Predictors of cardiopulmonary resuscitation and automated external defibrillator skill retention

Evidence for recency of practice standards for regulated health practitioners in Australia: a systematic review

BACKGROUND

Health practitioner regulators throughout the world use registration standards to define the requirements health practitioners need to meet for registration. These standards commonly include recency of practice (ROP) standards designed to ensure that registrants have sufficient recent practice in the scope in which they intend to work to practise safely. As the ROP registration standards for most National Boards are currently under review, it is timely that an appraisal of current evidence be carried out.

METHODS

A systematic review was conducted using databases (including MEDLINE, EMBASE, PsycInfo, and CINAHL), search engines, and a review of grey literature published between 2015 and April 2022. Publications included in the review were assessed against the relevant CASP checklist for quantitative studies and the Joanna Briggs Institute checklist for analytical cross-sectional studies.

RESULTS

The search yielded 65 abstracts of which 12 full-text articles met the inclusion criteria. Factors that appear to influence skills retention include the length of time away from practice, level of previous professional experience and age, as well as the complexity of the intervention. The review was unable to find a clear consensus on the period of elapsed time after which a competency assessment should be completed.

CONCLUSIONS

Factors that need to be taken into consideration in developing ROP standards include length of time away from practice, previous experience, age and the complexity of the intervention, however, there is a need for further research in this area.

Public knowledge of cardiovascular disease and response to acute cardiac events in three municipalities in Brazil

Objective

To conduct a landscape assessment of public knowledge of cardiovascular disease risk factors and acute myocardial infarction symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) awareness and training in three underserved communities in Brazil.

Methods

A cross-sectional, population-based survey of non-institutionalised adults age 30 or greater was conducted in three municipalities in Eastern Brazil. Data were analysed as survey-weighted percentages of the sampled populations.

Results

3035 surveys were completed. Overall, one-third of respondents was unable to identify at least one cardiovascular disease risk factor and 25% unable to identify at least one myocardial infarction symptom. A minority of respondents had received training in CPR or were able to identify an AED. Low levels of education and low socioeconomic status were consistent predictors of lower knowledge levels of cardiovascular disease risk factors, acute coronary syndrome symptoms and CPR and AED use.

Conclusions

In three municipalities in Eastern Brazil, overall public knowledge of cardiovascular disease risk factors and symptoms, as well as knowledge of appropriate CPR and AED use was low. Our findings indicate the need for interventions to improve public knowledge and response to acute cardiovascular events in Brazil as a first step towards improving health outcomes in this population. Significant heterogeneity in knowledge seen across sites and socioeconomic strata indicates a need to appropriately target such interventions.

Initial neonatal resuscitation: skill retention after the implementation of the novel 24/7 HybridLab® learning system

BACKGROUND

Ensuring long-term retention of the acquired practical skills is one of the major aims of a medical school. This depends on the application of training techniques and their combinations. In order to standardize the teaching process, to acquire and maintain a broad array of technical, professional, and interpersonal skills and competencies, and to improve the retention of practical skills, we developed a new training technique - the HybridLab^® learning method. It consists of an e-learning platform, hands-on simulation, carefully elaborated learning algorithms (DRAKON), peer-to-peer teaching, and assessment and feedback by peers, and later - by a remote instructor. Summary of the work: The subjects of the study were fifth-year students of the Lithuanian University of Health Sciences Medical Academy who during 2014-2015 were studying the obstetrics and gynecology module in the neonatology cycle. We analyzed the retention of practical skills in the initial neonatal resuscitation among students who were training with the use of our developed HybridLab^® technique at 6 and 12 months after the completion of the cycle.

SUMMARY OF RESULTS

After 6 and 12 months, mean changes in the subjects' evaluation scores (percentage drop-off between the first and the second total score) dropped by, respectively, 31.8% (SD: 27.5) and 7.7% (SD: 25.6), and did not differ statistically significantly (p = .2). In the group of subjects who were not given a possibility to remember the skills and the course of initial neonatal resuscitation, the mean change between the first and the second total evaluation scores was 42.5% (SD: 26.7). In students who were given such possibility, the mean change between the first and the second total evaluation scores was significantly smaller -12.7% (SD: 13.8) (p < .001). Changes in the evaluation scores of individual skills (first steps, mouth-to-mouth ventilation, and chest compressions) between the first and the second evaluation also differed statistically significantly and were smaller in the group of students who were given a possibility to remember their skills (p < .001).

