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Cardiopulmonary resuscitation training: A narrative review comparing traditional educational programs with alternative, reduced-resource methods of CPR instruction for lay providers

a b s t r a c t

This narrative review explores current literature base detailing the effectiveness of alternative CPR instruction as compared to traditional CPR courses in the lay population. Assessment of alternative instructional methods found that video self-instruction and simplified CPR formats resulted in equivalent performance of CPR metrics and practical scenario assessment performance, as compared to traditional CPR instruction courses. While additional research is needed to further substantiate the value of self-directed learning, interactive digital, and abbreviated formats, these studies also suggested equivalence in CPR performance compared to traditional courses. In view of the importance of bystander CPR in OHCA outcomes, and the barriers presented by traditional CPR education courses, we recommend that public safety leaders and CPR educators strongly consider the introduction of these programs within their communities and classrooms.

(C) 2022

  1. Introduction

In the United States, an estimated 155,000 persons per year are treated by EMS for out-of-hospital cardiac arrest (OHCA), with survival rates cited between 8 and 10%. [1,2] Global assessment of OHCA inci- dence and survival varies considerably although European studies re- port similar incidence and survival. [1,3] To improve poor outcomes, researchers and clinicians consider each phase along the cardiac arrest “Chain of survival“, spanning from initial identification of an arrest to the conclusion of post-arrest care. Among these phases, prompt recog- nition of a cardiac arrest and the delivery of cardiopulmonary resuscita- tion (CPR) have been shown to have the greatest impact on survival. [4] In the setting of OHCA, which by definition occurs beyond the medical setting, the ability of bystanders to initiate the “chain of survival” and perform CPR until the arrival of emergency medical services (EMS) dra- matically increases survival and favorable neurological outcome. Given these considerations, improving patient outcomes requires widespread training to increase the number of bystanders capable of recognizing cardiac arrest and delivering CPR, long before EMS and other medical personnel have arrived at the scene of the event.

Currently, courses traditionally employed to educate the lay public are limited by their instructor-student ratio as well as the ability to engage di- verse populations of potential trainees. Employment, transportation, and

* Corresponding author.

E-mail address: [email protected] (W. Brady).

childcare each present barriers to completing a traditional three- or four- hour lay provider CPR course. [5] Delivering instruction to rural regions or very large institutions is further limited by the availability of certified in- structors. Numerous programs have been individually designed to address these training barriers via reductions in instructional time, simplification of content, or virtual delivery of instruction. Despite these innovations, de- ployment of novel programs remains limited due to the known efficacy and dominance of traditional courses. This review aims to explore the ca- pabilities and shortcomings of alternative CPR instruction and to determine their efficacy among the lay population when compared to traditional CPR instruction, the three- or four-hour lay provider courses.

  1. Methods
    1. Search strategy

PubMed, OVID Medline, and Web of Science Core Collection were utilized to search for articles of interest. Three major categories of search terms were developed based on the goals of this paper:

  1. (Cardiopulmonary Resuscitation)
  2. (Education) OR (Training)
  3. (Novel) OR (Alternative) OR (Non-Traditional) OR (Simplified) OR (Shortened) OR (Condensed) OR (Video) OR (Self Instruction)

Search criteria were entered as direct keyword searchers of titles and abstracts as well as mapped to appropriate MeSH headings or

https://doi.org/10.1016/j.ajem.2022.03.053

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D. Edinboro and W. Brady American Journal of Emergency Medicine 56 (2022) 196204

subheadings, where applicable. The final search was conducted utilizing all three search categories combined with the operator “AND”. Addi- tional restrictions limited results to articles available in English and pub- lication no earlier than 1966. All databases were searched and results collected on June 28, 2021.

    1. Selection criteria

Studies were selected for inclusion if they compared traditional CPR courses to an alternative. The authors defined a “traditional” CPR course as containing either:

  1. An in-person didactic session with skills verification (lasting around 1.75 h or greater; based on AHA course recommendation [6])

OR

  1. An online didactic session with in-person skills verification (lasting around 2-3 h and 1.75 h or greater, respectively; based on AHA course recommendation [6])

Any course which did not meet these criteria was considered to be an “alternative” method and evaluated in this review unless otherwise excluded. All courses, traditional or alternative, were required to deliver their core instructional content within 1 to 2 days of course start in order to ensure that courses evaluated in this analysis were generally comparable to the single day, self-contained format utilized by the ma- jority of traditional CPR courses.

Study populations containing health care workers or students were excluded as these individuals have vastly different motivations and re- sources for developing proficiency in CPR when compared to the lay population.

