C2010 Worksheet EIT 013B 04 Oct 2009 doc Page 1 of 12 WORKSHEET for Evidence Based Review of Science for Emergency Cardiac Care Worksheet author s

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C2010 Worksheet EIT 013B 04 Oct 2009 doc Page 1 of 12 WORKSHEET for Evidence Based Review of Science for Emergency Cardiac Care Worksheet author s Powered By Docstoc
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               WORKSHEET for Evidence-Based Review of Science for Emergency Cardiac Care
Worksheet author(s)
                                            Date Submitted for review:
                                            4-8-09

Clinical question.
EIT-013B - In BLS providers (lay or HCP) requiring AED training (P), are there any specific training interventions (I)
compared with traditional lecture/practice sessions (C) that increase outcomes (eg. skill acquisition and retention, actual
AED use, etc.) (O)?

Is this question addressing an intervention/therapy, prognosis or diagnosis? Intervention
State if this is a proposed new topic or revision of existing worksheet: Proposed new topic
Conflict of interest specific to this question
Do any of the authors listed above have conflict of interest disclosures relevant to this worksheet?

Search strategy (including electronic databases searched).
OVID Medline (including Medline 1950-August 2009; EMBASE 1988- August 2009) (“training” OR “teaching” OR
“education” as text words) AND (“AED” OR “automatic external defibrillator” [MESH]).

This search identified 284 articles. After duplicate articles were removed, 171 references were reviewed for relevance.
From this 21papers were reviewed and 14 included in the worksheet.

AHA Endnote library was searched with the terms “AED” and “automatic external defibrillator”. All relevant references
had been identified with earlier search strategies.




• State inclusion and exclusion criteria

Inclusion criteria: Studies describing the effect of alternative training interventions on AED skill acquisition, retention or
  performance.

Exclusion criteria: Purely descriptive studies of courses with no evaluation of training.




• Number of articles/sources meeting criteria for further review:

16 articles studies met criteria for further review.

Six of studies were LOE 1, 8 studies were LOE 2 and 3 were LOE 4. All were manikin studies.
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                                                        Summary of evidence

                                              Evidence Supporting Clinical Question

                 Ropollo 2007*
    Good            (E1, E2)
                  Reder 2006*
                    (E1, E2)
                                                         #
                                          Beckers 2005 (E1)
                                                      #
     Fair                                Beckers 2005 (E1, E2)
                                     +                                         De Vries 2007* (E1)
                 De Vries 2008            Castren 2004* (E1)
                                                                              Kelley 2006* (E1, E2)
                      (E1)                  Jerin 1998* (E2)
                                                                               Gundry 1999* (E1)
                                          Mitchell 2008* (E1)
                                           Moule 2008* (E1)
                                                        +
                                          Xanthos 2009 (E1)

    Poor

                         1                         2                 3                 4                           5
                                                       Level of evidence

A = Return of spontaneous circulation          C = Survival to hospital discharge               E = Other endpoint
B = Survival of event                          D = Intact neurological survival                 Italics = Animal studies
E1 = skill acquisition                         E2 = skill retention
*=laypersons;                                  # = healthcare students;                         + = healthcare professionals

                                               Evidence Neutral to Clinical question


    Good

                                                                 +
                                               Mattei 2002 (E1)
     Fair


    Poor

                             1                          2                3              4                      5
                                                       Level of evidence

A = Return of spontaneous circulation          C = Survival to hospital discharge               E = Other endpoint
B = Survival of event                          D = Intact neurological survival                 Italics = Animal studies
E1 = skill acquisition                         E2 = skill retention
*=laypersons;                                  # = healthcare students;                         + = healthcare professionals

                                              Evidence Opposing Clinical Question

                 Meischke 2001* (E1,E2)
    Good           Mancini 2009* (E1)

                Reder 2006* (E1, E2)
     Fair


    Poor

                                 1                        2               3                 4                      5
                                                        Level of evidence
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A = Return of spontaneous circulation      C = Survival to hospital discharge               E = Other endpoint
B = Survival of event                      D = Intact neurological survival                 Italics = Animal studies
E1 = skill acquisition                     E2 = skill retention
*=laypersons;                              # = healthcare students;                         + = healthcare professionals

REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK:

 Traditional format of AED courses

 The current format of Basic Life Support and AED course outlined by ERC Guidelines 2005 lasts ‘approximately half a
 day’ and consists of ‘skill demonstrations, hands-on practice and lectures’. The recommended ratio of instructors to
 candidates is 1:6, with at least one manikin and one AED for each group of six candidates. The format of life support
 courses with AED use recommended by AHA, Heartsaver AED course, is classroom-based with instructor and video,
 group interaction and lasts 2.5 hrs without infant CPR. There is also Heartsaver CPR & AED online course with part 1
 delivers cognitive learning through Web-based, self-paced modules. (2 hours) Parts 2 and 3 require students to meet
 with an AHA Instructor to complete skills practice session and test.

 Included studies have examined the effect of alternative training intervention on AED skill acquisition, performance and
 retention, these include: training by layperson; shorter instructor based training; self-training (web-based and videos)
 and minimal training. None of the studies were designed as non-inferiority trials.

