Resuscitation 44 (2000) 143 – 148 www.elsevier.com/locate/resuscitation
Letters to the Editor A response to ‘A rationale for staged teaching of basic life support’ Every year we Americans confront the news that high school students have performed poorly on tests of math and science. Amidst the public outcry, no one ever suggests that the problem ought to be solved by making math simpler or streamlining physics. Yet faced with evidence that persons taking CPR classes cannot perform an adequate combination of compressions and ventilations, many authors argue that CPR itself ought to be simplified [1–6]. The simplification of CPR will, according to supporters, increase skill performance, retention, and bystander response. We distinguish ourselves from the simplification movement currently gathering steam in that we call primarily for focusing the instruction of CPR through the removal of gratuitous material unrelated to resuscitation, not for simplification of the technique. Nowhere is the case for simplifying CPR made more strongly than in the Resuscitation article ‘A rationale for staged teaching of basic life support’ [1]. We agree based on our own research [7–12] and the work of others [13–18] that CPR performance following traditional 2–4 h training classes is poor, but we cannot agree with the authors’ concept for addressing this problem by simplifying CPR itself any more than we would urge American high schools to stop teaching the quadratic formula or to reduce Newton’s laws to just one. The authors argue that ‘‘We are expecting too much from courses that usually last only 2 or 3 h’’ (4 h is more common in the US). Their reasoning that because existing courses occupying 2–4 h or more do not seem to be teaching CPR adequately, it is not possible to teach CPR in this time frame may seem reasonable prima facie, but the authors preclude the idea that it may be possible to teach CPR in the same time (or less) more effectively
with other training methods. Additionally, the authors ignore long-standing evidence demonstrating that modes of instruction other than those now employed by CPR training organizations can be more effective. Just after the introduction of public training in CPR, self-training methods were shown to be superior to classroom methods among youthful subjects [19]. Attempts to maximise the emphasis in CPR classes on psychomotor practice, termed ‘overtraining’ and ‘drilling’ by their authors, demonstrated that fostering mastery of (rather than mere exposure to) the CPR skills could increase learning and retention [20,21]. With Lars Wik [22] we demonstrated that individuals trained at home in informal 30–60 min sessions could perform better CPR as measured both by observer skill assessment and objective assessment with an instrumented manikin [23] than subjects trained in traditional 4-h CPR courses (TRAD). When the American Red Cross first introduced videotape as a means to deliver cognitive course content, it was shown to result in superior performance of subjects on cognitive tests as compared with instructor lectures [12]. The most compelling evidence yet that alternative methods of instruction can lead to superior outcomes from our development and evaluation of a video self-instructional method (VSI) [24,25]. Although Assar et al. cite and quote directly from our Resuscitation paper on VSI [25] evidence that TRAD is ineffective, they ignore the major point of our research which was to demonstrate superior subject skill performance following 34 min of VSI as compared with 4-h TRAD. Our findings come from a carefully controlled ‘quasi-experiment’ [26] involving 642 subjects. While the authors argue that CPR is too complex to be mastered, we found that subjects trained with VSI could, on the average, perform 12 out of 14 assessment and sequencing skills correctly compared with nine skills