DISCUSSION

The HybridLab^® learning method is a novel technique, and thus more studies are required to evaluate the significance of the HybridLab^® technique for long-time retention of practical skills.

CONCLUSION

As a result of the application of the HybridLab^® training technique, practical skill retention among medical students after 6 and 12 months dropped by only about 13%. A recall system significantly improved practical skill retention.

Effectiveness of feedback with a smartwatch for high-quality chest compressions during adult cardiac arrest: A randomized controlled simulation study

Previous studies have demonstrated the potential for using smartwatches with a built-in accelerometer as feedback devices for high-quality chest compression during cardiopulmonary resuscitation. However, to the best of our knowledge, no previous study has reported the effects of this feedback on chest compressions in action. A randomized, parallel controlled study of 40 senior medical students was conducted to examine the effect of chest compression feedback via a smartwatch during cardiopulmonary resuscitation of manikins. A feedback application was developed for the smartwatch, in which visual feedback was provided for chest compression depth and rate. Vibrations from smartwatch were used to indicate the chest compression rate. The participants were randomly allocated to the intervention and control groups, and they performed chest compressions on manikins for 2 min continuously with or without feedback, respectively. The proportion of accurate chest compression depth (≥5 cm and ≤6 cm) was assessed as the primary outcome, and the chest compression depth, chest compression rate, and the proportion of complete chest decompression (≤1 cm of residual leaning) were recorded as secondary outcomes. The proportion of accurate chest compression depth in the intervention group was significantly higher than that in the control group (64.6±7.8% versus 43.1±28.3%; p = 0.02). The mean compression depth and rate and the proportion of complete chest decompressions did not differ significantly between the two groups (all p>0.05). Cardiopulmonary resuscitation-related feedback via a smartwatch could provide assistance with respect to the ideal range of chest compression depth, and this can easily be applied to patients with out-of-hospital arrest by rescuers who wear smartwatches.

Magical manoeuvre: a 5-s instructor's intervention helps lightweight female rescuers achieve the required chest compression depth

Background

Adequate chest compression (CC) depth is crucial for resuscitation outcomes. Lightweight rescuers, particularly women, are often unable to achieve the required 5–6 cm CC depth. This nonrandomized cohort study investigated new strategies to improve CC performance.

Objective

To evaluate the effects of a 5-s instructor’s intervention on the depth of CCs performed by female rescuers during standard video self-instruction basic life support training.

Methods

Data were prospectively collected from January 2011 to January 2012 from 336 female medical and pharmacy students undergoing cardiopulmonary resuscitation (CPR) training at the Lithuanian University of Health Sciences. During the training process, the instructors performed a simple 5-s intervention (Andrew’s manoeuvre) with all of the rescuers in the study group. The instructor pushed 10 times on the shoulders of each trainee while she performed CCs to achieve the maximal required compression depth. Immediately after training, the participants were asked to perform a 6-min basic life support test on a manikin that was connected to a PC with Skill Reporter System software; the quality of the participants’ CPR skills was then evaluated.

Results

The CC depth in the study group increased by 6.4 mm (P<0.001) compared with the control group (52.9 vs. 46.6 mm). A regression analysis showed that Andrew’s manoeuvre increased the depth of the CCs among women by 14.87×(1−0.01×weight) mm.

Conclusion

A simple 5-s instructor’s intervention during the CPR training significantly improved the performance of the female rescuers and helped them achieve the CC depth required by 2010 resuscitation guidelines. Andrew’s manoeuvre is most effective among the women with the lowest body weight.