 Instructor professional background

 There are 2 studies which examined the background of course instructor and its impact on AED skill. Castren (Castren,
 2004, 305) conducted a non-randomised study with concurrent controls during which participants were split into two
 groups to be taught by either lay instructors or instructors who were health care professionals. Their BLS and AED
 skills were then tested in an OSCE 2-3 weeks after training session. Training format was ERC recommended 4 hour
 course with classroom teaching and hands on practice. AED skill score was not analyzed separately but the study found
 no significant difference between combined BLS/AED OSCE test score, however, the study was not designed as an
 non-inferiority trial. Xanthos (Xanthos, 2009, 224) conducted a randomized controlled trial during which 108 nurses
 were randomized to AED training by either a doctor or nurse instructor. Skill retention was measured in a written test
 and OSCE conducted 1 month after initial training. There was no difference found in the written test, however
 participants taught by nurses outperformed those taught by doctors in all 7 domains of the OSCE assessment.


 Self directed learning

 Computer based learning: A pilot study examined the effectiveness of a web-based BLS / AED self-training program
 amongst 16 lay persons (De Vries, 2007, 491). The web-based program included theory, scenario training and self-
 testing, but without practice on a manikin, or any instructor input. All volunteers performed the assessed skills in the use
 of an AED correctly but BLS skills of opening airway, ventilations and chest compression depth and rate were
 performed poorly. There was no association between the time a participant spent on-line and the quality of
 performance. The results suggest that it is possible to train people in AED skills using a micro-simulation web-based
 interactive program and without any practice on a manikin. Moule (Moule, 2008, 427) conducted a non-randomised
 study with concurrent controls in which 83 mental health staff were allocated to classroom teaching (2.5 hr lecture,
 n=55) or e-learning (3 hr access plus one hour manikin practice, n=22) and asked to complete a pre- and post-test
 questionnaire on AED use and a standardized scenario for BLS performance. The study found that e-learning group
 were faster to give the first shock (3.38 secs) and no difference was found for safety performance. Electrode pad
 placement, however, was poor for both groups. A cluster randomized study of high school students compared (1)
 interactive computer learning (2) interactive computer learning plus instructor led practical training (3) video based
 learning plus instructor led practical training (4) no training (Reder, 2006, 443). The study was supportive that some
 training (groups(1-3)) was better than no training (group 4) for BLS/AED skills. However hands-on practice (groups
 2+3) enhanced students’ performance (correct AED pad placement and CPR actions) compared to computer training
 only (group 1). Jerin et al (Jerin, 1998, 709) compared AED skill maintenance in emergency medical technicians (EMTs)
 during quarterly AED skill refresher training. Participants were allocated according to shift patterns to one of 3 groups.
 Two groups combined computer assisted learning with instructor facilitated learning whilst the control group involved
 instructor based training only. There were no differences between training groups in the increase in performance
 scores but the study was not based on non-inferiority design.
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 Video: Ropollo (Ropollo, 2007, 276) randomized 270 airline staff to traditional instructor led training (3 hours) or a 30
 min video self learning course (including mankin CPR practice but not AED use). Performance following 30-min training
 was equivalent to the multi-hour Heartsaver-Automated External Defibrillator training in all measurements, both
 immediately and 6 months after training. At 6 months, 84% of the 30-min training group was judged, overall, to perform
 cardiopulmonary resuscitation adequately with 93% performing chest compressions adequately and 93% with correct
 AED skills. Meischke (Meischke, 2001, 216) randomized 210 senior citizens (average age 71) to 45 minute video or
 instructor led training. The study found instructor led group were slightly faster in time to first shock at both immediate
 evaluations and at 3 months (average time differences of <20 seconds). Skill performance showed marked deterioration
 with time however in both groups. Mancini (Mancini, 2009, 159) compared a self directed DVD course with un-
 supervised manikin practice (CPR Anytime) with DVD instructions and practice manikin, with a traditional instructor-led
 course. Participants were randomized according to group size and in blocks. The self directed group performed skills
 less well than the instructor led group (lower scores for: calling 911, delivering chest compressions of adequate depth
 and clearing to victim to analyse and shock). It was noted subsequently that these points were not covered in enough
 detail in the DVD

 De Vries (De Vries, 2008, 76) examined efficacy and potential cost savings from self-training in AED use. The
 randomized controlled trial used BLS trained nurses to compare self directed training (with a poster and manikin
 practice) with traditional instructor training. There was no significant difference in AED performance found between the
 groups. If poster self-training were to be used instead of instructor-based courses, it was calculated that there would be
 a saving in costs of up to €6 for each nurse trained.

 Minimal training / No Training

 Kelley et al (Kelley, 2006, 299) examined learning outcomes following a condensed 1 hour BLS/AED course amongst
      th
 33 8 grade students. Initial skills assessment demonstrated that 29/33 (87.8%) students were proficient at BLS/AED
 following the 1 hour course. Four week later 28/33 (84.8%) students demonstrated skill retention in similar scenario
 testing. Students also showed improvement in written knowledge regarding AED use as shown by scores on an AHA
 based written exam (60.9% versus 77.3%; p < 0.001). However, there was no control group to compare with in this
 study.