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performed correctly by subjects in TRAD classes. While 22% of subjects in TRAD classes were rated ‘not competent’ (defined as not performing a combination of breaths resulting in any chest rise and chest compressions resulting in any movement of the sternum) only 2% of VSI subjects were so rated. Similarly, an additional 33% of subjects in TRAD classes were rated as ‘questionably competent’ versus 18% of those exposed to VSI. Subjects trained with VSI also showed significantly better retention of skills two months after training. Todd et al. compared VSI to TRAD in a group of 89 freshman medical students who were randomly assigned to either VSI or an AHA ‘Heartsaver’ (3–4 h) course. [27] Subjects trained in 34 min with VSI outperformed subjects trained in ‘Heartsaver’ courses 2 – 6 months after training. Most recently, we compared 34 min of VSI to 4 h of TRAD using subjects 40 years of age and over (mean age= 59) [28]. For those older subjects, TRAD appears to be highly ineffective with 69% of the subjects rated as ‘not competent’ and an additional 25% rated as ‘questionably competent’ (i.e. a scant 6% could perform CPR competently). Among the VSI subjects, 18% were considered not competent and 20% questionably competent (i.e. ten times as many VSI subjects as TRAD subjects, 62%, were competent to perform CPR). VSI has important features that enable superior mastery of CPR in about one eighth the time used by TRAD [24,25,28]. Like the earliest efforts at self-training, [19] the learner, not the instructor, determines the pace of instruction and practice. Like the attempts to increase mastery and retention through ‘overtraining’ or drilling, VSI has a strong emphasis on repetitive practice [20,21]. Our observation is that most subjects fully use the 25 min allocated for practice. Although TRAD courses may allocate similar amounts of time to practice [24,25,28], our observations suggest that little of the time is so used by the instructors or subjects [9,11]. Finally, the unique contribution of VSI is synchronous practice (‘practice as you watch’) with the videotape in the manner of an exercise video [25]. The fact that the design of TRAD classes (e.g. AHA and American Red Cross) allocates only a fraction of the instructional time to CPR skills practice implies that the rest of the time is devoted to something else [25]. Among the other topics covered in CPR courses are recognition of heart
attacks, prevention of heart disease through lifestyle changes, the physiology of CPR, first aid for foreign body obstructions of the airway, and the dissecting of the skills of performing CPR into rates, ratios, and measurements. VSI omits such material because it dilutes the central message, which is competent performance of this needed lifesaving skill [10,29]. If Assar et al. are correct that 2–3 h is not sufficient time to learn CPR, then what is any additional material doing in these courses, and why would not the first attempt to correct the problem be to excise such material from the courses? The authors appear to assume that CPR is likely to be needed in a public setting when the victim is unknown to the potential rescuer. Unfortunately for most victims of cardiac arrest, collapse usually occurs in the home [30–34], where other adults, such as family members or friends of the victim, are unlikely to be trained to perform CPR [35,36]. Assar et al. admit that the public has no reluctance to perform mouth-to-mouth resuscitation on family members; yet they advocate, as have Becker and colleagues with the authority of the AHA, [6] that eliminating mouth-to-mouth breathing from basic CPR training would lead to an increased rate of bystander CPR. The evidence that lay rescuers, as opposed to professional rescuers (who have occupational reasons to be connected about transmission of disease), may be reluctant to undertake CPR because mouth-tomouth ventilation is disagreeable is scant if not non-existent, as we have previously argued in Resuscitation [37]. The conclusion that because present training methods do not achieve CPR competency it must therefore be impossible to teach competent CPR in a reasonable time frame (2–4 h) must be swiftly rejected. It is dangerous and premature to discard the idea that the lay public can be trained to make an assessment of an emergency requiring CPR and to perform the skill competently consisting of both chest compressions and artificial respiration. Indeed, the authors ignore the strong evidence that alternative training methods show promise for training the lay public to perform CPR competently. Before we eliminate essential elements of effective CPR [38], let us devote our research efforts to finding effective training strategies that achieve CPR competence in a time frame and format that is attractive to the public. It is indeed
Letters to the Editors
high time that we rethink how we teach CPR to the public, [39] but we do not see the author’s notion to simplify CPR itself to be the best solution to existing problems with mass training of the lay population.
