A comparison of manikin CPR performance by lay persons trained in three variations of basic life support guidelines.

This paper reports on a randomised controlled trial comparing the acquisition and retention of cardiopulmonary resuscitation (CPR) skills by lay persons trained in three variations of basic life support. Training was provided either in 1992 European Resuscitation Council (ERC) guidelines, or in the 1997 International Liaison Committee on Resuscitation (ILCOR) Advisory Statement (adopted with minor revisions as 1998 ERC guidelines), and an American Heart Association 'call first' version of the 1997 ILCOR statement. Evaluation of manikin CPR using the established Cardiff tests (CARE and VIDRAP) showed that 51% of those trained in the current ILCOR guidelines performed effectively compared with 38% trained in the ERC 1992 guidelines and 25% trained in the 'call first' variation (P<0.01). Whilst the current ERC and ILCOR guidelines appeared easiest to learn, retention at 6 months was poor (14% effective) irrespective of method.

Lay CPR trainees: retraining, confidence and willingness to attempt resuscitation 4 years after training.

Two independent samples of 800 lay CPR trainees from an original cohort of 7584 were surveyed postally 4 years after training. Only 2% of respondents had used CPR, but 92 had used other aspects of their life support training. Those who had retrained were more confident than those who had not and 89% of those who had not retrained were willing to do so. More than 80% expressed willingness to perform full CPR on casualties who were unknown to them, but this fell to 40% where facial blood was present and 48% where the victim was a gay man.

Randomised controlled trials of staged teaching for basic life support. 1. Skill acquisition at bronze stage.

We have investigated a method of teaching community CPR in three stages instead of in a single session. These have been designated bronze, silver, and gold stages. The first involves only opening of the airway and chest compression with back blows for choking, the second adds ventilation in a ratio of compressions to breaths of 50:5, and the third is a conversion to conventional CPR. In a controlled randomised trial of 495 trainees we compared the performance in tests immediately after instruction of those who had received a conventional course and those who had had the simpler bronze level tuition. The tests were based on video recordings of simulated resuscitation scenarios and the readouts from recording manikins. Differences occurred as a direct consequence of ventilation being required in one group and not the other, some variation probably followed from unforeseen minor changes in the way that instruction was given, whilst others may have followed from the greater simplicity in the new method of training. A careful approach was followed by slightly more trainees in the conventional group whilst appreciably more in the bronze group remembered to shout for help (44% vs. 71%). A clear advantage was also seen for bronze level training in terms of those who opened the airway as taught (35% vs. 56%), for checking breathing (66% vs. 88%), and for mentioning the need to phone for an ambulance (21% vs. 32%). Little difference was observed in correct or acceptable hand position between the conventional group who were given detailed guidance and the bronze group who were instructed only to push on the centre of the chest. The biggest differences related to the number of compressions given. The mean delay to first compression was 63 s and 34 s, and the mean duration of pauses between compressions was 16 s and 9 s, respectively. Average performed rates were similar in the two groups, but more in the conventional group compressed too slowly whereas more in the bronze group compressed too rapidly. Observations were made for only three cycles of compression, but extrapolating these to the 8 min often considered a watershed for chances of survival for victims of cardiac arrest, an average of 308 compressions would be expected from those using conventional CPR compared with 675 for those using bronze level CPR. The implications of this difference are discussed.

Evaluating CPR performance in basic life support: the VIDRAP protocol.

This paper presents the second part of the validated Cardiff test for one rescuer basic life support skills, based on observation of video recording combined with the Recording Resusci Anne printout (VIDRAP). The authors believe that this is a robust evaluation tool which is capable of assessing the potential value to a casualty of a simulated resuscitation. The adoption of a widely accepted test methodology would facilitate comparison of research in different centres, which is not possible at present.

A rationale for staged teaching of basic life support.

Basic life support is a crucial part of the Chain of Survival. Unfortunately, however the skill is complex and cannot readily be acquired--let alone retained--in the course of a single training session. Although the problem has long been recognised, no new strategies have been widely implemented to counter the problem. We believe that staged teaching of CPR might provide a solution, and we have devised a program to test this new method. It involves three stages of instruction that we have called bronze, silver, and gold standards. The bronze standard involves opening the airway and providing chest compression without active ventilation: this alone may widen the window of opportunity for successful defibrillation in adult victims in out-of-hospital cardiac arrest. Ventilation is introduced at silver stage using a ratio of 50:5, with emphasis on its value in the resuscitation of children being used as motivation to bring people back for a second period of instruction. The gold stage teaches conventional CPR. A pilot study has been encouraging and a randomized trial on skill acquisition and skill retention is planned.