 Mitchell et al (Mitchell, 2008, 301) examined the effect of three types of brief training on the use of automatic external
 defibrillators (AEDs) by 43 lay users. The exposure training group read an article about AEDs that provided no
 operational instructions; the low-training group inspected the AED and read the operating instructions but was given no
 practice; and the high-training group watched a training video and performed a mock resuscitation using the AED but no
 manikin. After 2 weeks, participants were asked to perform a simulated AED resuscitation on a manikin. The results
 showed that most participants in each training group met minimum criteria of acceptable performance during the
 simulated manikin resuscitation. Time to first shock was set at 150 seconds and 92.3% of exposure only group and all
 participants in low and high training group performed first shock within acceptable time, however, exposure group was
 slower (107secs) than low and high training group (73 secs and 86 secs respectively). Training had no significant
 difference found in pad placement (p>0.08) but more training decreased errors by participants (1.43 in exposure group,
 0.67 in low training and 0.31 in high training).The study concluded that although untrained users were able to
 adequately use this AED, additional brief training improved user time to first shock. Gundry (Gundry, 1999, 1703-1707)
 compared AED use of untrained children with trained paramedic using mock cardiac arrest scenario. Mean time to
 defibrillation was 90+/-14 s (range, 69-111s) for the children and 67+/-10 s (range, 50-87 s) for the paramedics
 (P<0.0001). Electrode pad placement and safety was appropriate for all subjects. The study found that difference
 between the groups is small, considering that children as untrained first-time users.

 Beckers (Beckers, 2005, R110) compared AED use by medical students before and after a 15 min lecture. Time to first
 shock decreased significantly from 81.2 ± 19.2 sec to 56.8 ± 9.9s; p<0.01 with minimal theoretical training. The study
 also found that semiautomatic-AED was easier and quicker to use than an automatic defibrillator (before training: 77.5 ±
 20.5 s versus 85.2 ± 17 s, P ≤ 0.01; after training: 55 ± 10.3 s versus 59.6 ± 9.6 s, P ≤ 0.01). A further study by the
 same group (Beckers, 2007, 444) confirmed these findings and showed that skill retention after brief (15 minute) training
 remained high at 6 month follow up.


 Mattei et al (Mattei, 2002, 277) investigated whether nurses and physiotherapists can use an AED without prior training
 and found all untrained subjects could deliver a shock with an AED in 68.89±29.2s ( time ±S.D., range, 40-169 s).
 However, they also found that most participants failed to position the pads correctly (53%) or follow correct safety
 procedures (67%). After a standard 6 hour training session, the time to deliver a shock improved significantly to
 48.59±5.5s (range, 41-61 s, P<0.01) and all subjects placed the pads correctly and followed a safe defibrillation
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 procedure. The authors concluded that nurses and physiotherapists, with no previous AED training, can deliver a shock
 with an AED within a reasonable time but training improves speed of shock delivery, correct pad placement and safety.


Conclusion
 DISCLAIMER: Potential possible wording for a Consensus on Science Statement. Final wording
 will differ due to other input and discussion.

 CONSENSUS ON SCIENCE:

 Instructor Professional Background

 Evidence from one LOE 2 (quality fair) study (Castren, 2004, 305) showed that training by layperson is as effective as
 training by health care professional. Further evidence from one LOE 2 (quality fair) demonstrated that tuition by nurses
 as compared to doctors led to better skill acquisition. (Xanthos, 2009, 224)

 Alternatives to instructor led training

 Evidence from one LOE 1 (quality fair) (Reder, 2006, 443) and two LOE 2 studies (quality fair) (Jerin, 1998, 709; Moule,
 2008, 427) and one further LOE 4 (quality fair) (De Vries, 2007, 491-496) study supported the use of computer based
 AED training for enhancing AED skill acquisition and retention particularly when combined with manikin practice.

 Evidence from one LOE 1 (quality good) (Ropollo 2007, 276) supports and two LOE 1 (quality good) (Meischke, 2001,
 216; Mancini, 2009, 159) provide evidence against the use of video self instruction compared to instructor led training

 Evidence from one LOE1 (quality fair) (De Vries, 2008, 76-82) supported the use of training poster and manikin for
 learning AED skills.

 No Training/ Minimal training

 Evidence from one LOE 1 (quality fair)(Reder 2006, 443), one LOE 2(quality fair) (Mattei, 2002, 277) and one LOE 4
 (quality fair) (Gundry, 1999, 1703) showed that lay people and health care professionals could use an AED without
 training.

 Evidence from three LOE 2 (quality fair) (Beckers, 2005, R100; Beckers, 2007, 444; Mitchell, 2008, 301) support
 minimal training over no training (15 min lecture (Beckers, 2005, R100; Beckers, 2007); 1 hour lecture with manikin
 practice (Kelley, 2006, 229) or reading instructions (Mitchell, 2008, 301).




 TREATMENT RECOMMENDATION:



 Acknowledgements:
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                                                            Citation List
Beckers 2005

Beckers S, Fries M, Bickenbach J, Derwall M, Kuhlen R and Rossaint R. Minimal instructions improve the
performance of laypersons in the use of semiautomatic and automatic external defibrillators. Critical Care (2005)
9(2): R110-R116


