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http://jnep.sciedupress.com Journal of Nursing Education and Practice 2021, Vol. 11, No. 8
ORIGINAL RESEARCH
RCT comparing the clinical effectiveness of
conventional instructor-facilitated cardiac compression
training to technology enhanced training using
high-fidelity mannequins–A pilot study
Alison Pighills∗1,2, Rachel Waye1,3, Stephanie Taylor3, Vicki Braithwaite3, Daniel Lindsay4, Mohamad Alshurafa1
1Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, Queensland, Australia
2College of Healthcare Services, Division of Tropical Health and Medicine, James Cook University, Townsville, Queensland,
Australia
3Education and Training Department, Mackay Hospital and Health Service, Mackay, Queensland, Australia
4College of Public Health, Medical and Veterinary Sciences, Division of Tropical Health and Medicine, James Cook University,
Townsville, Queensland, Australia
Received: February 7, 2021 Accepted: April 7, 2021 Online Published: April 20, 2021
DOI: 10.5430/jnep.v11n8p69 URL: https://doi.org/10.5430/jnep.v11n8p69
ABS TR ACT
Introduction:
Healthcare professionals often provide substandard chest compression following cardiac arrest. This is deemed
a preventable harm because this skill can be acquired. The recent development of technology-enhanced cardiac compression
training devices provides an alternative to traditional instructor-facilitated training. This pilot study compared the effectiveness of
conventional and technology-enhanced training modalities.
Methods:
A pilot randomised controlled trial design was used in a regional hospital in Queensland. Following baseline
assessment, healthcare staff were randomised to one of three groups: traditional instructor-facilitated training; high-fidelity
mannequin training and continuous access to the training system to practise skills; and, high-fidelity mannequin training with no
further access to the training system to practise skills. The primary outcome, cardiac compression skill levels, was analysed using
analysis of co-variance, adjusting for predictive co-variates. Secondary measures were analysed using inferential statistics or
presented descriptively.
Results:
Between January and February 2017, 502 healthcare staff were recruited. At baseline, 21% were competent in cardiac
compression, increasing to 38% on reassessment. The mode of training did not affect skill level (F(92,392) = 0.061, p= .94),
however, participants in the high-fidelity mannequin training group who practised their skills had statistically significantly higher
reassessment scores (z = -2.34, p= .019). Baseline score and the number of times participants practised their skills were significant
predictors of reassessment scores (F(2,392) = 7.73, p= .001).
Conclusions:
Most hospital staff who may need to perform cardiac compression were not competent in this skill. Neither training
modality was more effective. Both training and practise increased cardiac compression skill levels, indicating that frequent,
low-dose training is required.
Key Words: Cardiac arrest, Cardiac compression, CPR, Patient safety, Education, Simulation
∗Correspondence:
Alison Pighills; Email: alison.pighills@health.qld.gov.au; Address: Mackay Institute of Research and Innovation, Mackay Base
Hospital, P.O. Box 5580, Mackay Mail Centre, Mackay, Queensland 4741, Australia.
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1. INTRODUCTION
The quality of chest compressions provided by healthcare
professionals and trained rescuers is notoriously poor.
[1–5]
Although, the positive relationship between effective chest
compressions, survival and favourable neurological outcome
is well established,
[3, 6–10]
research suggests that compression
depths are suboptimal for almost all patients.
[1, 3, 11]
Effec-
tive chest compressions are the foundation for downstream
resuscitation efforts and significantly positively influence
outcome.
[3, 12]
To provide the best chance of return of spon-
taneous circulation (ROSC) adult chest compressions should
be delivered at a rate of 100-120/min, to a depth of at least
50mm, with release to allow complete chest wall recoil and
minimal interruption to compression.
[7, 12]
Substandard chest
compression is deemed a preventable harm because effec-
tive cardiopulmonary resuscitation can be taught and skills
acquired.[6]
Chest compression knowledge is described as knowing and
performing the correct actions sequence, and skill is defined
as using the correct rate, depth and hand position.
[13]
Real
time objective measurement and feedback significantly im-
prove the quality of chest compression skill and effective
skills training increases survival rates following cardiac ar-
rest.[9, 14–17]
Annual recertification of cardiac compression skill is manda-
tory for most healthcare organisations, as recommended by
international resuscitation councils.
[5, 7, 18]
The provision of
cardiac compression training is generally through annual
instructor-facilitated training with subjective assessment of
participants, which usually takes approximately an hour, how-
ever, guidelines suggest that retraining cycles of 1-2 years are
insufficient to maintain competence.
[5, 18]
A number of issues
have been identified regarding training of acute health care
staff in compression skills, including: recommended retrain-
ing timeframes; the logistical management and resourcing
of training; objectively measuring effectiveness in staff capa-
bility; and, the cost of retraining cycles.
[5]
Compliance with
retraining regimens is also variable and often poor.
Skills retention following cardiac compression training sig-
nificantly declines over the first two to six months,
[5, 13, 19, 20]
with less than 50% of trainees remaining proficient at five
months.
[21]
Skills decay rapidly after initial training,
[7, 19, 22]
and 1-2 yearly retraining cycles do not maintain compe-
tence in compression skills.
[7]
Compression skills are further
affected by the urgency and emotive circumstances of the
resuscitation situation and lack of regular exposure to real
life events in human patients.