    1. Article analysis

1714 articles were retrieved during the initial search with 1215 re- maining after removal of duplicate items. Initial screening based on rel- evance of article titles returned 165 studies. Further screening of abstracts returned 29 papers which then underwent full text review. Full text review determined whether articles met full inclusion criteria for this review based on study population, design, and comparison courses utilized. 20 articles met all inclusion criteria after full text re- view and were included in the analysis.

Articles were read and data recorded regarding the study popula- tion, design, nature of the control and experimental instruction style, outcome measures, major findings and conclusions. Each article was sorted into one of five major categories of alternative instruction listed below:

  1. Video Self-Instruction (VSI)
  2. Abbreviated Traditional Instruction
  3. Interactive Digital Instruction
  4. Self-Directed Learning (SDL)
  5. Simplified CPR Instruction

Articles were reviewed by both authors and determined to be sup- portive (i.e., training modality was equal to or superior to the traditional course) or unsupportive (i.e., training modality was inferior to the tradi- tional course) of the alternative instruction category to which they were previously assigned.

  1. Results
    1. Article characteristics

Articles were sorted into one of five previously described categories based on instructional technique employed in the experimental group. Nine articles were determined to utilize video self-instruction, two uti- lized an abbreviated traditional instruction format, one utilized

interactive digital instruction, three utilized self-directed learning, and five utilized a simplified CPR instruction model. Additionally, all articles ultimately included in this analysis were published between 1991 and 2021. Details of study demographics and design included in Table 1.

    1. Video self-instruction

Video self-instruction (VSI) courses delivered instructional content using video-based materials and limited instructor intervention to guid- ance regarding utilization of the materials provided; these VSI studies are listed in Table 2. The majority of studies included in this group pro- vided participants with manikins for psychomotor skills practice.

Two studies found significant improvement in the quality of com- pressions immediately after VSI when compared to traditional. [7,8] Four studies reported equivalence in CPR skills immediately after VSI or traditional instruction. [9-12] Two separate studies from Bylow et al. reported overall CPR skill inferiority for VSI trained subjects imme- diately after instruction.

Multiple studies assessed retention of CPR skills and found equiva- lent or improved performance for VSI compared to traditional groups with assessments beginning at 1.5 months and continuing out to 12 months post-instruction. [12-14] This includes a decline to equivalence for initially superior instructor-involved formats utilized by Bylow et al. in their 2019 study. [11] Exceptions to equivalence in performance were significant declines in VSI Ventilation volume noted at 2 month follow- up by Einspruch et al. and maintenance of superiority for instructor- involved formats utilized by Bylow et al. in their 2021 study. [9,15]

Each study reported overall CPR competency scores related to par- ticipant performance of Resuscitation algorithms during a practical sce- nario. The majority report equivalence between VSI and traditional instruction with improvement in some cases. [7-10,12-14] Braslow et al. reported a decrease in participant hesitancy and apparent confu- sion during practical assessment after VSI, as well as an increased likeli- hood for traditionally trained subjects to omit procedures or take inappropriate action. [7] Isbye et al. reported declines in time to first shock among their VSI cohort. [14] Bylow et al. found the opposite effect on time to first shock immediately after instruction although superiority of traditional instruction was eliminated at 6 months post-instruction.

[11] Two additional studies found VSI participants were less likely to contact 911 than their traditionally-trained counterparts. [9,13]

Five VSI studies in this analysis assessed participant attitudes toward CPR knowledge, Willingness to perform CPR, and confidence in ability to perform CPR. Four found no significant difference in self-reported will- ingness to perform CPR or confidence in ability to perform CPR. [7,8,12,13] Bylow et al. reported initial superiority after traditional in- struction for self-rated ability to perform compressions and ventilations, self-rated ability to use an AED and overall confidence. Only self-rated ability to perform ventilations and use an AED remained higher than VSI at 6 month follow-up. [11]

    1. Abbreviated traditional instruction

Abbreviated traditional instruction courses delivered instructional content via live instructor or online modules within a period of time shorter than that allotted for a traditional course; these abbreviated tra- ditional instruction courses are listed in Table 3. Two studies were in- cluded in this group and both provided participants with manikins for psychomotor skills practice.

No significant difference in compression or ventilation metric qual- ity was detected between abbreviated or traditional instruction imme- diately afterward or at 6 and 12 month follow-up. [16,17] Roppollo et al. reported matching declines in Compression quality for both groups at 6 month follow-up. [17]

Assessment of practical skills by both studies found no significant dif- ferences in performance of abbreviated and traditional with few excep- tions. [16,17] Roppolo et al. report abbreviated instruction participants

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Table 1

Performance of video self-instruction compared to traditional CPR instruction.