Introduction There is evidence that use of automated external defibrillators (AEDs) by laypersons improves rates of
survival from cardiac arrest, but there is no consensus on the optimal content and duration of training for this purpose. In
this study we examined the use of semiautomatic or automatic AEDs by laypersons who had received no training
(intuitive use) and the effects of minimal general theoretical instructions on their performance.
Methods In a mock cardiac arrest scenario, 236 first year medical students who had not previously attended any
preclinical courses were evaluated in their first study week, before and after receiving prespecified instructions (15 min)
once. The primary end-point was the time to first shock for each time point; secondary end-points were correct electrode
pad positioning, safety of the procedure and the subjective feelings of the students.
Results The mean time to shock for both AED types was 81.2 ± 19.2 s (range 45–178 s). Correct pad placement was
observed in 85.6% and adequate safety in 94.1%. The time to shock after instruction decreased significantly to 56.8 ±
9.9 s (range 35–95 s; P ≤ 0.01), with correct electrode placement in 92.8% and adequate safety in 97%. The students
were significantly quicker at both evaluations using the semiautomatic device than with the automatic AED (first
evaluation: 77.5 ± 20.5 s versus 85.2 ± 17 s, P ≤ 0.01; second evaluation: 55 ± 10.3 s versus 59.6 ± 9.6 s, P ≤ 0.01).
Conclusion Untrained laypersons can use semiautomatic and automatic AEDs sufficiently quickly and without instruction.
After one use and minimal instructions, improvements in practical performance were significant. All tested laypersons
were able to deliver the first shock in under1 min.
                  st
LOE 2before (1 test with no instructions) and after effect (15min lecture no practical session, 1 use in previous test);
Quality good, supportive. Also compared automatic and semi-automatic defibrillators.

Beckers 2007

Beckers S, Fries M, Bickenbach, Skorninga M, Derwalla M, Kuhlenb R, Rossainta R. Retention of skills in
medical students following minimal theoretical instructions on semi and fully automated external defibrillators.
Resuscitation (2002) 72:444-450

Aim of the study: There is consent that the use of automated external defibrillators (AED) by laypersons improves
survival rates in case of cardiac arrest, but no evident consensus exists on the content and duration of training for this
purpose. Acceptance of the implementation of Public Access Defibrillation programmes will depend on practical and
target-oriented training concepts. The aim of this prospective randomised interventional study was to evaluate long-term
effects of a specific, minimal training programme on using semiautomatic and fully automatic AEDs in simulated cardiac
arrest.
Materials and methods: In a mock cardiac arrest scenario 59 medical students with no specific previous medical
education were tested during their first semester at medical school. Students who passed any medical emergency
training were excluded. The subjects were evaluated before and after attending specified instructions of 15 min duration
and after a period of 6 months. Main end points were time to first shock, electrode-positioning and safety throughout the
procedure.
Results: Mean time to first shock without prior instructions was 77.7±17.05 s. After instruction there was a significant
improvement to 56.5±9.5 s (p≤0.01) and after 6 months this time had only slightly elongated (59.9±8.9 s; p≤0.01).
Initially, correct electrode placement was observed in 84.4%. No difference was found immediately and 6 months after
instructions (93.2% and 98.3%). All individuals performed safely.
                   st
LOE 2 before (1 test with no instructions) and after effect (15min lecture no practical session, 1 use in previous test);
Quality good, supportive. Randomisation only applies to semi-automatic and automatic AEDs.


Castren 2004

Castren M, Nurmi, Laakso J, Kinnunen A, Backman R, Niemi-Murola L. Teaching public access defibrillation to
lay volunteers—a professional health care provider is not a more effective instructor than a trained lay person.
Resuscitation (2004) 63: 305-310
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Background: Survival improves in witnessed out-of-hospital cardiac arrest if the victim receives bystander-initiated
cardiopulmonary resuscitation and rapid defibrillation (BLS/AED). The European Resuscitation Council has a simple
programme to teach these life-saving skills that require no previous experience of automated external defibrillators
(AEDs). To be able to implement the use of AEDs widely, many instructors are needed, and therefore, lay persons may
also be used as trainers. The purpose of this randomized study was to compare lay volunteers trained by a lay person
with those trained by a health care professional using the Objective Structured Clinical Examination (OSCE).
Methods: Eight instructors, including four lay persons and four health care professionals, were given a basic course and
an instructor course in CPR-D by the same instructor. All newly trained instructors trained 38 lay volunteers (19 pairs)
who had no previous training in the use of a defibrillator. The lay volunteers performed the OSCE 2–3 weeks after the
course. The OSCE comprised two scenarios with a manikin: the first, a patient in cardiac arrest with ventricular
fibrillation, and the second, an imminent cardiac arrest with asystole as the initial rhythm. The same OSCE was
performed by a group of lay first aiders practicing every 2 weeks who served as the control group.
Results: No statistical difference was present between the two groups of lay volunteers in the OSCE. All were able to use
the AED and follow instructions. They identified patients with ventricular fibrillation and cardiac arrest, but had difficulties
identifying cases with imminent cardiac arrest. The control group of trained first aiders performed significantly more
effectively than the newly trained lay persons.
Conclusions: No significant benefit exists in the trainer being a health care professional, but thorough training and
subsequent rehearsing of the skills learned are crucial.

LOE 2; Quality Fair, supportive. Study compared skill performance of AED use as well as quality of CPR of layperson
trained by HCP or layperson instructor. OSCE score not specific to AED use.

