocardiology gives clues for new directions. Fibrillation and defibrillation thresholds are influenced by the peripheral sympathetic and parasympathetic nervous systems and impulses from the frontal cerebral cortex. CPR for cardiac arrest of the mother in advanced pregnancy requires modifications and outcome data. Until more recognizable critical factors for ROSC are identified, titrated sequencing of ACLS measures, based on physiologic rationale and sound judgement, rather than rigid standards, gives the best chance for achieving survival with good cerebral function.