[5]
International consensus is to
provide high frequency, low dose cardiac compression train-
ing, to prevent skill degradation, using mannequins which
provide directive feedback (high-fidelity mannequins) to en-
hance skill acquisition, as trainers are unable to reliably iden-
tify sub-optimal compressions, thus, are unable to provide
consistent corrective feedback.[7,23]
Advances in simulation technology have led to the develop-
ment of technology-enhanced cardiac compression training
devices. High-fidelity mannequins incorporate the latest in
computer technology into a realistic-looking full body which
provides comprehensive feedback to the trainee. These man-
nequins provide objective, real time, audio-visual feedback
on compression rate, depth, release and hand position dur-
ing assessment and have been shown to be more effective
than instructor-facilitated training and subjective assessment,
undertaken by assessors.
[4, 14, 20, 24, 25]
Research reveals that
high-fidelity mannequins enhance trainees’ ability to provide
high quality continuous chest compressions of appropriate
rate and depth.
[3, 5, 9, 20, 26, 27]
One such device is the Ameri-
can Heart Association Resuscitation Quality Improvement
(RQI) training system (Laerdel Pty Ltd.), which is purported
to: provide objective measurement of cardiac compression
skills and record training compliance rates; enable health-
care providers to embed high-quality cardiac compression
performance, through annual learning modules and quarterly
self-directed 10-minute drills; and, be more cost effective
compared to conventional instructor-facilitated training and
e-Learning methods.
[24]
Use of high-fidelity simulation has
a positive effect on skill acquisition and retention.[19,26]
This pilot study evaluated the difference in staff cardiac com-
pression skill levels between a group who underwent training
using a high-fidelity mannequin via the RQI training system
and a control group who underwent the traditional instructor-
facilitated training provided by the Hospital and Health Ser-
vice. We additionally examined skill levels between different
disciplines.
Our research questions were:
1) Is technology enhanced cardiac compression training more
effective in improving skills, as compared to conventional
instructor-facilitated cardiac compression training, for health
care staff who may have to perform cardiac compression as
part of their role?
2) Does practising cardiac compression skills between assess-
ments increase skill level as compared to no skills practise?
3) At what timepoint post training do cardiac compression
skills decline?
4) Were cardiac compression skill levels different between
disciplines, at baseline and on re-assessment?
This study has several unique aspects. Evaluating time to
skills degredation has been identified as an important re-
search focus to determine whether brief booster training
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sessions are sufficient for skill retention over time.
[28]
There
is a paucity of research assessing skill retention over a longer
follow-up period. Finally, few studies have evaluated the
clinical effectiveness of different training modalities in a re-
alistic clinical setting, and few have taken place in a regional,
as opposed to a municipal, location.
2. METHODS
A three-group randomised controlled trial (RCT) was car-
ried out in a regional hospital in Queensland, Australia
and received ethics approval from Townsville Human
Research Ethics Committee (HREC/16/QTHS/82). AC-
TRN:ACTRN12620000434998.
The trial comprised of a control group who received usual
instructor-facilitated training via mannequins incorporating
either no feedback or low-fidelity visual feedback mecha-
nisms (group A – traditional training); an intervention group
who were trained using the RQI training system and had
continuous access to the system to practice their cardiac
compression skills throughout the trial (group B – RQI con-
tinuous access), to replicate how the system is intended to
be used; and, an intervention group who were trained using
the RQI training system but had no other interaction with the
system throughout the trial (group C – RQI one off access),
to mimic group A’s inability to practise skills.
The pilot study was divided into two elements as follows:
Element 1: Effectiveness of cardiac compression train-
ing and skill retention
The difference in health care staff competence in perform-
ing cardiac compression was measured between the con-
trol group, which underwent traditional instructor-facilitated
training, and the two intervention groups, which received
skills training and objective feedback via the RQI training
system and had continuous access to the system to practise
skills (group B) or one off access for training purposes only
(group C). The difference in competence in performing car-
diac compression was also measured between doctors, nurses,
health practitioners and operational officers. Staff cardiac
compression skill levels were measured over various time-
points, to elicit the timeframe over which staff maintained
competence.
Element 2: Intensity of skills practice
The difference in staff competence in performing cardiac
compression with differing levels of skills practice was mea-
sured between groups. This was achieved by reviewing the
number of times each group B participant accessed the RQI
training system to practice cardiac compression skills outside
of the baseline and reassessment timepoints.
Health care staff were eligible to be included in the study if
they: were medical, nursing, allied health or identified opera-
tional staff who may be required to provide cardio-pulmonary
resuscitation as part of their role; were permanent or tem-
porary employees, with contracts ending after the study end
point; worked in any unit in the regional Hospital; and, were
over 18 years of age. Staff were excluded if they: were
planning extended leave during the study period; were on a
modified return to work program that excluded them from
performing cardiac compression; or, were unable to perform
cardiac compression due to pregnancy, injury or ill health.
The primary outcome measure was the level of competence
in cardiac compression (% score at baseline, three and six-
month follow up assessments). This was measured by the
RQI training system which provided an objective, compos-
ite measure of compression rate, depth, release and hand
position, summarised as a percentage skill score, with
≥
75% indicating a successful resuscitation attempt. Secondary
measures included the proportion of people who passed the
objective assessment on the RQI training system (75% or
over), time to skill degradation and the number of times staff
in group B practised cardiac compression skills.
We determined that a 20% difference between group mean
competency scores would be highly clinically significant.