De Vries 2007

De Vries W, Handley A. A web-based micro-simulation program for self-learning BLS skills and the use of an
AED. Can laypeople train themselves without a manikin? Resuscitation (2007) 75: 491-8

Aim: Various methods, including self-instruction, have been used to try to improve the acquisition of basic life support
skills. This is a preliminary report of the effectiveness of a web-based self-training program for BLS and the use of an
AED.
Methods: Sixteen volunteers completed on-line training in their own time over a period of 8 weeks. The program included
theory, scenario training and self-testing, but without practice on a manikin, or any instructor input. The volunteers were
assessed, without prior warning, in a scenario setting. A recording manikin, expert assessors and video recording were
used with a modified version of the Cardiff Test.
Results: All 16 volunteers performed the assessed skills in the use of an AED correctly. Most of the skills of BLS
assessed were performed well. Chest compression depth and rate were performed less well (59% and 67% of
participants, respectively, performed correctly). Opening the airway and lung inflation were performed poorly (38% and
13% of participants performed correctly), as was checking for safety (19% participants performed correctly). There was
no significant correlation between the time a participant spent on-line and the quality of performance. Only 5 of the
volunteers had ever attended a BLS course or used a resuscitation manikin before the assessment; their performance
scores were not significantly better than those of the other 11 volunteers.
Conclusion: These results suggest that it may be possible to train people in BLS and AED skills using a micro-simulation
web-based interactive program but without any practice on a manikin. This seems to be particularly the case for the use
of an AED, where performance achieved a uniformly high standard.

LOE 4; Quality fair, supportive. Study compared BLS skills as well as AED use in layperson trained by web based
program, no manikin/practice. No control group.

De Vries 2008

de Vries W, Schelvis M, Rustemeijer I, Bierens J. Self-training in the use of automated external defibrillators: The
same results for less money. Resuscitation (2008) 76:76-82

Purpose: To compare the educational benefits and cost-effectiveness of initial AED training for nurses, already trained in
basic life support, by a 3-h, instructor-based course, with self-training by means of an instructional poster, a resuscitation
manikin, and a training AED.
Methods: Thirty general ward nurses from a single regional hospital were randomly allocated to one of two groups for
training in the use of an AED. Fifteen nurses were trained by a certified instructor and 15 nurses participated in self-
training using a poster, manikin, and training AED. Each nurse was assessed on 17 aspects of performance between 13
and 16 days after training.
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Results: The two groups were comparable for gender, seniority, and experience in resuscitation. No significant
differences in performance were found between the groups for 14 of the skills tested. For three skills, there were
statistical differences, but these were not considered to be of clinical relevance. If poster self-training were to be used
instead of instructor-based courses, it was calculated that there would be a saving in costs of up to D 47 for each nurse
trained.

LOE 1; Quality fair, supportive. Compared skill performance of BLS and AED use in self training using manikin and
poster with 3 hour instructor based training. Self training is more cost effective.

Gundry 1999

Gundry J.W., Comess K.A., DeRook F.A., Jorgenson D., Bardy G.H. Comparison of naive sixth-grade children
with trained professionals in the use of an automated external defibrillator. Circulation. 100(16)(pp 1703-1707),
1999.

Background - Survival after out-of-hospital cardiac arrest (OHCA) is strongly influenced by time to defibrillation. Wider
availability of automated external defibrillators (AEDs) may decrease response times but only with increased lay use.
Consequently, this study endeavored to improve our understanding of AED use in naive users by measuring times to
shock and appropriateness of pad location. We chose sixth-grade students to simulate an extreme circumstance of
unfamiliarity with the problem of OHCA and defibrillation. The children's AED use was then compared with that of
professionals. Methods and Results - With the use of a mock cardiac arrest scenario, AED use by 15 children was
compared with that of 22 emergency medical technicians (EMTs) or paramedics. The primary end point was time from
entry onto the cardiac arrest scene to delivery of the shock into simulated ventricular fibrillation. The secondary end point
was appropriateness of pad placement. All subject performances were videotaped to assess safety of use and
compliance with AED prompts to remain clear of the mannequin during shock delivery. Mean time to defibrillation was
90+/-14 seconds (range, 69 to 111 seconds) for the children and 67+/-10 seconds (range, 50 to 87 seconds) for the
EMTs/paramedics (P<0.0001). Electrode pad placement was appropriate for all subjects. All remained clear of the
'patient' during shock delivery. Conclusions - During mock cardiac arrest, the speed of AED use by untrained children is
only modestly slower than that of professionals. The difference between the groups is surprisingly small, considering the
nivete of the children as untutored first-time users. These findings suggest that widespread use of AEDs will require only
modest training.

LOE 4; Quality fair, supportive. Study demonstrated that un-trained school children could use an AED without training

Jerin 1998

Jerin J, Ansell B, Larsen M, Cummins R. Automated External Defibrillators: Skill Maintenance Using Computer-
assisted Learning. Academic Emergency Medicine (1998) 5(7): 709-717

Objective: To determine whether computer-assisted learning (CAL) can maintain the automated external defibrillation
(AED) skills of emergency medical technicians (EMTs).
Methods: The authors conducted a 1-year prospective comparison of an AED-skill training software program, running on
desktop computers, with traditional instructor-led training. The subjects were experienced EMT-Ds (EMT-defibrillation),
already trained in automated defibrillation (n = 105) employed as full-time professional EMT-D fire fighters. Two of the 3
groups (groups A and C) in the study were assigned to use the CAL program for 6 months. The third group (group B)
remained on the normal, instructor-led training regimen. Pre- and post-study skill levels were measured using a skills
performance test.
Results: A secular trend of improved mean treatment scores was observed across all 3 groups [mean rise of 0.49 point
(p = 0.01), repeated-measures analysis of variance]. There were no differences between training groups in the increase
in performance scores (p = 0.3). The 1- time cost of supplying the CAL program to the 105 EMT-Ds was $1,575,
significantly less than the $3,240- per-year cost associated with instructor-led training.
Conclusions: The authors observed satisfactory AED skill maintenance for experienced EMT-Ds using CAL to replace 2
of 4 quarterly instructor-led skills reviews. CAL has cost and convenience advantages over instructor-based skill
maintenance and is an acceptable alternative.

