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One-Hour CPR Training

The American Heart Association and American Red Cross have successfully taught citizen/bystander CPR courses for more than 20 years. As a result, cardiac arrest victims treated in the prehospital setting have experienced an increased survival rate when trained bystanders come to their aid. 1-3

The shorter the period between cardiac arrest, CPR and defibrillation, the faster patients regain consciousness. 4,5 Thus, when well-trained citizens take the first step in resuscitation by initiating CPR and activating EMS, early defibrillation and ALS units have an improved chance of preserving the quality of a patients life.5 But many citizens hesitate when it comes to taking CPR. A 1983 Gallup poll revealed that time and inconvenience are key deterrents for potential CPR student. Traditional 4- or 8-hour courses are often perceived as too time consuming, and class locations often involve a 30-minute commute each way.

We have evaluated successful CPR courses and have designed an original field study. Our goal was to discover whether effective CPR techniques could be somehow reconfigured and taught in a shorter course. By using adult-education principles, through which students receive immediate visual feedback on their efforts, we developed a 1-hour, video enhanced teaching system. This system not only maintains the same level of quality content associated with longer courses, but also encourages student participation and allows instructors to teach more students with less stress.

The Study

Our study shows that and enhanced 1-hour CPR class produces equal or higher evaluation scores than those found in traditional 4- or 8-hour courses. Objective documentation generated by the same enhanced manikin used in traditional CPR training offers proof of the course's effectiveness.

One hundred students were divided into two groups: control and experimental. Each group was further divided into six individual classes of approximately eight students each; thus performance of the control and experimental groups was actually and average of the six subgroups' scores.

The individuals chosen to participate in the study were employees of the Los Angeles Times, who were selected by the newspaper's safety officer. They represented both sexes, were of random ages, and included various ethnic and educational backgrounds. The group mix was intended to reflect a cross section of the population at large.

Instruction

The control group was trained in CPR by instructors from a Los Angeles AHA-authorized CPR center. Members of this group were taught the accepted 4-hour AHA Heartsaver course (Module 1, 1987, BLS manual).

Each of the six control-group classes was led by a different instructor, each of whom, followed the course structure as outlined in the BLS instructors manual. Approximately 3 hours of verbal instruction were followed by a demonstration of manikin* use, student practice and data collection from each student's second run-through. Two students shared one manikin, and each received approximately 8 minutes of practice. The instructor watched the student, evaluated performance and provided verbal feedback. This usually took about 4 hours. The independent evaluator documented each student's results.

The experimental group was trained via a 43-minute video lecture that concisely covered the verbal portion of the one-rescuer AHA Heartsaver course. A Los Angels AHA Affiliate faculty member (a registered nurse) was the featured instructor in the videotape. This instructor monitored the tape and assisted students in manikin practice after they viewed the program.

As in the control group, students were paired, with each allotted approximately 8 minutes of mannequin practice. Data were similarly collected after the students' second run-throughs. The key difference in the course was that the students themselves watched the Skillmeter, thus receiving immediate, comprehensive feedback for each compression or ventilation performed.

Practice sessions were monitored. The total program time was approximately 1 hour.

Evaluation Criteria

This study utilized the acceptable CPR performance results established by the AHA's Emergency Cardiac Care (ECC) Committee, which are set at 90% accuracy in chest compressions and 92% in ventilations.

Testing for one-rescuer CPR, according to the AHA instructors manual (1987), must be uncoached and conducted in the presence of a CPR instructor. If the student fails, retesting should occur after remedial practice.

Testing includes:

1. Initial assessment,
2. Four cycles of compressions/ventilations,
3. Reassessment,
4. Resumption of CPR.

Within this framework, four CPR categories are evaluated: sequencing, timing, compressions, and ventilations.

To ensure credibility, we engaged a local law firm to administer and collect data. The firm's representative acted as the "independent evaluator," and objective data collector during class meetings.