Author Title

Year

Compression Quality Compared to Traditional

Ventilation Quality Compared to Traditional

Practical Scenario Compared to Traditional

Participant Attitude

Batcheller CPR performance of subjects over forty is better et al. following half-hour video self instruction

compared to traditional four-hour classroom

Braslow CPR training without an instructor: development

2000

1997

Significant improvement; VSI errors skewed to excessive depth

Significant improvement; VSI errors

Significant improvement; VSI errors skewed to

over-inflation

Significant improvement; VSI

62.7% competency after VSI compared to 6.2% after traditional; Lower rated performance in response check and pulse check after VSI

13 out of the 14 CPR skills assessed more often

No difference in self-rated confidence to perform CPR

No difference in self-rated

et al. and evaluation of a video self-instructional system for effective performance of

cardiopulmonary resuscitation

skewed to excessive depth

errors skewed to overinflation

performed correctly by VSI; Reduced hesitation to initiate CPR among VSI cohort

confidence to perform CPR

Bylow Self-learning training versus instructor-led et al. training for basic life support: A cluster

randomized trial

Bylow Learning Outcome After Different Combinations

2019

2021

No significant difference in % correct compressions between VSI and instructor-led education utilizing the same video material

Specific data not provided for

No significant difference in % correct ventilations between VSI and instructor-led education utilizing the same video material

Specific data not provided for

VSI scored significantly lower on BLS algorithm immediately after instruction; equivalence found at 6 month follow-up

Self-Directed VSI-based formats saw no improvements

Self-rated CPR/AED knowledge and confidence was significantly lower after VSI; equivalence found for compressions and confidence at

6 month follow-up

Not assessed.

et al. of Seven Learning Activities in Basic Life Support

self-instruced VSI interventions due

self-instruced VSI

over control, instructor-led instruction; Improvement in

on Laypersons in Workplaces: a Cluster Randomized, Controlled Trial

Chung Comparing the effectiveness of video

2010

to poor performance among clusters

Signficant reductions in VSI skills

interventions due to poor performance among clusters

Signficant reductions in VSI

practical skills only seen for those groups which were provided additional instructional tools alongside an instructor

No significant difference in overall CPR performance at

Significant increase in

et al self-instruction versus traditional classroom

instruction targeted at cardiopulmonary resuscitation skills for laypersons: a prospective

found in hand position, and depth of compression. All other skills returned

equivalent performance

skills found in assessment of chest rise; all other skills

returned equivalent

immediate time point or 12 month follow-up

willingness to provide CPR observed in both VSI and

traditional; no direct comparison

randomized controlled trial

Einspruch Retention of CPR skills learned in a traditional

2007

VSI and traditional declined to level

performance

Greater percentage and rate of

No significant difference in rate of skill decline at

presented

Not assessed.

et al. AHA Heartsaver course versus 30-min video self-training: A controlled randomized study

Isbye Laypersons may learn basic life support in

2006

of uninstructed controls at 2 month follow-up

VSI associated with significantly

decline observed after VSI at 2 month follow-up

VSI associated with

2 month follow-up

No significant difference in BLS performance score

Not assessed.

et al. 24 min using a personal resuscitation manikin

higher compression depth (p = 0.005); Incorrect hand

placement in over 80% of subjects

significantly greater ventilation volumes

(p = 0.006)

between 24 min VSI and 6 h instruction; VSI more likely to call for help and less likely to check respirations

Lynch Effectiveness of a 30-min CPR self-instruction

2005

from both groups

No difference detected in the mean

Mean percentage of adequate

VSI subjects significantly more likely to be rated

Not assessed.

et al. program for lay responders: a controlled randomized study

Todd et al. Simple CPR: A randomized, controlled trial of

1999

percentage of compressions with proper Hand placement after VSI; depth equivalent and inadequate across all groups

No significant difference in

ventilations significantly higher after VSI

No significant difference in

adequate in overall performance

No significant difference in mean skill performance

VSI and traditional subjects

video self-instructional cardiopulmonary resuscitation training in an African American church congregation

compression performance after VSI; mean number of compressions performed in 2 min numerically higher in VSI

detectable ventilations after VSI

score; VSI significantly more likely to locate compression point and less likely to call 911

reported comparable scores on their CPR fears/attitudes questionnaire

D. Edinboro and W. Brady American Journal of Emergency Medicine 56 (2022) 196204

Table 2

Performance of abbreviated instruction compared to traditional CPR instruction.

Author Title

Year

Compression Quality Compared to Traditional

Ventilation Quality Compared

to Traditional

Practical Scenario Compared to Traditional

Participant Attitude

Chien Traditional versus blended CPR et al. training program: A randomized

2020

No significant difference in rate, percentage with full recoil, or mean

Not assessed.