LOE 2; Quality fair, supportive. Cross over trial design, randomised according to shift work. Skill retention examined in
speed and treatment categories, not individually broken down into components.

Kelley 2006
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Kelley J, Richman P, Ewy G, Clark L, Bulloch B, Bobrow B. Eighth grade students become proficient at CPR and
use of an AED following a condensed training programme. Resuscitation (2006) 71:229-236

Objective: To evaluate a new, 1-h, condensed training programme to teach continuous chest compression
cardiopulmonary resuscitation (CCC-CPR) and automated external defibrillator (AED) skills to a cohort of eight grade
public school students.
Methods:
Study design-prospective, interventional trial;
Study population-convenience sample of students from two eighth grade classes;
Study setting-urban, public school;
Study protocol-written parental consent was obtained. Student attitudes, prior experience and baseline knowledge were
sampled using an initial questionnaire and a modified American Heart Association (AHA) CPR/AED pre-test. Students
received training in continuous chest compression CPR (CCC-CPR) and AED use through a new condensed training
programme. Student CCC-CPR and AED skills were immediately tested in a standardized fashion by the study team.
Four weeks later, written and practical examinations were retaken by the same students supervised by the study team.
Examination score differences were analyzed using matched pair t-tests. All tests were two tailed with alpha set at 0.05.
Confidence Intervals (CI) 95% were calculated as appropriate. The primary outcome measure was the percentage of
students who could correctly perform CCC-CPR and application/operation of an AED in a mock adult cardiac arrest
scenario.
Results: Thirty-three eligible subjects completed the programme; mean age 13.7 years; 48.5% female. Eight participants
reported some prior training in CPR and AED use. Following initial training, 29/33 (87.8%) subjects demonstrated
proficiency at CCC-CPR and AED application/operation in a mock adult cardiac arrest scenario. At four-weeks, 28/33
(84.8%) subjects demonstrated skill retention in similar scenario testing. Subjects also showed improvement in written
knowledge regarding AED use as shown by scores on an AHA based written exam (60.9% versus 77.3%; p < 0.001).
Conclusion: With our focused, condensed training program, eighth grade public school students became proficient in
CCC-CPR and AED use. This is the first study to document the ability of middle school students to learn and retain CCC-
CPR and AED skills for adult sudden cardiac arrest victims with such a curriculum.

LOE 4; Quality fair, supportive. No control group. Assessment of skill acquisition and skill retention at 4 weeks with
written and practical session of CPR and AED skills


Mancini 2009

Mancini ME. Cazzell M. Kardong-Edgren S. Cason CL. Improving workplace safety training using a self-directed
CPR-AED learning program. AAOHN Journal. 57(4):159-67, 2009

Adequate training in cardiopulmonary resuscitation (CPR) and use of an automated external defibrillator (AED) is an
important component of a workplace safety training program. Barriers to traditional in-classroom CPR-AED training
programs include time away from work to complete training, logistics, learner discomfort over being in a classroom
setting, and instructors who include information irrelevant to CPR. This study evaluated differences in CPR skills
performance between employees who learned CPR using a self-directed learning (SDL) kit and employees who attended
a traditional instructor-led course. The results suggest that the SDL kit yields learning outcomes comparable to those
obtained with traditional instructor-led courses and is a more time-efficient tool for CPR-AED training. Furthermore, the
SDL kit overcomes many of the barriers that keep individuals from learning CPR and appears to contribute to bystanders'
confidently attempting resuscitation.

LOE 1, quality good. Opposing results in self directed group was significantly worse in calling for help, chest compression
depth and clearing victim to analyse and shock. Deficiencies were found on DVD and improved upon but trial was not
repeated to give results after improvement.

Mattei 2002

Mattei L, Mckay U, Lepper M, Soar J. Do nurses and physiotherapists require training to use an automated
external defibrillator? Resuscitation (2002) 53:277-280

Healthcare staff with the duty to perform CPR should also be capable of using an automated external defibrillator (AED).
We investigate whether nurses and physiotherapists can use an AED without prior training. Subjects were tested on a
manikin during a cardiac arrest scenario. All 15 untrained subjects could deliver a shock with an AED in 68.89±29.2s (
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time ±S.D., range, 40-169 s). Most failed to position the pads correctly (53%) or follow correct safety procedures (67%).
After a standardised training session, the time to deliver a shock improved significantly to 48.59±5.5s (range, 41-61 s,
P<0.01) and all subjects placed the pads correctly and followed a safe defibrillation procedure. This study shows that
nurses and physiotherapists, with no previous AED training, can deliver a shock with an AED. Training improves speed
of shock delivery, correct pad placement and safety. This study suggests that it is feasible to train healthcare
professionals to use an AED with relatively little training. This should allow rapid deployment of AEDs in those areas of
the hospital where cardiac arrests are infrequent and staff do not have rhythm recognition skills.