Community life support training: does it attract the right people?

Members of the public recruited by means of a local newspaper campaign for basic life support instruction by mass training sessions. Six hundred and seventy-two were trained and a random sample of 241 completed a questionnaire on their attitudes and willingness to attempt cardiopulmonary resuscitation in an emergency. At the end of the course almost all (99%) approved the concept of community training and 198 (82%) believed themselves capable of saving a life using the techniques they had been taught. Sixty-seven percent of respondents were related to someone with a heart problem and more than 97% expressed willingness to resuscitate a relative. Half would be willing to attempt resuscitation in unpleasant circumstances, but only a quarter thought that they might do so if the casualty had vomited. The campaign was successful in recruiting members of the public related to those with a higher risk of cardiac arrest and producing life supporters who intended to use their skills, should they be required.

Assessing with CARE: an innovative method of testing the approach and casualty assessment components of basic life support, using video recording.

The resuscitation community is now moving towards a set of basic life support guidelines but different countries and training centres have their own individual methods of instruction. It would be advantageous if a universal testing method were available to facilitate intercentre comparison. This could lead to an international course which had been rigorously assessed and evaluated. Taking this as a starting point, the Cardiff Assessment of Response and Evaluation (CARE) was developed. CARE is an innovative assessment technique using video recording for testing the preliminary steps of life support as outlined by the European Resuscitation Council. The assessment was validated by testing 67 members of the public who had been trained in cardiopulmonary resuscitation, 27 shortly after instruction and 40 between 6 and 18 months after instruction. All subjects were tested without prior warning and video recorded for independent scoring by two researchers and a paramedic training officer. Scores were compared using the k correlation which showed a high level of agreement between observers. Video recording and marking using the CARE schedule and guidelines is a reliable method for assessing the preliminary steps in life support.

Effectiveness of the BBC's 999 training roadshows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards.

OBJECTIVE: To examine the competence of a cohort trained in cardiopulmonary resuscitation by the BBC's 999 training roadshows. DESIGN: Descriptive cohort study applying an innovative testing procedure to a nationwide systematic sample. The test sample received an unsolicited home visit and without warning were required to perform cardiopulmonary resuscitation on a manikin while being videoed. The videos were then analysed for effectiveness and safety using the new test. SETTING: Nine cities and surrounding areas in the United Kingdom. SUBJECTS: 280 people aged between 11 and 72. RESULTS: Thirty three (12%) trainees were able to perform effective cardiopulmonary resuscitation, but of these 14 (5%) performed one or more elements in a way that was deemed to be potentially injurious. Thus only 19 (7%) trainees were able at six months to provide safe cardiopulmonary resuscitation. In addition, large numbers of subjects failed to shout for help, effectively assess the status of the patient, or alert an ambulance. Significantly better performances were recorded by those under 45 years old (31 (14%) v 2 (4%) gave effective performances respectively, P < 0.05), those who had attended a subsequent cardiopulmonary resuscitation course (8 (40%) v 25 (10%) gave effective performances respectively, P < 0.0001), and those confident in their initial ability (26 (20%) v 7 (6%) gave effective performances respectively, P < 0.005). Females were significantly less likely than males to perform procedures in a harmful way (117 (62%) v 10 (12%) performed safely respectively, P < 0.005). CONCLUSION: Television is an effective means of generating large training cohorts. Volunteers will cooperate with unsolicited testing in their home, such testing being a realistic simulation of the stress and lack of forewarning that would surround a real event. Under such conditions the performance of cardiopulmonary resuscitation was disappointing. However, retraining greatly improves performance.

The need for wider dissemination of CPR skills: are schools the answer?

The value of instructing members of the public in CPR is now widely recognised, but community training schemes which rely largely on volunteers may fail to reach their targets. CPR training for lay people is often a once only activity and it has been shown that, without revision, skills deteriorate rapidly. By teaching CPR in secondary schools all social classes and ethnic groups could be reached, and retention of skills improved by regular revision. Health education has shown that it may be beneficial to use older pupils as instruction assistants.