References [1] Assar S, Chamberlain D, Colquhon M, Donnelly P, Handley AJ, Leaves S, Kern KB, Mayor S. A rationale for staged teaching of basic cardiac life support. Resuscitation 1998;39:137–43. [2] Flint LS, Billi JF, Kelley K, Mandel L, Newell L, Stapleton ER. Education in adult basic life support training programs. Ann Emerg Med 1993;22:466– 74. [3] Handley AJ, Becker LB, Allen M, van Drenth A, Dramer FD, Montgommery EB. Single rescuer adult basic life support. Resuscitation 1997;34:101–8. [4] Handley JA, Handley AJ. Four-step CPR — improving skill retention. Resuscitation 1998;3:3–8. [5] Morgan CL, Donnelley PD, Lester CA, Assar DH. Effectiveness of BBC’s 999 training roadshows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. Br Med J 1996;313:912–6. [6] Becker LB, Berg RA, Pepe PE, Idris AH, Aufderheide TP, Barnes TA, Stratton SJ, Chandra NC. A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation: a statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association. Resuscitation 1997;35:189–201. [7] Braslow A. Cardiopulmonary resuscitation skill performance of emergency medical technicians serving rural communities. Masters Thesis, University Park, PA: Pennsylvania State University, 1980. [8] Braslow A. An Evaluation of the Knowledge and Practices of Basic Cardiac Life Support Instructors. UrbanaChampaign, IL: Dissertation, University of Illinois. 1985. [9] Kaye W, Rallis SF, Mancini ME, Linhares KC, Angell ML, Donavan DS, Zajano NC, Finger JA. The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum. Resuscitation 1991;21:67–87. [10] Braslow A. CPR: a skill for everyone? In: Proceedings of the Australian Resuscitation Council Spark of Life Conference. Melbourne, Victoria. Australia Resuscitation Council, 1993:18. [11] Brennan RT, Braslow A. Skill mastery in cardiopulmonary resuscitation classes. Am J Emerg Med 1995;13:505–8. [12] Brennan RT, Braslow A. Skill mastery in public CPR classes. Am J Emerg Med 1998;16:653–7. [13] Weaver FJ, Ramirez AJ, Dorfman SB, Raizner AE. Trainee’s retention of cardiopulmonary resuscitation: how quickly they forget. J Am Med Assoc 1979;241:901–3.
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[14] Mandel LP, Cobb LA. Initial and long-term competency of citizens trained in CPR. Emerg Health Serv Q 1982;1:49. [15] Wilson E, Brooks B, Tweed WA. CPR skills retention of lay basic rescuers. Ann Emerg Med 1983;12:482. [16] Skinner DV, Camm AH, Miles S. Cardiopulmonary resuscitation sills of preregistration house officers. Br Med J 1985;290:1549– 50. [17] Wynne G, Marteau TM, Johnston M, Whiteley CA, Evans TR. Inability of nurses to perform basic life support. Br Med J 1987;294:1198– 9. [18] Hoeyweghen RJ, Bossaert LL, Mullie A, et al. Quality and efficiency of bystander CPR. Resuscitation 1993;26:47 – 52. [19] Berkebile D, Benson C, Ersoz B, Barhnill B, Safar P. Public education in heart-lung resuscitation: evaluation of three self-training methods in teenagers. In: National Conference on Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care, Dallas. American Heart Association, 1975:13. [20] Tweed WB, Wilson E, Isfeld B. Retention of cardiopulmonary resuscitation skills after initial overtraining. Crit Care Med 1980;8:651 – 3. [21] Kittleson MJ. CPR drilling. Health Educ 1980;11:22–3. [22] Wik L, Brennan RT, Braslow A. A peer-training model for instruction of basic life support. Resuscitation 1995;29:119 – 28. [23] Brennan RT, Braslow A, Batcheller AM, Kaye W. A reliable and valid method for evaluating cardiopulmonary resuscitation training outcomes. Resuscitation 1996;32:85 – 93. [24] Braslow A, Brennan RT, Newman NM, Kaye W. A self-instructional system for one-rescuer cardiopulmonary resuscitation: abstract. Circulation (Suppl) 1995;92:834. [25] Braslow A, Brennan RT, Newman MM, Bircher NG, Batcheller AM, Kaye W. CPR training without an instructor: development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation 1997;34:207 – 20. [26] Cook TD, Campbell DT. Quasi-experimentation: design and analysis issues for field settings. Boston, MA: Houghton-Mifflin, 1979. [27] Todd KH, Braslow A, Brennan RT, Lowery DW, Cox RJ, Lipscomb LE, Kellerman AL. Randomized, controlled trial of video self-instruction versus traditional CPR training. Ann Emerg Med 1998;31:364 – 3699. [28] Batcheller A, Brennan RT, Braslow A, Urrutia A, Kaye W. Cardiopulmonary resuscitation (CPR) performance of subjects over forty is better following half-hour video self-instruction compared to traditional four-hour classroom. Resuscitation 2000;43:101 – 110. [29] Brennan RT. Student, instructor, and course factors predicting achievement in CPR training classes. Am J Emerg Med 1991;9:220 – 4. [30] Becker LB, Ostrander MP, Barrett J, Kondos GT. Survival from cardiopulmonary resuscitation in a large metropolitan area: where are the survivors? Ann Emerg Med 1991;20:355 – 61.