LOE 2; Quality fair, supportive for time to first shock, oppose for placement of electrodes and safety. Although time to
first shock is significantly reduced by training, mean time is less than 1 minute and authors conclude that shocking with
AED does not require prior training. Randomised to training (6 hr combined BLS, AED course) and no training prior to
testing.


Meischke 2001

Meischke H, Rea T, Eisenberg M, Schaeffer S, Kudenchuk P. Training Seniors in the Operation of an Automated
External Defibrillator: A Randomized Trial Comparing Two Training Methods. Annals Of Emergency Medicine
(2001) 38(3):216-222

Study objective: This study evaluated the differences in efficacy of 2 methods for training seniors in the use of an
automated external defibrillator (AED). We tested the hypothesis that each training method (face-to-face instruction
compared with video-based instruction) would result in similar AED performance on a manikin.
Methods: Two hundred ten seniors from various senior centres were randomized to receive face-to-face or video-based
instruction on AED skills. Seniors were assessed individually and tested on the speed and quality of AED performance.
We retested 177 of these initial trainees 3 months after initial training. Similar performance measures were assessed.
Results: Although there were statistically significant differences between the 2 training methods in terms of average time
to shock at both evaluations, the results in general demonstrate that there were no clinically meaningful distinctions (time
differences of <20 seconds) between the AED performance of seniors trained with a video and seniors trained in a face-
to face setting at the initial training or at the retention assessment. At the initial evaluation, overall performance was
satisfactory, with greater than 98% trained with either method delivering a shock. However, at the 3-month follow-up,
almost one fourth of trainees were not able to deliver a shock, and almost half were not able to correctly place the pads
on the manikin.
Conclusion: We believe that seniors can be trained equally well in AED performance with video-based self-instruction or
face-to-face instruction. How to maintain acceptable AED performance skills over time remains a challenge.

LOE 1; Quality fair, opposing. Unblinded study. Randomised sequentially to instructor based training (15min lecture &
30min practice) or video based training (11min video & upto 45min practice). Statistically different time intervals to
delivering shock was found (20 seconds).

Mitchell 2008

Mitchell KB. Gugerty L. Muth E. Effects of brief training on use of automated external defibrillators by people
without medical expertise.
Human Factors. 50(2):301-10, 2008.

OBJECTIVE: This study examined the effect of three types of brief training on the use of automatic external defibrillators
(AEDs) by 43 lay users. BACKGROUND: Because AEDs were recently approved for home use, brief training for
nonprofessional users needs investigation. METHOD: During training, the exposure training group read an article about
AEDs that provided no information on how to operate them; the low-training group inspected the AED and read the
operating instructions in the paper-based manual but was not allowed to use the device; and the high-training group
watched a training video and performed a mock resuscitation using the AED but no manikin. All participants returned 2
weeks later and performed a surprise simulated AED resuscitation on a manikin. RESULTS: Most participants in each
training group met criteria of minimally acceptable performance during the simulated manikin resuscitation, as measured
by time to first shock, pad placement accuracy, and safety check performance. All participants who committed errors
were able to successfully recover from them to complete the resuscitation. Compared with exposure training, the low and
high training had a beneficial effect on time to first shock and errors. CONCLUSION: Untrained users were able to
adequately use this AED, demonstrating walk-up-and-use usability, but additional brief training improved user
performance. APPLICATION: This study demonstrated the importance of providing high-quality but brief training for
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home AED users. In conjunction with other findings, the current study helps demonstrate the need for well-designed
training for consumer medical devices.

LOE 2; Quality fair, Pseudorandomised trial as adjusted randomisation to ensure equal skill mix. Supportive for brief
training on time to first shock.

Moule 2008

Moule P. Albarran JW. Bessant E. Brownfield C. Pollock J. A non-randomized comparison of e-learning and
classroom delivery of basic life support with automated external defibrillator use: a pilot study. International
Journal of Nursing Practice. 14(6):427-34, 2008 Dec.

This pilot study investigated whether computer-based learning package followed by practical instruction and traditional
classroom methods were comparable in developing knowledge and skills in basic life support with automated external
defibrillator. Eighty-three mental health care professionals were allocated to one of two groups. Twenty-eight completed
an e-learning package, and the remaining 55 received delivery of content in a classroom. Using standardized
assessment methods, comparisons of participant knowledge gain and performance in resuscitation were made.
Significant increases in knowledge followed training. No differences were found with basic resuscitation skills or in the
time taken to the first shock; however, both groups were inaccurate with electrode pad placement. E-learners performed
slightly better in 21 of the 30 observed skills. Overall group performance did not differ suggesting computer-based
education has the potential to prepare learners in resuscitation knowledge and skills to comparable levels of classroom
courses.

LOE 2, quality fair. Supportive for AED performance following web-based learning. Non-randomised pilot study.