No significant difference in scoring after VSI

Not assessed.

controlled non-inferiority study

Roppolo Prospective, randomized trial of the

2007

percentage of compressions with adequate depth and rate after VSI; results comparable at 6 and 12 months

No significant difference in rate after

No significant differences

VSI subjects more likely to

Not

et al. effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Airlines Study

VSI; result maintained at 6 months

detected except for a trend toward larger mean tidal volumes after VSI; performance equivalent at 6 months

call 911 with no other significant differences in performance; performance equivalent at 6 months

assessed.

were more likely to call 911 and provide adequate ventilation during their scenario than those who took a traditional course. While 6 month follow-up found a significant 12% reduction in adequate CPR performed by abbreviated participants and traditional instruction participants had significant reductions in provision of response check, hand position accu- racy, compression depth, and overall CPR scores; reconciliation of these mutual declines found no significant difference in overall practical sce- nario performance. Abbreviated participants also produced a significant, two second reduction in time taken to assess for signs of life. [17]

Assessment of AED knowledge and use by Roppolo et al. found that, despite no hands-on experience in AED operation, the abbreviated co- hort performed numerically better than the traditional cohort when assessed for successful pad placement and shock delivery. No significant difference was detected between the two groups for overall perfor- mance or time to placement. [17]

Neither study assessed self-reports of CPR knowledge, willingness to perform, and confidence in their ability to perform CPR.

    1. Interactive digital instruction

Interactive digital instruction courses delivered instructional con- tent using a digital device (computer, tablet, mobile phone, etc.) with some interactive component (ie. game, challenge, animation) and with- out any additional input from a live instructor; these interactive digital instruction courses are listed in Table 4. One study was determined to fall within this category. Only some participants were provided with manikins for psychomotor skills practice.

Reder, Cummings, and Quan utilized two interactive digital instruc- tion groups, one of which received additional hands-on instruction for practical skills. [18] All instructional groups delivered a higher percent- age of successful compressions compared to uneducated controls (9%), although groups that received interactive digital instruction without practice (21%) performed numerically worse than those with practice (28%) or traditionally instructed (29%) groups. At 2 month follow-up, differences among instructional groups declined, ranging from 19 to 23%, while superiority over controls remained (10%). Percentage of suc- cessful ventilations was low among both interactive digital instruction with practice and traditional (14-15%) although notable numerical

differences existed between these groups and interactive digital in- struction alone (5%) or uneducated controls (3%).

Assessment of overall CPR ability found participants who received interactive digital instruction alone performed worse than traditional and interactive digital with hands-on immediately after instruction and at 2 month follow-up. No difference was detected between interac- tive digital with hands-on practice and traditional instruction.

Mean AED performance scores were lower after interactive digital without hands-on practice (80%) when compared to interactive digital with practice or traditional (91-92%). Retention at 2 months was equiv- alent across all instruction groups.

No significant differences in written CPR and AED knowledge were found between the traditional and interactive digital (with or without hands-on instruction) at either two days or two months post- instruction.

Self-report of CPR knowledge, willingness to perform, and confi- dence in their ability to perform CPR were not assessed.

    1. Self-directed learning

Self-directed learning courses delivered instructional content, or key elements thereof, by any means other than video and without the input of an instructor; these self-directed learning courses are listed in Table 5. Three studies were determined to fall within this category. Two of the three studies provided manikins for psychomotor skills prac- tice alongside theoretical content.

No study included in this category directly assessed quantitative metrics for compression or ventilation quality.

Two studies utilized a self-directed learning method with no live in- struction and found no significant difference in practical CPR perfor- mance after experimental or traditional instruction although both groups scored poorly overall. [19,20] At three month follow-up Coleman et al. found self-directed learning participants performed sig- nificantly better compressions during CPR skills assessment with no dif- ferences noted for patient assessment, ventilation, or overall CPR performance scores. [19] Rahmati, Yaghoubinia, and Mehrabady noted improvement from pre-test written knowledge scores within both groups. [20]

Table 3

Performance of digital instruction compared to traditional CPR instruction.

Author

Title

Year

Compression Quality Compared to Traditional

Ventilation Quality Compared to Traditional

Practical Scenario Compared to Traditional

Participant Attitude

Reder,

Comparison of three instructional

2006

Mean percentage of successful

Mean percentage of successful

Digital modules with

Not

Cummings

methods for teaching

compressions following digital

ventilations following digital

hands-on practice

assessed.

and Quan

cardiopulmonary resuscitation and

modules with hands-on practice

modules with hands-on practice

produced equivalent BLS

use of an automatic external

was similar to traditional; superior

was similar to traditional; superior

performance, superior to

defibrillator to high school students

to modules alone

to modules alone

modules alone

D. Edinboro and W. Brady American Journal of Emergency Medicine 56 (2022) 196204

Table 4

Performance of self-directed instruction compared to traditional CPR instruction.