To detect a difference of 0.2 between the experimental and
control group means with 0.9 power, we calculated that we
would need to study 132 subjects in each group (equating
to 396 participants) to be able to reject the null hypothesis,
that the population means of the experimental and control
groups are equal. The Type I error probability associated
with this test of the null hypothesis was 0.05. Allowing for
20% attrition, in anticipation of high staff turnover, we aimed
to recruit 475 participants.
Recruitment took place from 16th January to the 28th Febru-
ary 2017. Staff were recruited by electronic invitation, re-
searchers visiting clinical areas and inviting staff to partici-
pate, word of mouth and opportunistic recruitment. Potential
participants were given a participant information sheet and
asked to complete and return a consent form. Once partici-
pants had provided informed consent, a baseline assessment
of cardiac compression skill was carried out.
Baseline, three and six-month follow-up assessments of car-
diac compression skill level were carried out with all three
groups, using the RQI training system. Study participants
were blinded to the outcome of the baseline and follow-up as-
sessments. Feedback components were deactivated or could
not be seen or heard by the participants, so that participants
were unaware of their individual results, which were stored
electronically on the RQI training system. In addition, out-
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come assessors and the statistician were blinded to group
allocation, but it was not possible to blind participants.
At the baseline assessment, the participant’s employee identi-
fication (ID) number and group allocation were entered into
the RQI training system to enable group A and C participants
to be deactivated until their reassessment. This was to pre-
vent them from accessing the RQI training system to practise
cardiac compression skills between assessments. Group B
had access to the RQI training system to practise cardiac
compression skills throughout their participation in the trial.
Participants were randomised in blocks of 12 within each
discipline (medical, nursing, allied health, operational) to
the three groups, to equally distribute participant numbers
for each discipline between groups. A computer-generated
randomisation code was created, using simple web-based
randomisation, and participants were randomised in the or-
der that they attended for baseline assessment within each
discipline.
The control group (A) was trained in cardiac compression
skills via instructor-facilitated training, which lasted approxi-
mately 15 mins. This involved training in Basic Life Support
(BLS), including instruction on compression and defibrilla-
tion techniques and assessment of BLS skills through ob-
servation of performance using mannequins, incorporating
either no feedback or low-fidelity visual feedback mecha-
nisms. Trainers ensured that participants achieved skill levels
consistent with a pass before completing their training ses-
sion.
Groups B and C were trained in cardiac compression skills
via the RQI training system with standardised instructions
for recommended use. Once logged onto the system they:
watched a video recording demonstrating the correct cardiac
compression technique; carried out compressions on the man-
nequin whilst receiving visual and auditory feedback on their
technique in relation to compression rate, depth, release and
hand position; and, completed scenarios.
Staff were able to complete the cardiac compression training
on the RQI training system independently, however, most re-
quired trainers to show them how to access and navigate the
system. This enabled the trainers to ensure that participants
achieved a pass (cardiac compression skill score of
≥
75%)
before they ceased their training session.
Weekly reports were generated from the RQI training sys-
tem database providing the staff ID of participants who had
accessed the system for initial training, reassessments or
skills practise. These reports were screened to determine
whether any staff in groups A and C had accessed the system
to practise their compression skills so that this variable could
be included in the analysis. To ensure data integrity, scores
for every baseline and follow-up assessment were recorded
on a spreadsheet and cross checked with the RQI system
output. Regular reminders were emailed to participants to
complete their training and undergo reassessments, outlining
reassessment due dates.
Analysis methods
Descriptive statistics summarised recruitment, attrition and
combined averages for all cardiac compression attempts
and best cardiac compression attempts. The primary out-
come was cardiac compression skill level. We carried out a
multiple-regression analysis, in the form of analysis of co-
variance, to adjust for predictive co-variates, which included
baseline competence scores and the number of times group
B participants (continuous access to the RQI training system)
practised their compression skills.
Secondary measures included: the difference in baseline and
reassessment cardiac compression scores based on job type,
analysed using a mixed factorial analysis of variance; the
difference between disciplines in their level of competence
in cardiac compression over time, analysed using Chi-square;
predictors of reassessment scores, analysed via multiple lin-
ear regression; the association between reassessment score
and the number of times the RQI training system was ac-
cessed to practise skills, analysed via Spearman’s correlation
coefficient; and, the difference in re-assessment scores be-
tween the three groups and an unplanned control group who
did not receive any training, analysed via the Kruskal-Wallis
test.
A survival analysis was carried out to identify the timepoint
post training when cardiac compression skills declined. In
the absence of data to judge what a clinically significant
decline in cardiac compression skills would be, we took a
decline of
≥
10% in score from baseline to reassessment,
as the indicator of a decline in cardiac compression skills,
to determine whether “the event” had taken place. Signifi-
cance tests were 2-sided at the 5% level for both primary and
secondary outcomes.
3. RES ULTS
Recruitment exceeded the target of 475 with 502 participants
recruited during January and February 2017. We required
baseline and follow-up data for 132 participants in each of the
three arms of the trial and achieved 132 in the control group
(group A), 133 in the continuous access to the RQI training
system (group B) and 128 in the one-off access to the RQI
training system (group C). Three hundred and ninety-three
participants provided baseline and follow-up data reflecting
a 22% attrition rate. Attrition did not appear to be related to
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the study outcome, with 83% of attrition due to staff leaving
the organisation, moving to another facility, taking extended
leave or being unable to perform cardiac compression due to
physical limitations and only 17% being unexplained or due
to workload pressure. Despite the high attrition rate, partici-
pants lost to follow-up had similar baseline characteristics
to those retained in the study and the cause of attrition was
likely random (staff turnover). Figure 1 shows participant
flow through the study including reasons for attrition of 109
participants (see Figure 1).