Reder 2006

Reder S, Cummings P, Quan L. Comparison of three instructional methods for teaching cardiopulmonary
resuscitation and use of an automatic external defibrillator to high school students. Resuscitation (2006) 69:
443-453

Objective: To evaluate new instructional methods for teaching high school students cardiopulmonary resuscitation (CPR)
and automated external defibrillator (AED) knowledge, actions and skills.
Methods: We conducted a cluster-controlled trial of 3 instructional interventions among Seattle area high school
students, with random allocation based on classrooms, during 2003—04. We examined two new instructional methods:
[1] interactive-computer training and [2] interactive-computer training plus instructor led (hands-on) practice, and
compared them with traditional classroom instruction that included video, teacher demonstration and instructor-led
(hands-on) practice, and with a control group.
We assessed CPR and AED knowledge, performance of key AED and CPR actions, and essential CPR ventilation and
compressions skills 2 days and 2 months after training. All outcomes were transformed to a scale of 0—100%.
Results: For all outcome measures mean scores were higher in the instructional groups than in the control group. Two
days after training all instructional groups had mean CPR and AED knowledge scores above 75%, with use of the
computer program scores were above 80%. Mean scores for key AED actions were above 80% for all groups with
training, with hands-on practice enhancing students’ positive outcomes for AED pad placement. Students who received
hands-on practice more successfully performed CPR actions than those in the computer program only group. In the 2
hands-on practice groups the scores for 3 of the outcomes ranged from 57 to 74%; they were 32 to 54% in the computer
only group. For the outcome of continuing CPR until the AED was available scores were high, 89 to 100% in all 3 training
groups.

LOE 1; Quality Fair, supportive. Both CPR and AED skills were tested with written and practical sessions in groups that
have interactive computer learning ± instructor, video based learning ± instructor and traditional instructor based
learning. Skill retention tested at 2 months due to school schedule. Key AED steps are used as outcomes: turn AED on,
apply pads, press shock button when advised.

Ropollo 2007

Ropollo L, Pepe P, Campbell L, Ohman K, Kulkarni H, Miller R, Idris A, Bean L, Bettes T, Idris AH. Prospective,
randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary
resuscitation and automated external defibrillators: The American Airlines Study. Resuscitation (2007) 74: 276-
285
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Objective: A head-to-head trial was conducted to compare laypersons’ long-term retention of life-saving psychomotor
and cognitive skills learned in the traditional multi-hour training format for basic cardiopulmonary resuscitation and
automated external defibrillator use to those learned in an abbreviated (30 min) course.
Methods: Laypersons were randomized to either: (1) the traditional multi-hour Heartsaver-Automated External
Defibrillator® (Heartsaver-AED®) group; or (2) the 30-min course group (cardiopulmonary resuscitation, choking, and
automated external defibrillator use). Immediately after training, and at 6 months, participants were provided identical
individual testing scenarios. In addition to audio—video recordings, computerized recordings of compression rate/depth,
ventilation rates, and related pauses were obtained and subsequently rated by blinded reviewers.
Results: Performance following 30-min training was either equivalent or superior (p < 0.007) to the multi-hour Heartsaver-
Automated External Defibrillator training in all measurements, both immediately and 6 months after training. Although
retention of certain skills deteriorated over the 6 months among a significant number of participants from both groups,
84% of the 30-min training group still was judged, overall, to perform cardiopulmonary resuscitation adequately.
Moreover, 93% still were performing chest compressions adequately and 93% continued to apply the automated external
defibrillator and deliver shocks correctly.
Conclusions: Using innovative learning techniques, 30-min cardiopulmonary resuscitation and automated external
defibrillator training is as effective as traditional multi-hour courses, even after 6 months. Thirty-minute courses should
decrease labour intensity, demands on resources, and time commitments for cardiopulmonary resuscitation courses,
thus facilitating more widespread and frequent retraining.

LOE 1; Quality good, supportive. Video self instruction with no practice in 30 min compared with traditional teaching,
CPR skills and AED use tested immediately and retention at 6 months. Better results for AED use immediately after
training but statistically not significant. Skill retention is equivalent to traditional group.

Xanthos 2009

Xanthos T. Ekmektzoglou KA. Bassiakou E. Koudouna E. Barouxis D. Stroumpoulis K. Demestiha T. Marathias
K. Iacovidou N. Papadimitriou L. Nurses are more efficient than doctors in teaching basic life support and
automated external defibrillator in nurses. Nurse Education Today. 29(2):224-31, 2009 Feb

BACKGROUND: Cardiac arrest (CA) is a leading cause of death worldwide. The European Resuscitation Council (ERC)
has developed basic life support/automated external defibrillation (BLS/AED) courses for uniform training in out-of-
hospital CA. OBJECTIVE: The present study compares the resuscitation skills of two groups of nursing staff, one taught
by newly trained ERC nurse-instructors and the other by newly trained doctor-instructors. METHOD: Eighteen doctors
and 18 nurses were asked to teach a total of 108 nurses in a (BLS/AED) course. One month after its completion, all 108
nurses were asked to be re-evaluated, with the use of the objective structured clinical examination. CONCLUSIONS: No
statistical significant difference between the two groups was noted in the written test, in contrast with data collected from
the practice skills check-list. Nurses in group A could easily identify the patient in cardiac arrest but had difficulties
concerning chest compressions and handling the AED. Nurses in group B were more focused during the performances,
used AED more accurately and continued cardiopulmonary resuscitation with no delays. Nurses prove to be more
efficient in training nurses.

LOE 2; Quality fair, supportive. Overall score from written test and OSCE practical test compared. Better OSCE score for
group taught by nurses and it includes BLS as well as AED skills.

				
DOCUMENT INFO
Description: Instructor Training Questionnaire Worksheet document sample