Author Title Year Compression Quality Compared to Traditional

Ventilation Quality Compared to Traditional

Practical Scenario Compared to Traditional

Participant Attitude

Coleman et al Comparing methods of

cardiopulmonary resuscitation instruction on learning and retention

1991 Not assessed. Not

assessed.

No significant difference detected after SDL; only difference at 3 months were significantly higher scores in ciruclation after SDL

No significant difference in willingness and confidence to perform CPR outside the study

Rahmati, Yaghoubinia, and Mehrabady

Comparing the Effect of Lecture-Based Training and Basic Life Support Training Package on Cardiopulmonary Resuscitation Knowledge and Skill of Teachers

2017 No significant difference in scores for CPR skill performance or CPR written knowledge after SDL at 2 or 6 weeks; Mean post-test scores for skill and written knowledge numerically higher for traditional instruction at 2 weeks and lower than SDL at 6 weeks

Not assessed.

Suss-Havemann et al.

Implementation of Basic Life Support training in schools: a randomized controlled trial evaluating

self-regulated learning as alternative training concept

2020 Not assessed. Not

assessed.

Mean pass rate of 25% with no significant difference after SDL and equivalent decline over 9 months.

No significant difference in self-efficacy for helping during cardiac arrest after

self-directed practice; Ratings of diminished emotional arousal and willingness to help significantly greater after traditional; Scores universally decreased over 9 months

Suss-Havemann et al. incorporated self-directed learning into prac- tical skills sessions following a standardized instructor-led lecture. No significant difference in mean pass-rate for the practical scenario was detected between groups when assessed immediately after instruction or at nine month follow-up. [21]

    1. Simplified CPR instruction

Simplified CPR courses delivered deliberately simplified instruc- tional content, largely via instruction of compression-only CPR. Pres- ence of a live instructor or use of traditional instruction techniques was not considered and additional instructional content covering AED use was permitted. Data on participant attitudes and additional study findings can be found in Table 6. Four studies utilized hands-only

instruction and the fifth assessed a simplified four versus eight step CPR algorithm. Every study provided a manakin for practice of psycho- motor skills.

Assessment of compression, and ventilation in the case of traditional instruction controls, was conducted by four studies included in this cat- egory. Assessing for appropriate compressions, a normalized metric which considers the number of compressions possible based on CPR style, Nishiyama et al. found equivalence or improvement after hands- only at multiple time points up to 12 months. [22,23] Ko et al. reported similar findings utilizing an adequate compressions metric. [24] Assess- ment of a simplified 4-step CPR algorithm found no difference immedi- ately following as well as 1 and 6 weeks after instruction. [25]

When assessing overall CPR performance during practical scenarios, Handley and Handley found that simplified CPR participants were more

Table 5

Performance of simplified CPR instruction compared to traditional CPR instruction.

Author Title Year Compression Quality Compared to Traditional

Ventilation Quality Compared to Traditional

Practical Scenario Compared to Traditional

Participant Attitude

Handley and Handley

Four-step CPR–improving skill retention

1998 No data presented No data presented

4-step BLS sequence subjects were significantly more likely to perform all steps correctly compared to 8-step sequence; no significant decay at 1 or 6 week follow-up

Not assessed.

Ko et al. Easy-to-learn cardiopulmonary resuscitation training programme: a randomized controlled trial on

laypeople’s resuscitation performance

2018 Significantly higher proportion of adequate compressions after simplified CPR at initial 2 month time point

N/A Significantly higher CPR algorithm score seen after simplifed CPR training at initial 2 month time point; hands-off time significantly less after simplified CPR

Not assessed.

Nishiyama et al.

Nishiyama et al.

Effectiveness of simplified chest compression-only CPR training for the general public: A randomized controlled trial

Long-term Retention of Cardiopulmonary Resuscitation Skills After Shortened Chest

Compression-only Training and Conventional Training: A Randomized Controlled Trial

2008 Significantly higher proportion of appropriate compressions after simplified CPR with similar decline at 1 month follow-up

2014 No signficant difference in proportion of appropriate compressions after simplified CPR at 6 months; Significantly greater proportion of appropriate chest compressions after simplified CPR at 1 year follow-up

N/A Numerically shorter time to first compression and significantly less time without chest compression after simplified CPR

N/A Significant reduction (10s) in time to first compression after simplified CPR at 6 months and 1 year follow-up

Not assessed.

Not assessed.

Swor et al. A randomized controlled trial of chest compression only CPR for older adults

–a pilot study

2003 No data presented N/A No significant difference in skill retention after simplified CPR at 2 month follow-up

No significant difference in willingness to provide CPR or overall

self-efficacy

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American Journal of Emergency Medicine 56 (2022) 196204

201

Table 6

Overview of all studies included in analysis.