Figure 1. Participant flow through the study
Attrition was equally distributed between groups (see Figure
1). In total, 21% of doctors; 25% of nurses; 20% health prac-
titioners, and; 11% of operational staff were lost to follow-up.
Of those lost to follow-up 68% did not receive any training
via the study.
At baseline, only 21% of staff passed the blinded cardiac
compression assessment (see Table 1). A Chi-square analy-
ses revealed a significant association between disciplines and
performance on the cardiac compression assessment (
χ2
(3)
= 12, p= .007).
Table 1. Participant baseline characteristics by group
Characteristic Group A
control
(n = 168)
Group B
continuous
(n = 169)
Group C
one off
(n = 165)
Discipline group – Number (%)
Doctor
Nurse
Health Practitioner
Operational Officer
29 (17)
92 (55)
26 (16)
21 (13)
31 (18)
90 (53)
25 (15)
23 (14)
28 (17)
91 (55)
24 (15)
22 (13)
Mean baseline CPR score - Mean (SD) 38 (34) 36 (35) 38 (34)
Passed baseline cardiac compression assessment – Number (%) 40 (24) 34 (20) 31 (19)
Median days from previous training to baseline assessment - Number (IQR) 205 (209) 185 (259) 188 (216)
Attrition - Number (%) 36 (21) 36 (21) 37 (22)
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The baseline assessment of cardiac compression skills was
passed by 33% of the 88 doctors in the study; 17% of the 273
nurses; 16% of the 75 health practitioners; and, 26% of the
66 operational officers. Doctors had a significantly higher
rate of passing their assessment than nurses (
χ2
(1) = 9.92,
p= .002), and health practitioners (
χ2
(1) = 6.18, p= .013),
but not operational officers (p> .05). No other significant
differences based on discipline were found (see Table 2).
Table 2. Participant characteristics by discipline stream
Characteristic Doctors
n = 88 Nurses
n = 273 Health Practitioners
n = 75 Operational
Officers n = 66
Median days from previous training to baseline
assessment - Number (IQR) 229 (230) 183 (184) 206 (289) 201 (250)
Passed baseline cardiac compression assessment -
Number (%) 29 (33) 47 (17) 12 (16) 17 (26)
Passed follow-up assessment - Number (%) 33 (47) 70 (34) 28 (47) 19 (32)
Attrition - Number (%) 18 (21) 69 (25) 15 (20) 7 (11)
Completed the trial - Number (%) 70 (80) 204 (75) 60 (80) 59 (89)
On reassessment, 38% of staff passed the blinded cardiac
compression assessment. There was no statistically signif-
icant association between disciplines and performance on
reassessment (
χ2
(3) = 6.40, p= .094). Of the staff who com-
pleted the reassessment, 47% of the 70 doctors; 34% of the
204 nurses; 47% of the 60 health practitioners; and, 32% of
the 59 operational officers passed the blinded reassessment
(see Table 2).
There was no significant difference in the proportion of doc-
tors or operational officers passing the baseline compared
to the reassessment (
χ2
(1) = 3.23, p= .07;
χ2
(1) = 0.61, p
= .43 respectively). There was a significant difference in
the proportion of nurses and health practitioners passing the
baseline compared to the reassessment (
χ2
(1) = 18.41, p <
.0001; χ2(1) = 14.95, p< .0001 respectively).
A 2 x 4 mixed factorial analysis compared the difference in
baseline and reassessment cardiac compression scores based
on job type. There was a significant main effect for assess-
ment timepoint (baseline or reassessment) (F(1,389) = 21.97,
p< .001), and for job type (F(1,389) = 3.81, p= .01), with
no significant interaction (F(3,389) = 1.36, p= .26). Indepen-
dent of assessment timepoint, doctors scored significantly
more highly on the cardiac compression assessments than
nurses (p= .005). No other significant differences based
on job type were found. Independent of job type, partici-
pants scored significantly more highly on their reassessment
than they did at baseline (p< .001) (see Table 3 for descrip-
tive statistics for this analysis). This analysis shows that all
groups improved over time, regardless of job type.
Table 3. Estimated Marginal Means (SE) for cardiac compression scores based on timepoint and job type
Variable Mean (SD) cardiac compression scores averaged for baseline and
reassessment timepoints within discipline groups
Job Type
Doctor 54.45 (3.24)
Nurse 41.83 (1.90)
Health practitioner 44.85 (3.50)
Operational officers 43.82 (3.53)
Variable Mean (SD) cardiac compression score averaged across all discipline
groups for baseline and reassessment timepoints
Assessment
Timepoint
Baseline 40 (1.98)
Reassessment 52.48 (2.11)
Figures 2 and 3 summarise the combined averages for all
cardiac compression attempts and best cardiac compression
attempts respectively for all participants in the trial collec-
tively. These figures show that compression attempts failed
based on compression rate followed by compression depth,
which were the parameters with the lowest scores. Hand
position and release (recoil) achieved the highest scores and
were both above the 75% pass mark.
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Figure 2. Combined averages for all cardiac compression attempts
We intended to carry out the first reassessment of cardiac
compression skill level at three months post cardiac compres-
sion training, however, despite several participant reminders,
the first reassessment took place at a variety of timepoints
post training (median 133 days, IQR 68). In addition, only 20
participants attended for a second reassessment of skill level,
which was scheduled for 6 months post baseline assessment
(group B n = 19; group A n = 1). Therefore, results for the
second reassessment were not analysed.