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[31] Eisenberg MS, Horwood BT, Cummins RO, ReynoldsHaertie R, Hearne TR. Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med 1990;19:179–86. [32] Lombardi G, Gallagher J, Gennis P. Outcome of out-ofhospital cardiac arrest in New York City: the pre-hospital arrest survival evaluation (PHASE) study. J Am Med Assoc 1994;271:678–83. [33] Gallagher ED, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest. J Am Med Assoc 1995;274:1922–5. [34] Litwin PE, Eisengberg MS, Hallstrom AP, Cummins RO. The location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987;16:787–91. [35] Goldberg JJ, Gore JM, Love DG, Ockene JK, Dalen JE. Layperson CPR — are we training the right people? Ann Emerg Med 1984;13:701–4. [36] Brennan RT, Braslow A. Are we training the right people yet?: a survey of participants in public cardiopulmonary resuscitation classes. Resuscitation 1998;37:21–5. [37] Braslow A, Brennan RT. Layperson CPR: a response to a reappraisal of mouth-to-mouth ventilation during bystander initiated cardiopulmonary resuscitation: letter. Resuscitation 1998;36:78–9. [38] Safar P, Bircher N, Pretto E Jr., Berkebile P, Tisherman SA, Marion D, Klain M, Kochanek PM. A reappraisal of mouth-to-mouth ventilation during bystander-inititated cardiopulmonary resuscitation: letter. Resuscitation 1988;36:75–6. [39] Kaye W, Mancini ME. Teaching adult resuscitation in the United States — time for a rethink. Resuscitation 1998;37:177–87. Robert T. Brennan Department of Administration, Planning, and Social Policy, Graduate School of Education Har6ard Uni6ersity, Cambridge, MA 02138, USA E-mail: robert –
[email protected] Allan Braslow Braslow and Associates, Braslow & Associates, 7 Farm Hill Road Stamford, CT 06902, USA
William Kaye Di6ision of Critical Care Medicine, Departments of Surgery and Medicine, Room 223, The Miriam Hospital, Brown Uni6ersity, 164 Summit A6enue, Pro6idence, RI 02906, USA
A response to Brennan et al. 1
We welcome debate on staged CPR, particularly with such distinguished colleagues as Robert Brennan, Allan Braslow, and William Kaye whose views must always command attention. We are, of course, aware of their own efforts to improve the teaching of CPR, and indeed their work has been an inspiration to us in questioning current instructional concepts. They must certainly take credit for their own seminal work in this important area. Readers may well agree, however, that they have misunderstood our intentions as set out in our paper. Our primary aim was not to ‘simplify CPR itself’. In describing an experiment in the staged teaching of CPR, we were doing no more than suggesting a different way to a common goal. Thus, in groups taught in conventional instructor-led classes (still by far the most commonly used mode of instruction) we set out to, in a randomised trial, skill acquisition and skill retention from staged learning in three sequential classes, as opposed to the usual single classes. The end result was still intended to be full conventional CPR, although we recognised that the less highly motivated may not progress that far (a subsequent paper will show that the majority, but by no means all, are willing to re-attend to learn how to provide artificial ventilation). Neither was our strategy intended to replace other improved types of learning, such as the successful video self-instruction system (VSI) mentioned above. We see our suggested method as potentially complementary and suitable for different types of students. Our colleagues in the United States are fortunate if they can instruct students over a single 4-h session. This is not usually considered an option in many parts of Europe. Staged teaching is another way of gaining more training time, and may indeed have additional advantages. It has not previously been investigated in adult volunteers,
PII: S 0 3 0 0 - 9 5 7 2 ( 0 0 ) 0 0 1 4 0 - 4 1 David Assar, who was the first author of our paper, died in September 1999.