Author

Title

Year

Instruction Style

Participants

Assessment Intervals

Parameters Assessed

General Findings

Batcheller et al.

Braslow et al.

CPR performance of subjects over forty is better following half-hour video self instruction compared to traditional four-hour classroom

CPR training without an instructor: development and evaluation of a video self-instructional

2000

1997

VSI

VSI

202

642 (total); 477

Immediate

Immediate; 60 days

CPR Metrics; CPR Attitude

CPR Metrics; CPR

Equivalence to Traditional CPR Equivalence to

Bylow et al.

system for effective performance of cardiopulmonary resuscitation

Self-learning training versus instructor-led training for basic life support: A cluster

2019

VSI

(traditional/VSI comparison arm)

1301

Immediate; 6 mos

Attitude

CPR Metrics; CPR

Traditional CPR

Equivalence to

Bylow et al.

randomized trial

Learning Outcome After Different Combinations of Seven Learning Activities in Basic Life

2021

VSI

2623

6 mos (primary

Attitude

CPR Metrics; Practical

Traditional CPR

Supportive of

Chien et al.

Support on Laypersons in Workplaces: a Cluster Randomized, Controlled Trial

Traditional versus blended CPR training program: A randomized controlled non-inferiority

2020

Abbreviated

832

endpoint); Immediate

(secondary endpoint) Immediate; 6 mos; 12

Scenario

CPR Metrics; CPR

Instructor Involved

Formats Only Equivalence to

Chung et al

study

Comparing the effectiveness of video self-instruction versus traditional classroom

2010

VSI

256

mos

Immediate; 6 mos

Knowledge

CPR Metrics; CPR

Traditional CPR

Equivalence to

instruction targeted at cardiopulmonary resuscitation skills for laypersons: a prospective

(telephone); 12 mos

Attitude

Traditional CPR

Coleman et al

randomized controlled trial

Comparing methods of cardiopulmonary resuscitation instruction on learning and retention

1991

Self-Directed

49

Immediate; 3 mos

Practical Scenario; CPR

Equivalence to

Einspruch et al.

Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30-min video

2007

VSI

222

Immediate; 2 mos

Attitude

CPR Metrics; Practical

Traditional CPR

Equivalence to

Handley and

self-training: A controlled randomized study

Four-step CPR–improving skill retention

1998

Simplified

48

Immediate; 1 wk.; 6wks

Scenario

CPR Metrics; Practical

Traditional CPR

Equivalence to

Handley

Scenario

Traditional CPR

Isbye et al.

Ko et al.

Laypersons may learn basic life support in 24 min using a personal resuscitation manikin

Easy-to-learn cardiopulmonary resuscitation training programme: a randomized controlled

2006

2018

VSI

Simplified

238

85

3 mos

2 mos

CPR Metrics; Practical Scenario

CPR Metrics; Practical

Equivalence to Traditional CPR

Equivalence to

Lynch et al.

trial on laypeople’s resuscitation performance

Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled

2005

VSI

285

Immediate

Scenario

CPR Metrics; Practical

Traditional CPR

Equivalence to

Nishiyama et al.

randomized study

Effectiveness of simplified chest compression-only CPR training for the general public: A

2008

Simplified

223

Immediate; 1 mo

Scenario

CPR Metrics; Practical

Traditional CPR

Equivalence to

randomized controlled trial

Scenario

Traditional CPR

Nishiyama et al.

Rahmati,

Long-term Retention of Cardiopulmonary Resuscitation Skills After Shortened Chest

Compression-only Training and Conventional Training: A Randomized Controlled Trial Comparing the Effect of Lecture-Based Training and Basic Life Support Training Package on

2014

2017

Simplified

Self-Directed

146

120

6 mos; 12 mos

2 wks; 6 wks

CPR Metrics; Practical Scenario

Practical Scenario; CPR

Equivalence to

Traditional CPR Equivalence to

Yaghoubinia, and Mehrabady

Reder, Cummings

Cardiopulmonary Resuscitation Knowledge and Skill of Teachers

Comparison of three instructional methods for teaching cardiopulmonary resuscitation and

2006

Abbreviated

784

2 days; 2 mos

Metrics

CPR Metrics; Practical

Traditional CPR

Equivalence to

and Quan

use of an automatic external defibrillator to high school students

Scenario; AED

Knowledge/Use

Traditional CPR

Roppolo et al.

Suss-Havemann

Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Air- lines Study

Implementation of Basic Life Support training in schools: a randomized controlled trial

2007

2020

Abbreviated

Self-Directed

270

600

Immediate; 6 mos

Immediate; 9 mos

CPR Metrics; CPR Knowledge; AED Knowledge/Use

Practical Scenario; CPR

Equivalence to Traditional CPR

Equivalence to

et al.