After controlling for baseline score and the number of times
group B participants practised their cardiac compression
skills on the RQI training system, there was no statistically
significant difference between groups in mean cardiac com-
pression score on reassessment (F(2, 392) = 0.061, p= .94),
indicating that the mode of training delivery did not affect
skill level. A multiple linear regression showed that base-
line cardiac compression score (
β
= 0.171, p= .001) and
the number of times participants practised their skills (
β
=
0.105, p= .001) were both significant predictors of reassess-
ment cardiac compression scores (F(2,392)=7.73, p= .001),
with higher baseline scores and a greater number of times
practising cardiac compression skills improving overall re-
assessment performance.
Only 57% of participants in group B practised their cardiac
compression skills between assessments. Statistically signif-
icantly higher reassessment scores were achieved by those
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participants in group B who practised their skills on the RQI
training system (median 61, IQR 72) than those in the other
groups combined, including group B participants who didn’t
practice, (median 46, IQR 76, z = -2.34, p= .019).
Figure 3. Combined averages for best cardiac compression attempts
There was no correlation between baseline score and number
of times participants in group B, who had continuous access
to the RQI training system, practised their cardiac compres-
sion skills (rho = .032, p= .240), indicating that staff were
unaware of their skills deficit.
Only 64% of all participants in the study attended training
in cardiac compression skills (73% of those who provided
follow-up data), even though this training is mandatory, and
participants agreed to undertake ether instructor-facilitated
or RQI based training on signing up to the study. In ad-
dition, there was wide variation in the time from baseline
assessment to when participants attended training (median
161, IQR 114). Reassessment scores were statistically sig-
nificantly higher for those who attended training (median 58,
IQR 69) than for those who did not (median 32, IQR 76, z =
-3.14, p= .002).
The participants who did not receive any training formed an
unplanned control group. When reassessment scores were
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compared for participants in the 3 intervention groups who
received cardiac compression training and a control group
of participants who did not using the Kruskal-Wallis test,
there was a statistically significant difference between the
four groups (
χ2
(3) = 11.30, p= .01), indicating that train-
ing improved performance. Participants in group B (RQI
continuous access) had significantly higher median scores
on reassessment than those in the unplanned control group,
p= .002 (see Table 4). No other statistically significant
differences were found.
Table 4.
Reassessment results for the three groups including
the unplanned no intervention control group, excluding
those lost to follow-up
Group Median (IQR)
reassessment score
No training – unplanned control (n = 107) 32 (76)
Group A – instructor-facilitated training (n = 104) 53.5 (68)
Group B - RQI continuous access (n = 99) 64 (80)
Group C - RQI one-off access (n = 83) 58 (70)
Survival analysis revealed that there was no statistically sig-
nificant difference between groups in time to a 10% decline
in cardiac compression skill score from training to reassess-
ment (
χ2
= 0.095, p= .954) and that the median time to a
10% decline in mean score was 245 days (approximately 8
months) (95% CI 227-263).
There was a statistically significant negative correlation be-
tween time from training to reassessment and reassessment
mean score (r= -.142, p= .016) reinforcing that reassess-
ment scores decreased as time from training to reassessment
increased. This result should be interpreted cautiously due
to the low r value.
Baseline and reassessments were blinded; thus, participants
were only made aware of their score after their reassessment.
Upon discovering their final score, many participants opted
to practise their cardiac compression skills immediately post
reassessment. There was a statistically significant negative
correlation between the reassessment score and the number
of times participants practised immediately after the reassess-
ment (correlation coefficient -0.114, p= .024), indicating
that the lower the score the more times participants practised
their skills, although the r value is low.
4. DISCUSSION
At baseline only 1 in 5 staff were competent in cardiac
compression, increasing to 1 in 3 on reassessment. Base-
line scores were 15% lower than that found in a paediatric
study,
[28]
and consistent with other research which found
cardiac compression skills to be suboptimal in all study
groups.
[2]
Indeed, cardiac compression skills have previously
been found to be highly variable in the hospital setting.
[11]
Of note, medical and operational staff had the highest mean
scores at baseline, possibly because they are the disciplines
who tend to do the hands-on chest compressions when re-
quired in hospital.
Although, cardiac compression training increased health-
care staff skill levels, neither training modality was signif-
icantly more effective than the other. These findings re-
flect some previous studies,
[2, 28]
although, the majority of
research,
[5, 9, 24]
including systematic reviews,
[29]
has found
automated cardiac compression training to be superior to
instructor-facilitated training. Indeed, when Group B partic-
ipants practised between assessments on the RQI training
system, as intended, their skill scores were statistically sig-
nificantly higher than those of the other groups combined.
However, these scores were not clinically significant because
the median (61% vs 46%) was still below the 75% cut off,
indicating a successful resuscitation attempt.
There appeared to be a lack of self-awareness of cardiac com-
pression skill deficits, possibly due to a lack of bio-feedback
during the assessments. Participants in the control group
didn’t receive bio-feedback during instructor-facilitated train-
ing and those in the RQI training system groups, who didn’t
access the system to practise their skills, were unaware of
their actual, as opposed to perceived, skill level. Indeed,
many participants only practised cardiac compression skills
when they received feedback on their score post final reassess-
ment and realised that their competence level was lower than
perceived. Indeed, other research has found that medical staff
reported a perception of high efficacy in cardio-pulmonary re-
suscitation, which didn’t correspond with high skill levels.
