Cardiopulmonary resuscitation performance of subjects over forty is better following half-hour video self-instruction compared to traditional four-hour classroom training.

Cardiopulmonary resuscitation (CPR) training is not well targeted to family members of individuals at highest risk of cardiac arrest. Participants in traditional CPR classes (TRAD) average 31 years of age, while family members of cardiac patients average 55 years. Video self-instruction (VSI) can reach older individuals and others who do not participate in TRAD classes. VSI is a combination of a 34-min videotape and an inexpensive manikin intended for use in the home, where three-quarters of all out-of-hospital cardiac arrests occur. We exposed 202 subjects 40 years of age and older (mean age 59.4 years, S.D. = 10.9) to either TRAD or VSI, and tested them individually immediately following training rising validated methods including measurement by means of a Laerdal-Skillmeter manikin. According to American Heart Association (AHA) criteria, VSI subjects performed an average of 20.8% of all compressions and 25.1% of all ventilations correctly, compared with 3.4% of compressions and 1.7% of ventilations by TRAD subjects (P < 0.0001). VSI subjects performed an average of 10.1 of the total 14 CPR assessment and sequence skills correctly, compared with an average of 4.7 for TRAD (P < 0.0001). On a measure of overall performance, 62.7% of the VSI subjects were rated 'competent' or better (i.e. capable of performing CPR that 'would probably be effective'), compared to 6.1% of TRAD subjects (P < 0.0001). Only 17.8% of VSI subjects were rated as 'not competent' (i.e. unable to obtain a combination of any chest rise and any compression of the sternum) compared with 69.1% of TRAD subjects. VSI provides an effective, convenient, and inexpensive means of training persons over 40 years of age that achieves skill performance superior to TRAD.

Skill mastery in public CPR classes.

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

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

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

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

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

CPR training without an instructor: development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation.

Traditional classroom-based instruction of cardiopulmonary resuscitation (CPR) has failed to achieve desired rates of bystander CPR. Video self-instruction (VSI) is a more accessible alternative to traditional classroom instruction (TRAD), and it achieves better CPR skill performance. VSI employs a 34-min training tape and an inexpensive manikin. VSI combines simplified and reordered content focusing on the delivery of one-rescuer CPR with the 'practice-as-you-watch' approach of an exercise video. Performance of CPR skills immediately following VSI was compared to performance immediately following TRAD using an instrumented manikin, a valid and reliable skill checklist, and an overall competency rating. Compared with TRAD subjects, VSI subjects performed more compressions correctly (P < 0.001), more ventilations correctly (P < 0.001), and more assessment and sequence skills correctly (P < 0.001). TRAD subjects delivered twice as many compressions that were too shallow, and underinflated the lungs twice as often. VSI subjects were rated 'competent' or better 80.0% of the time, compared with TRAD subjects, who achieved this rating only 45.1% of the time (P < 0.001). TRAD subjects were rated to be 'not competent' in performing CPR nearly 10 times more often than VSI subjects (P < 0.001). Subjects 40 years of age and older performed better after VSI than after TRAD. Superior skill performance among subjects exposed to VSI persisted 60 days following training. VSI has the potential to reach individuals unlikely to participate in TRAD classes because of its greater convenience, lower cost, and training in about 0.50 h compared with 3-4 h for TRAD classes.

The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction.

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

A reliable and valid method for evaluating cardiopulmonary resuscitation training outcomes.

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

Future directions for resuscitation research. I. Advanced airway control measures.

The efficacy of 'basic' airway control without equipment, using the combination of backward tilt of the head, forward displacement of the mandible, and separation of lips and teeth (i.e. the triple airway maneuver) has been well established. Direct mouth-to-mouth and mouth-to-nose ventilation must continue to be taught to the public. Further improvements are needed for pocket-size mouth-to-mouth barriers to combat infection risks. Dissemination of appropriate information on disease transmission is needed to ensure ventilation by health professionals, using exhaled air ventilation adjuncts and other devices. Much knowledge exists about the pathophysiology of airway obstruction. For patients in coma or anesthesia with airway obstruction, which resists basic airway control measures and standard tracheal intubation, available 'advanced' airway control measures should be mastered and improved. Preparedness for advanced airway control measures differs between elective management of the anticipated difficult airway for anesthesia and emergency airway control with unanticipated difficulties encountered during the ordinary sequential application of measures. Challenges include education research and development of new devices. For airway clearing, pharyngeal intubation, difficult tracheal intubation, cricothyrotomy, transtracheal jet ventilation and emergency use of oxygen - what could and should be taught, to whom, and how? Which new devices and training systems should be developed? The most important alternative to orotracheal or nasotracheal intubation recommended for the development of novel devices and teaching methods for health professionals, are cricothyrotomy (with wide enough airway to also enable spontaneous breathing of air), and translaryngeal or transtracheal oxygen jet ventilation. We recommend openness in communication and joint planning between anesthesiologists, emergency care providers, and appropriate educators, engineers and industries.