Swor et al.

evaluating self-regulated learning as alternative training concept

A randomized controlled trial of chest compression only CPR for older adults–a pilot study

2003

Simplified

74

3 mos

Attitude

Practical Scenario, CPR

Traditional CPR

Equivalence to

Attitude

Traditional CPR

Todd et al.

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation

1999

VSI

107

1.5-2 mos (participant choice)

CPR Metrics; Practical Scenario; CPR Attitude

Equivalence to Traditional CPR

D. Edinboro and W. Brady American Journal of Emergency Medicine 56 (2022) 196204

likely to correctly perform the shortened 4-step sequence (EMS activa- tion, airway manipulation, ventilation and compression) and performed their first compression 30 s earlier than those taught the 8-step se- quence. [25] Equivalence or reduction in time to first resuscitation pro- cedure (compression or ventilation) were seen after hands-only instruction when assessed 1, 2, 6, and 12 months after instruction. [22-24] Swor et al., working exclusively with adults older than 55, found equivalent performance between hands-only and traditional co- horts at 3 month follow-up when assessed by observers using a compre- hensive scoring checklist. [26]

AED skills including pad placement, clearance of the area, and time to defibrillation were not significantly different after hands-only or tra- ditional instruction immediately after instruction and experienced equivalent declines at one month follow-up. [22]

  1. Discussion

Due to the extensive and heterogeneous nature of CPR education re- search, this analysis set rigorous criteria for study design and population to facilitate appropriate assessment and comparison of the studies in- cluded. Grouping of alternative instructional methods allowed for near-direct comparison of studies within each category and develop- ment of consensus regarding the efficacy of each approach. As noted above, we separated the alternative instructional methods into five cat- egories, including video self-instruction, abbreviated traditional instruc- tion, interactive digital instruction, self-directed learning, and simplified CPR instruction.

Aggregation of nine video self-instruction studies found this ap- proach to be equally effective as traditional instruction when delivering CPR education to the lay-population. VSI studies included in this analy- sis demonstrated equivalence or improvement over traditional ap- proaches in multiple settings and over multiple time points up to one year. Notable exception to this trend is found in a 2010 study conducted by Sarac and Ok which was not included in this analysis due to its study design which delivered instruction as 12 weekly two-hour classes. This study found significantly lower rates of correct compressions and venti- lations among the VSI participants. [27] Considering a study population composed exclusively of university students enrolled in a first aid elec- tive, these results likely reflect differences in intrinsic motivation be- tween learners who seek out CPR courses in their community and those attending an elective course unrelated to their degree outcome. In these circumstances, Sarac and Ok suggest the presence of a live in- structor may improve VSI outcomes by boosting confidence and facili- tating practice during VSI. Given the specific conditions under which this study employed VSI, its findings do not impact overall confidence in the equivalence of VSI to traditional instruction.

Simplified CPR curriculums, which included hands-only and a 4-step resuscitation algorithm, were assessed based on the results of five stud- ies and found to provide equivalent or improved outcomes in overall CPR performance, compression quality and time to first Resuscitation procedure. SDL, abbreviated instruction, and digital instruction catego- ries contained three, two, and one paper, respectively. Keeping in mind the limitations of these smaller sample sizes, all studies reported equivalence between their alternative approach and traditional instruc- tion. Notably, these findings were confirmed at time points out to three months, one year, and 2 months in the SDL, abbreviated, and digital cat- egories, respectively.

Considering the findings of this analysis, multiple benefits may be realized through the implementation of alternative CPR instruction within a community. Formats like abbreviated and hands-only instruc- tion require 50% of the time allotted for traditional courses, allowing in- structors to teach more courses or serve more localities in a given amount of time. VSI, SDL, and digital instruction require no instructor input and can be deployed in settings which are too dense (universities, corporations, etc.) to be served effectively by live instructors, as well as rural areas which are too sparsely populated to be efficiently served by a

live instructor. More importantly, alternative methods provide benefits to participants by reducing obligations of time and cognitive load. Roppolo et al. found that participants randomized to traditional instruc- tion were more likely to withdraw from the study and most often cited the larger time commitment as their reason. [17] Given these findings, flexibility in scheduling and reductions in instructional time would allow for individuals with busy or atypical work schedules to more eas- ily engage with CPR education. Benefit may also be obtained via reduc- tions in performance anxiety among participants who engage in formats with no live instructor, allowing unmonitored practice with a manikin.