A tool to improve competence in the management of emergency patients by rural clinic health workers: a pilot assessment on the Thai-Myanmar border

Background

Shoklo Malaria Research Unit has been providing health care in remote clinics on the Thai-Myanmar border to refugee and migrant populations since 1986 and 1995, respectively. Clinics are staffed by local health workers with a variety of training and experience. The need for a tool to improve the competence of local health workers in basic emergency assessment and management was recognised by medical faculty after observing the case mix seen at the clinic and reviewing the teaching programme that had been delivered in the past year (Jan-13 to March-14).

Aims

To pilot the development and evaluation of a simple teaching tool to improve competence in the assessment and management of acutely unwell patients by local health workers that can be delivered onsite with minimal resources.

Methods

A structured approach to common emergencies presenting to rural clinics and utilizing equipment available in the clinics was developed. A prospective repeated-measures observed structured clinical examination (OSCE) assessment design was used to score participants in their competence to assess and manage a scenario based ‘emergency patient’ at baseline, immediately post-course, and 8 weeks after the delivery of the teaching course. The assessment was conducted at 3 clinic sites and staff participation was voluntary. Participants filled out questionnaires on their confidence with different scenario based emergency patients.

Results

All staff who underwent the baseline assessment failed to carry out the essential steps in initial emergency assessment and management of an unconscious patient scenario. Following delivery of the teaching session, all groups showed improved competence in both objective assessment and subjective confidence levels.

Conclusions

Structured and practical teaching and learning with minimal theory in this resource limited setting had a positive short-term effect on the competence of individual staff to carry out an initial assessment and manage an acutely unwell patient. Health-worker confidence likewise improved. Workplace assessments are needed to determine if this type of skills training impacts upon mortality or near miss mortality patients at the clinic.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-015-0041-x) contains supplementary material, which is available to authorized users.

Realistic expectations for public access defibrillation programs

PURPOSE OF REVIEW

Public access defibrillation programs have increased dramatically over the past 15 years. This review will focus on their effectiveness and operational characteristics and discuss the characteristics of successful programs, which can improve outcomes.

RECENT FINDINGS

Automated external defibrillators increase survival from cardiac arrest when used by a bystander. Recent studies show that the best outcomes are achieved when devices are placed in areas with a high frequency of cardiac arrest and there is ongoing supervision with emergency plans and cardiopulmonary resuscitation training. Programs are cost-effective under these circumstances, but become very inefficient when placed in areas of low risk. There are few adverse events related to the public access defibrillation programs and volunteers are not harmed. Unguided placement results in devices not being used and a decline in organizational structure of the program. As most cardiac arrests occur in the home, the impact on overall survival remains low.

SUMMARY

Automated external defibrillators are highly effective at reducing death from ventricular fibrillation and easy access in public areas is most effective. Placement must be prioritized based on public health impact and characteristics of the community.

Comparison of instructor-led automated external defibrillation training and three alternative DVD-based training methods

BACKGROUND

Self-directed BLS-training, using a personal training manikin with video has been shown to be as effective as instructor-led training. This has not previously been investigated for AED-training.

MATERIALS AND METHODS

This prospective, randomized study with a non-inferiority design compared traditional instructor-led training with three DVD-based AED-training methods (2.5min DVD without practice; 4.5min DVD with manikin practice; 9min DVD with manikin practice and scenario training). After DVD BLS-training, 396 participants were assigned to one of the four AED-training methods by randomization stratified for age. Participants were tested immediately after the training (post-test) and 2 months later (retention-test) using modified Cardiff criteria. The primary endpoint was the percentage of providers scoring 70% or higher on testing. The secondary endpoints were the mean scores and differences per item per age group.

RESULTS

Comparison non-inferiority could not be accepted for the post-test or retention-test. Relative risk (RR) and 95% confidence interval (CI) of passing for DVD without practice, with manikin practice and with manikin practice and scenario training compared to instructor-led training were 0.36 (0.25-0.53), 0.35 (0.24-0.51), 0.55 (0.38-0.79), respectively for the post-test, and 0.82 (0.68-0.97), 0.82 (0.68-0.97), and 0.84 (0.70-1.00), respectively for the retention-test. The performance of participants in all DVD-based training groups was significantly higher on the retention-test than on the post-test. Those receiving scenario training scored higher on the post-test compared to the other DVD-training groups (p<0.001).