Future directions for resuscitation research. II. External cardiopulmonary resuscitation basic life support.

In sudden cardiac deaths outside hospitals, the present performance of external cardiopulmonary resuscitation-basic life support (CPR-BLS), as a bridge to advanced life support (ALS) attempts for restoration of spontaneous circulation (ROSC), still yields suboptimal results. Therefore, future education research should develop more effective, simpler and quicker ways to enable everyone to acquire the necessary BLS skills. Individualized self-training by lay persons is being revived. Although airway control and direct mouth-to-mouth ventilation skills are difficult to acquire, they must continue to be taught to the lay public and health professionals, primarily for use on relatives and friends where infection risk is not a problem. In children and trauma victims, steps A and B alone may be lifesavers. The best way to ventilate and oxygenate during the initiation of brief external CPR-BLS should be re-evaluated. There is a great difference between animals and humans in the behavior of the airway and thorax during coma, and thus in the need for added positive pressure ventilation. During chest compressions in humans, steps A and B are needed. Details deserve re-evaluation. The low perfusion pressures (borderline blood flows) produced by standard external CPR remain the most serious limitation of this method. In spite of extensive efforts so far, novel laboratory research to remedy this limitation is important for the development of more effective emergency artificial circulation. The results of such studies are greatly influenced by different details in animal models. Active compression-decompression (ACD) external CPR, also called 'push-pull' CPR, with a plunger-type device used by hand or a machine, and intermittent abdominal compression (IAC) external CPR are both promising modifications of standard external CPR. Both need further experimental and clinical clarification. For BLS, developing a more effective purely manual CPR-BLS method for help in rapid ROSC should be given high priority. Portable external CPR machines need improvements. They will serve for bridging ROSC-resistant cases through transport and ALS attempts, primarily by freeing the hands of health professionals for more effective sophisticated ALS measures.

Skill mastery in cardiopulmonary resuscitation training classes.

The authors evaluated skill levels of trainees (n = 48) who were taught cardiopulmonary resuscitation (CPR) in "American Red Cross: Adult CPR" classes offered at a work site. The evaluation used a validated skill checklist and a Laerdal Skillmeter mannequin to assess trainee competence. Only 1 in 10 of the trainees could correctly perform all 12 CPR skills assessed by the skill checklist. Fewer than 12% of all compressions met published standards, and fewer than 25% of the ventilations met the standards as evaluated by the Skillmeter mannequin. All trainees felt confident they could use their CPR skills in an actual emergency; 64% were "very confident." Videotape recordings of the practice sessions showed that instructors overlooked many errors in CPR performance and that trainees provided little corrective feedback to one another. The role of instructors in assisting CPR skill practice and in evaluating skill mastery is questioned.

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

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

Causes of delay in seeking treatment for heart attack symptoms.

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

Football fatalities in actuarial perspective.

The relative risk of death among school and college varsity football players was calculated as a replication of a statistical exercise published a decade earlier. The purpose of the original exercise had been to demonstrate the epidemiological necessities and pitfalls in using fatality data to approach the hazardousness of sport. The purpose of this replication was to examine the stability of the findings of that exercise. In 1964, football was found not to constitute an additional risk of death to its participants compared to the overall mortality rate of young males adjusted for comparability by exposure to a football season. Further, compared to the automobile-related mortality rate of this population, football was much safer. In 1974 (and 1975), the frequency of football fatalities has declined, and the respective actuarial ratios consequently remained favorable to football. Fatality data, however, have limited utility in the search for preventive practices in sport. What is needed is continuous surveillance of all significant injuries and illnesses, using epidemiological principles.