Potential pitfalls associated with implementation of alternative ap- proaches largely involve the increase in material resources required to implement them in addition to concerns regarding reductions in self- efficacy. Chung et al. noted the importance of cost consideration when seeking to implement any alternative method which provides individ- ual manikins and instructional resources rather than utilizing shared classroom resources. [12] Indeed, provision of practice manikins for each individual does introduce new costs which may become a signifi- cant barrier when seeking to educate a large number of individuals. Ed- ucation without the use of manikins may be possible; however, their use is recommended by both AHA and ERC guidelines and only two studies assessed in this analysis failed to indicate whether participants were provided with practice manikins. [28,29] Overall, considerations of cost must be balanced with increased access to populations where traditional instruction is difficult to provide for any number of reasons. Hosting a cheaper traditional course is a more efficient use of resources only if adequately attended and thus some settings may better utilize resources by devoting them to remote-capable alternative approaches like VSI, SDL, or digital instruction.

Reductions in self-efficacy were noted by Bylow et al. during assess- ment of VSI instruction, although most benefits of traditional instruction faded by 6 months. Additional concerns were raised by Sarac and Ok who conducted their course among university students in an elective first aid course. These concerns highlight an important consideration when seeking to deliver alternative instruction without a live instructor in populations where intrinsic motivation to complete the course and/ or provide CPR in real-life may be low. Solutions will likely be needed to encourage participant engagement with self-paced material, al- though mere exposure to and familiarization with CPR material may re- sult in slight improvements in bystander CPR or increased willingness to engage in dispatcher-assisted CPR. Notably, study measurements of self-efficacy do not reflect actual probability of CPR delivery during a real-life scenario and additional research will be needed to determine how closely these values are linked.

Poor ventilation performance observed across instructional groups suggests additional benefit for utilization of hands-only instructional techniques. During their study of hands-only instruction, Ko et al. found that 39.39% of participants who received traditional instruction did not attempt to deliver any ventilations during practical simulation. Of those who did, over half delivered ventilations of inappropriate vol- ume. [24] In two separate studies Nishiyama et al. found that appropri- ate ventilations were delivered only 37.55% and 36.62% of the time after conventional CPR instruction. [22,23] Inadequate ventilation perfor- mance was observed in VSI studies as well. [7,9,14] Considering that in- struction on ventilation does not often result in its effective delivery, instructional time may be better devoted to building confidence in chest compression; an element of resuscitation known to influence neu- rological outcomes after CPR. [30] Development of future CPR courses for the lay population should consider the benefits of a focused, compression-based curriculum which reduces cognitive load and in- structional time.

Finally, this analysis found that participants in both alternative and traditional instructional styles often failed to perform CPR skills to levels determined to be adequate by study authors. Seven studies, with at least one from each instructional category, reported poor performance across

D. Edinboro and W. Brady American Journal of Emergency Medicine 56 (2022) 196204

experimental and traditional cohorts. [9,10,13,16,18,19,26] Improving the efficacy of CPR education will likely require alteration beyond in- structional style itself to include incorporation of educational theory and practice which are optimized for target populations ranging from adolescent to older adult learners. Development of population specific approaches based on educational theory may improve learning when instructing homogenous populations such as those found in schools, community organizations, or senior centers.

Despite the benefits of alternative CPR instruction outlined in this analysis, additional research will be required to determine whether styles which do not utilize a live instructor are effective in larger sample sizes. Many of the studies included here are limited in their utility by bias associated with convenience and volunteer sampling which may have contributed to higher levels of intrinsic motivation within experi- mental populations. The importance of intrinsic motivation highlighted by the findings of Sarac and Ok necessitates further investigation re- garding how and why participants in VSI, SDL, or digital courses com- plete their course requirements and whether some form of in-person guidance or evaluation, however brief, might improve completion rates. Ultimately, the successful deployment of independently- completed alternative instructional methods hinges on whether partic- ipants utilize the resources provided to complete the entirety of their training. In settings where independent learning does not result in course completion, resources may be better directed toward delivery of alternative or traditional styles of CPR education which utilize live in- structors to facilitate engagement and administer assessments.

  1. Conclusion

We undertook this narrative review to address the need for a greater understanding of the effectiveness of alternative CPR instruction as it compares to traditional CPR courses in the lay population. Assessment of alternative instructional methods found that VSI and Simplified CPR formats result in equivalent performance of CPR metrics and during practical scenario assessment. While additional research will be re- quired to further substantiate the value of SDL, digital, and abbreviated formats, these studies also suggested equivalence in CPR performance compared to traditional courses. In view of the importance of bystander CPR in OHCA outcomes, and the barriers presented by traditional CPR education courses, we recommend that public safety leaders and CPR educators strongly consider the introduction of these programs within their communities and classrooms.

Conflict of interest

None.

CRediT authorship contribution statement

Dolan Edinboro: Validation, Writing – original draft, Writing – review & editing, Resources, Data curation, Formal analysis, Investigation, Methodology, Project administration. William Brady: Writing – review & editing, Writing – original draft, Validation, Supervision, Project adminis- tration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

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