[30]
This demonstrates the influence of feedback on behaviour
and highlights the need for change management processes,
and possibly enticements, to encourage staff to practise car-
diac compression skills.
Cardiac compression skill levels declined equally between
groups at around eight months post training. Conversely,
other studies have found that skill retention was significantly
higher in the groups trained using high-fidelity mannequins,
as opposed to instructor-facilitated training, and that skills
significantly declined as early as five months post train-
ing.
[9, 31]
To this end, three-monthly skills retraining cy-
cles are advocated,
[19, 32]
as skills decline more quickly than
knowledge.[13]
Of note, 36% of staff did not attend any cardiac compression
training during the study (42% of doctors; 40% of nurses;
24% of operational; and, 24% of health practitioner staff),
even though training is mandatory, and staff enrolled in the
study agreed to attend training. The staff groups with the
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lowest training participation rates were most likely to be
involved in a real-life cardio-pulmonary resuscitation event.
When groups were analysed, based on whether they attended
training, results showed a statistically significant difference
between the group which attended training and the group
which did not, with the RQI continuous access group (B)
achieving the highest median score. This reflects the effec-
tiveness of training in increasing cardiac compression skill
levels.
[23]
Indeed, operational and health practitioner staff
had the highest training attendance rates (76%) and showed
the greatest improvement in mean cardiac compression score
between baseline and reassessment. The number of staff at-
tending training may reflect the effectiveness of management
processes within staff groups.
4.1 Pilot Learnings
4.1.1 Training
This pilot study afforded several learnings for a future defini-
tive trial. The median timeframe from baseline assessment
to training was 161 days (IQR 114). Providing training at the
point of recruitment would have removed this variability and
ensured that all participants enrolled in the study received
training. We anticipated that staff would be able to follow
written and on-screen instructions to undertake independent
training on the RQI system, however, in practice, assessors
helped most participants in groups B and C to navigate the
RQI training system. This was probably due to unfamiliarity
with, and counter intuitiveness of, the system and/or limited
time to work out how to navigate it. This was unanticipated
and time consuming for study team members, although it
enabled them to ensure that staff didn’t abort training until
they had achieved the required skill level (pass score 75%+).
Some participants did their training independently and re-
ceived audio and visual feedback on performance. Upon
recruitment, it would have been beneficial to give partici-
pants in group B instruction on how to use the RQI training
system and information on where the systems would be lo-
cated for ease of access for skills practise.
Group A was trained using no feedback or low-fidelity man-
nequins, therefore, groups B and C may have had some
advantage by being trained on the high-fidelity mannequins
that were used for the re-assessments.
A blinded assessment of skill acquisition immediately post
training was not carried out, as has happened in other stud-
ies.
[19]
This would have provided a benchmark of post train-
ing skill levels and an accurate measure of skill retention post
training to reassessment. Our assessment of skill level was
carried out at recruitment, however, given the time lag from
recruitment to training, objective measures of skill level at
both of these timepoints would have been informative.
It wasn’t possible to determine which interactions with the
RQI training system were for baseline training, reassessment
or skills practice. However, study team members carried
out baseline and reassessments, supervised training for most
participants and recorded the dates and reasons for these con-
tacts. Therefore, a blinded study team member was able to
determine the nature of contacts with the system by assuming
that contacts outside of scheduled assessments and training
were for skills practice.
4.1.2 Skills practise
The RQI training system was accessed by 27% of group
C participants outside of scheduled assessment and train-
ing timepoints. This was probably to complete training in
more than one session, although it is possible that these
participants practised skills on these occasions. Group A
participants were deactivated on the system post baseline
assessment and group C participants post training, with both
reactivated for reassessment. There was an inevitable time
lag between remotely deactivating group C participants post
training and re-activating them for their assessment and a
period between baseline assessment and training when they
were able to access the RQI training system as training some-
times didn’t occur until a few months post baseline assess-
ment. Therefore, group C participants could have practised
their compression skills and introduced dilution of effect
bias to the study. In addition, the withdrawals predominantly
hadn’t undertaken their training, so both unofficial skills
practice and attrition may have been reduced with training at
the point of recruitment.
Participants required prompting to undertake their training,
practise their skills (group B only) and complete reassess-
ments. Regular reminders were emailed to participants with
pending actions. Indeed, we assumed that group B would
want to access the system for skills practise, but they rarely
did so.
4.1.3 Reassessment
We intended to re-assess groups at three and six-months,
but, in practice, there was wide variation in the timepoint
at which participants completed their three-month reassess-
ment. Indeed, some reassessments took place up to a year
post baseline assessment. This potentially affected the va-
lidity of the re-assessment data by introducing confounding
factors which may have affected objective comparison. How-
ever, this variability was beneficial for the survival analysis
because it provided more data points to estimate time to skills
degradation. Indeed, only 20 participants were re-assessed
twice, therefore, the data from the second reassessment was
disregarded. This reflects one of the challenges in conduct-
ing a prospective study over an extended timeframe, with
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busy health care workers, and is probably a reason why most
published studies report reassessment over a very short time-
frame.
5. CONCLUSION
In this pilot, most staff who may need to perform cardiac
compressions in hospital were not competent, only 1/5th
were competent at baseline increasing to 1/3rd post training.