CONCLUSIONS

DVD-based AED-training without scenario is not recommended. Scenario training is a useful addition, but instructor-facilitated training remains the best method.

[First-year medical residents' self-assessment of skill in basic life support and automatic external defibrillation]

OBJECTIVE

To determine first-year medical residents' perception of their competence in basic life support (BLS) and the use of automatic external defibrillation (AED).

MATERIAL AND METHODS

Course in BLS and AED accredited by the European Resuscitation Council with pre- and post-course self-assessment. The post-training questionnaire was administered immediately after the course and 8 months later. The data recorded covered (a) prior training and experience, (b) self-assessment of BLS and AED skills (9 items, scored 1-5), (c) the skill considered most difficult, and (d) satisfaction (13 items, scored 0-10).

RESULTS

The questionnaire was initially completed by 71 residents; 31 also responded 8 months later. Self-assessment scores improved immediately after the course (P = .0001). Scores had fallen 8 months later (P = .0001) but were still significantly higher than pre-course perception of skill (P = .017). More than 95% of the residents considered themselves to be competent after the course and more than 80% felt competent 8 months later, with the exception of skills in bag-mask ventilation (74.2%) and removal of a foreign body (61.3%). The skill considered most difficult was bag-mask ventilation. Mean (SD) BLS and AED scores for real-life situations were 8.48 (1.33) and 9.19 (0.94), respectively, after the course and 7.32 (1.4) and 7.29 (1.32) at 8 months (P = .0001). Overall satisfaction was high.

CONCLUSIONS

The residents perceived themselves as competent to give BLS and AED immediately after the course and 8 months after training, although fewer felt as competent at the second assessment. Bag-mask ventilation was considered the most difficult skill.

Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition

Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.

Training Retention of Level C Personal Protective Equipment Use by Emergency Medical Services Personnel

OBJECTIVES

To assess the six-month training retention for out-of-hospital providers donning and doffing Level C personal protective equipment (PPE).

METHODS

In this prospective observational study, 36 out-of-hospital providers enrolled in a paramedic program were trained in Level C (chemical-resistant coverall, butyl gloves, and boots and an air-purifying respirator) PPE use. A standardized training module and checklist of critical actions developed by a hazardous materials (hazmat) technician were used to evaluate donning and doffing. Students were trained until they were able to correctly don and doff the Level C PPE. An investigator used the checklist accompanying the training module to assess proficiency and remediate mistakes. Six months after initial training, the subjects were reassessed using the same investigator and checklist. Errors were designated as either critical (resulted in major self-contamination of the airway, such as early removal of the respirator) or noncritical (potentially resulted in minor self-contamination not involving the airway).

RESULTS

Only five subjects (14.3%) were able to don and doff PPE without committing a critical error. The most common critical errors were premature removal of the respirator (65.7%; n = 23) and actions allowing the contaminated suit to touch the body (54.3%; n = 19). The most common noncritical error was possible self-contamination due to the boots not being removed before exposing other body parts (37.1%; n = 13). Of the seven subjects (20%) with additional prior hazmat training, only two donned and doffed PPE without committing a critical error.

CONCLUSIONS

Retention of proper donning and doffing techniques in paramedic students is poor at six months after initial training. Even in subjects with previous hazmat, firefighter, and emergency medical services training, critical errors were common, suggesting that current training may be inadequate to prevent harmful exposures in emergency medical services personnel working at a hazmat or weapons of mass destruction incident.

The effect of time on CPR and automated external defibrillator skills in the Public Access Defibrillation Trial

BACKGROUND

The time to skill deterioration between primary training/retraining and further retraining in cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) for lay-persons is unclear. The Public Access Defibrillation (PAD) trial was a multi-center randomized controlled trial evaluating survival after CPR-only versus CPR+AED delivered by onsite non-medical volunteer responders in out-of-hospital cardiac arrest.

AIMS

This sub-study evaluated the relationship of time between primary training/retraining and further retraining on volunteer performance during pretest AED and CPR skill evaluation.