Results

Overall, the experimental group averaged 85% compliance with the ECC standards, compared to 41% from the control group.

Sequencing

Six of the vital sequencing criteria recorded on the Skillmeter.

Differences between the experimental and control groups occurred as follows:

• Patient responsiveness was checked by only 12% of the control group, as compared with 96% of the experimental group.
• First and second pulse checks were done 8% and 0% of the time, respectively, in the control group, and 63% and 60%, respectively, in the experimental; group.

Chest Compressions

The differences between the two groups in the number and rate of compressions were minimal, but the percentage of correct compressions differed greatly. The experimental group performed at 88%,while the control group's correct compressions reached only 6%.

Chest-Compression Errors

"Too little" pressure was the only category in which both groups performed comparable.

For other compression errors, the experimental group had a maximum of three errors in 64 compressions, while the control group made up to 51 mistakes in 62 compressions.

Note; In a few of the control-group classes, instructors told to err by compressing too much rather than too little, which may have increased some students' aggressiveness.

Ventilations

Again, the experimental group performed at a higher level, with 86% correct, as compared to 44% in the control group.

Ventilation Errors

The control group gave approximately four ventilations out of 10 that were too hard or fast, resulting in stomach distention. This group also gave four of 10 ventilations with too much volume.

The experimental group had fewer than one of 10 ventilations with either of these mistakes.

Other Indicators The experimental group performed at the recommended rate of 15:2, while the control group performed at 14:2.

As for the total time taken to perform the recommended sequencing, the experimental group took an average of 122 seconds, while the control group averaged 104. The ECC recommends a maximum of 111 seconds.

The clinical significance of both of these results has never been discussed, and the difference noted here are most likely of no consequence.

Nonstatistical

When the data were analyzed, greater swings were apparent in the scores of the control group. For example, the percentage of correct ventialtions between two control-group classes differed by 42%, whereas the greatest swing among experimental-group classes was about 20%.

These results could indicate that video instruction is more consistent. Indeed, this conclusion is supported by various comments made by individual instructors in this study. One anecdote regarding compression depth nay have significantly affected some students' performance scores. When an approved and concise video presentation is accompanied by experienced instructor monitoring, it may be concluded that fewer of these variables will affect student training.

There was a time factor to consider with the experimental group. Even though the length of the video presentation remained the same, practice and test time caused the class to exceed 1 hour of more than six students attended.

On the other hand, the video presentation could be shortened even further, as introductory information on "prudent heart living" and "signs and symptoms" could be deleted, with little anticipated change in performance results. One may argue, however, that this preventive material is valuable.

Conclusion

This study illustrates that the traditional and effective skills of CPR can be taught more efficiently. In the 1-hour enhanced course, students interact directly with the CPR feedback screen that monitors their techniques. The course actually trains students in the use of the screen, allowing instructors to troubleshoot as students practice.

The course structure in the study resulted in higher scores for the experimental group. It appears the 1-hour enhanced course can produce equal or better skill development than that associated with the longer course.

References

1. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: Importance of rapid provision and implications for program planning. JAMA 241:1905-1907, 1979.
2. Copley DP, Mantle JA, Rogers WJ, et al. Improved outcomes for prehospital cardiopulmonary collapse with resuscitation by bystanders. Circulation 56:901-905, 1977.
3. Cummins RO, Eisenberg MS, Hallstrom AP, et al. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med 3:114-118, 1985.
4. Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 319:661-666, 1988.
5. Cummins RO, Ornato JP, Thies WH, et al. Improving survival from sudden cardiac arrest: The chain of survival concept. Circulation 83:1832-1847, 1991.

Author; Robert S. Ambrose, BS, Paramedic is a CPR instructor and 15-year veteran of Washington State EMS. Samuel J Stratton, MD, is the medical director of the Los Angeles County EMS Agency Paramedic Training Institute and an emergency physician at St. Mary's Medical Center in Long Beach, CA.