Both training and practise increased skill scores suggesting
that frequent low-dose training in cardiac compression is
required.
Neither training modality was more effective than the other.
Technology-enhanced devices, which provide immediate,
objective feedback without the need for an instructor to be
present, provide an alternate staff training model to instructor-
facilitated training. They could improve patient outcomes,
allow for higher frequency training and assist hospitals to
manage the logistics and cost of providing cardiac compres-
sion training.
[5]
If technology-enhanced training devices are
accessible for low dose training 24 hours a day, they are
likely to increase competence, confidence and willingness
to undertake cardiac compression in clinical situations.
[18]
However, it is also important to consider other contextual
factors, such as drills, and team work, in addition to cardiac
compression technique.
[32]
It would be valuable for future
research to determine which training modality is the most
cost effective.
The evidence is not sufficiently robust to determine whether
increased competence on mannequins translates to higher
quality cardiac compression, performed during actual re-
suscitative attempts, and improved patient outcomes such
as return of spontaneous circulation and survival without
neurological impairment.[9, 29]
This pilot trial was valuable in confirming that the approach
taken was suitable to test the effects of the intervention and
to identify methodological limitations. Sufficient pilot data
was generated to test the postulated mechanisms of effect and
confirm the feasibility and utility of proposed data collection
methods, in preparation for a definitive trial.
FUNDING SUPPORT
Funding to conduct this study was provided by the Mackay
Hospital and Health Service, the Mackay Institute of Re-
search and Innovation and the Mackay Hospital Foundation.
ACKNOWLEDGEMENTS
We would like to thank the funding bodies and the Health
Service staff who participated in this research.
CON FLI CT S OF INTEREST DISCLOSURE
The authors declare that there is no conflict of interest.
REFERENCES
[1]
Stiell IG, Brown SP, Christenson J, et al. What is the role of chest
compression depth during out-of-hospital cardiac arrest resuscita-
tion? Critical Care Medicine. 2012; 40(4): 1192. PMid:22202708
https://doi.org/10.1097/CCM.0b013e31823bc8bb
[2]
Zapletal B, Greif R, Stumpf D, et al. Simulation and education:
Comparing three CPR feedback devices and standard BLS in a sin-
gle rescuer scenario: A randomised simulation study. Resuscitation.
2014; 85: 560-566. PMid:24215730
https://doi.org/10.1016/
j.resuscitation.2013.10.028
[3]
Aguilar SA, Asakawa N, Saffer C, et al. Addition of Audiovisual
Feedback During Standard Compressions Is Associated with Im-
proved Ability. Western Journal of Emergency Medicine. 2018; 19(2):
437. PMid:29560078
https://doi.org/10.5811/westjem.20
17.11.34327
[4]
Cheng A, Brown LL, Duff JP, et al. Improving cardiopulmonary
resuscitation with a CPR feedback device and refresher simulations
(CPR CARES Study): a randomized clinical trial. JAMA Pediatrics.
2015; 169(2): 137-144. PMid:25531167
https://doi.org/10.1
001/jamapediatrics.2014.2616
[5]
Johnson M, Peat A, Boyd L, et al. The impact of quantitative feed-
back on the performance of chest compression by basic life support
trained clinical staff. Nurse Education Today. 2016; 45: 163-166.
PMid:27522335
https://doi.org/10.1016/j.nedt.2016.08
.006
[6]
Meaney PA, Bobrow BJ, Mancini ME, et al. CPR quality: improving
cardiac resuscitation outcomes both inside and outside the hospi-
tal: a consensus statement from the American Heart Association.
Circulation. 2013.
[7]
Hazinski MF, Nolan JP, Aickin R, et al. Part 1: Executive Summary:
2015 International Consensus on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science With Treatment Rec-
ommendations. Circulation. 2015; 132: S2-S39. PMid:26472854
https://doi.org/10.1161/CIR.0000000000000270
[8]
Talikowska M, Tohira H, Finn J. Cardiopulmonary resuscitation
quality and patient survival outcome in cardiac arrest: A system-
atic review and meta-analysis. Resuscitation. 2015; 96: 66-77.
PMid:26247143
https://doi.org/10.1016/j.resuscitatio
n.2015.07.036
[9]
Kirkbright S, Finn J, Tohira H, et al. Review article: Audiovisual
feedback device use by health care professionals during CPR: A sys-
tematic review and meta-analysis of randomised and non-randomised
trials. Resuscitation. 2014; 85: 460-471. PMid:24361457
https:
//doi.org/10.1016/j.resuscitation.2013.12.012
[10]
Wallace SK, S AB, B BL. Quantifying the Effect of Cardiopul-
monary Resuscitation Quality on Cardiac Arrest Outcome. Circula-
tion: Cardiovascular Quality and Outcomes. 2013; 6(2): 148-156.
PMid:23481533
https://doi.org/10.1161/CIRCOUTCOMES.1
11.000041
Published by Sciedu Press 79
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2021, Vol. 11, No. 8
[11]
Vadeboncoeur T, Stolz U, Panchal A, et al. Clinical Paper: Chest
compression depth and survival in out-of-hospital cardiac arrest. Re-
suscitation. 2014; 85: 182-188. PMid:24125742
https://doi.or
g/10.1016/j.resuscitation.2013.10.002
[12]
Stiell IG, Brown SP, Christenson J, et al. What is the role of chest com-
pression depth during out-of-hospital cardiac arrest resuscitation?