METHODS

Volunteers at 1260 facilities in 24 North American regions underwent training/retraining according to facility randomization, which included an initial session and a refresher session at approximately 6 months. Before the next retraining, a CPR and AED skill test was completed for 2729 volunteers. Primary outcome for the study was assessment of global competence of CPR or AED performance (adequate versus not adequate) using chi(2)-test for trends by time interval (3, 6, 9, and 12 months). Confirmatory (GEE) logistic regression analysis, adjusted for site and potential confounders was done.

RESULTS

The proportion of volunteers judged to be competent did not diminish by interval (3, 6, 9, and 12 months) for either CPR or AED skills. After adjusting for site and potential confounders, longer intervals to further retraining was associated with a slightly lower likelihood of performing adequate CPR but not with AED scores.

CONCLUSIONS

After primary training/retraining, the CPR skills of targeted lay responders deteriorate nominally but 80% remain competent up to 1 year. AED skills do not deteriorate significantly and 90% of volunteers remain competent up to 1 year.

An evaluation of objective feedback in basic life support (BLS) training

BACKGROUND

Studies show that acquisition and retention of BLS skills is poor, and this may contribute to low survival from cardiac arrest. Feedback from instructors during BLS training is often lacking. This study investigates the effects of continuous feedback from a manikin on chest compression and ventilation techniques during training compared to instructor feedback alone.

MATERIALS AND METHODS

A prospective randomised controlled trial. First-year healthcare students at the University of Birmingham were randomised to receive training in standard or feedback groups. The standard group were taught by an instructor using a conventional manikin. The feedback group used a 'Skillreporter' manikin, which provides continuous feedback on ventilation volume and chest compression depth and rate in addition to instructor feedback. Skill acquisition was tested immediately after training and 6 weeks later.

RESULTS

Ninety-eight participants were recruited (conventional n=49; Skillreporter n=49) and were tested after training. Sixty-six students returned (Skillreporter n=34; conventional n=32) for testing 6 weeks later. The Skillreporter group achieved better compression depth (39.96mm versus 36.71mm, P<0.05), and more correct compressions (58.0% versus 40.4%, P<0.05) at initial testing. The Skillreporter group also achieved more correct compressions at week 6 (43.1% versus 26.5%, P<0.05).

CONCLUSIONS

This study demonstrated that objective feedback during training improves the performance of BLS skills significantly when tested immediately after training and at re-testing 6 weeks later. However, CPR performance declined substantially over time in both groups.

Retention of skills in medical students following minimal theoretical instructions on semi and fully automated external defibrillators

AIM OF THE STUDY

There is consent that the use of automated external defibrillators (AED) by laypersons improves survival rates in case of cardiac arrest, but no evident consensus exists on the content and duration of training for this purpose. Acceptance of the implementation of Public Access Defibrillation programmes will depend on practical and target-oriented training concepts. The aim of this prospective randomised interventional study was to evaluate long-term effects of a specific, minimal training programme on using semiautomatic and fully automatic AEDs in simulated cardiac arrest.

MATERIALS AND METHODS

In a mock cardiac arrest scenario 59 medical students with no specific previous medical education were tested during their first semester at medical school. Students who passed any medical emergency training were excluded. The subjects were evaluated before and after attending specified instructions of 15 min duration and after a period of 6 months. Main end points were time to first shock, electrode-positioning and safety throughout the procedure.

RESULTS

Mean time to first shock without prior instructions was 77.7+/-17.05 s. After instruction there was a significant improvement to 56.5+/-9.5 s (p<or=0.01) and after 6 months this time had only slightly elongated (59.9+/-8.9 s; p<or=0.01). Initially, correct electrode placement was observed in 84.4%. No difference was found immediately and 6 months after instructions (93.2% and 98.3%). All individuals performed safely.

CONCLUSION

First year medical students with minimal instruction are able to use semiautomatic as well as fully automatic AED sufficiently fast and safe without prior training. A significant improvement in time to first shock can be detected up to 6 months after receiving non-specific instructions of 15 min duration.