Critical care medicine. 2012; 40(4): 1192-1198. PMid:22202708
https://doi.org/10.1097/CCM.0b013e31823bc8bb
[13]
Hamilton R. Nurses’ knowledge and skill retention following car-
diopulmonary resuscitation training: A review of the literature. Jour-
nal of Advanced Nursing. 2005; 51(3): 288-297. PMid:16033596
https://doi.org/10.1111/j.1365-2648.2005.03491.x
[14]
Buléon C, Parienti JJ, Halbout L, et al. Original Contribution:
Improvement in chest compression quality using a feedback de-
vice (CPRmeter): a simulation randomized crossover study. Amer-
ican Journal of Emergency Medicine. 2013; 31: 1457-1461.
PMid:24035507
https://doi.org/10.1016/j.ajem.2013.07
.029
[15]
Baxley SM, Trowbridge C, Cason Carolyn L, et al. A counterbal-
anced cross-over study of the effects of visual, auditory and no
feedback on performance measures in a simulated cardiopulmonary
resuscitation. BMC Nursing. 2011; 10(1): 15. PMid:21810239
https://doi.org/10.1186/1472-6955- 10-15
[16]
Hostler D, Everson-Stewart S, Rea TD, et al. Effect of real-time feed-
back during cardiopulmonary resuscitation outside hospital: prospec-
tive, cluster-randomised trial. BMJ (Clinical Research Ed.). 2011;
342: d512-d512. PMid:21296838
https://doi.org/10.1136/
bmj.d512
[17]
Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest Com-
pression Fraction Determines Survival in Patients With Out-of-
Hospital Ventricular Fibrillation. Circulation. 2009; 120: 1241-1247.
PMid:19752324
https://doi.org/10.1161/CIRCULATIONAHA
.109.852202
[18]
Greif R, Lockey AS, Conaghan P, et al. European Resuscitation
Council Guidelines for Resuscitation 2015. Section 10. Education
and implementation of resuscitation. Resuscitation. 2015; 95: 288-
301. PMid:26477418
https://doi.org/10.1016/j.resuscit
ation.2015.07.032
[19]
Ackermann AD. Featured Article: Investigation of Learning Out-
comes for the Acquisition and Retention of CPR Knowledge and
Skills Learned with the Use of High-Fidelity Simulation. Clinical
Simulation in Nursing. 2009; 5: e213-e222.
https://doi.org/10
.1016/j.ecns.2009.05.002
[20]
Aqel AA, Ahmad MM. High-Fidelity Simulation Effects on CPR
Knowledge, Skills, Acquisition, and Retention in Nursing Students.
Worldviews on Evidence-Based Nursing. 2014; 11(6): 394-400.
PMid:25213578 https://doi.org/10.1111/wvn.12063
[21]
Mpotos N, De Wever B, Cleymans N, Raemaekers J, Valcke M,
Monsieurs KG. Simulation and education: Efficiency of short indi-
vidualised CPR self-learning sessions with automated assessment and
feedback. Resuscitation. 2013; 84: 1267-1273. PMid:23511844
ht
tps://doi.org/10.1016/j.resuscitation.2013.02.020
[22]
Sutton RM, Niles D, Meaney PA, et al. Low-dose, high-frequency
CPR training improves skill retention of in-hospital pediatric
providers. Pediatrics. 2011; 128(1): e145-e151. PMid:21646262
https://doi.org/10.1542/peds.2010-2105
[23]
Bhanji F, Finn JC, Lockey A, et al. Part 8: Education, Implemen-
tation, and Teams: 2015 International Consensus on Cardiopul-
monary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Circulation. 2015; 132: S242.
PMid:26472856
https://doi.org/10.1161/CIR.0000000000
000277
[24]
Díez N, Rodríguez-Díez MC, Nagore D, et al. A randomized trial of
cardiopulmonary resuscitation training for medical students: voice
advisory mannequin compared to guidance provided by an instruc-
tor. Simulation in Healthcare. 2013; 8(4): 234-241. PMid:23588058
https://doi.org/10.1097/SIH.0b013e31828e7196
[25]
Kardong-Edgren SE, Oermann MH, Odom-Maryon T, et al. Simula-
tion and education: Comparison of two instructional modalities for
nursing student CPR skill acquisition. Resuscitation. 2010; 81: 1019-
1024. PMid:20566391
https://doi.org/10.1016/j.resuscit
ation.2010.04.022
[26]
Yeung J, Meeks R, Edelson D, et al. The use of CPR feedback/prompt
devices during training and CPR performance: A systematic re-
view. Resuscitation. 2009; 80(7): 743-751. PMid:19477574
https:
//doi.org/10.1016/j.resuscitation.2009.04.012
[27]
Mundell WC, Kennedy CC, Szostek JH, Cook DA. Simulation tech-
nology for resuscitation training: a systematic review and meta-
analysis. Resuscitation. 2013; 84(9): 1174-1183. PMid:23624247
ht
tps://doi.org/10.1016/j.resuscitation.2013.04.016 v
[28]
Sutton RM, Niles D, Meaney PA, et al. “Booster” training: evaluation
of instructor-led bedside cardiopulmonary resuscitation skill train-
ing and automated corrective feedback to improve cardiopulmonary
resuscitation compliance of Pediatric Basic Life Support providers
during simulated cardiac arrest. Pediatric Critical Care Medicine: a
journal of the Society of Critical Care Medicine and the World Feder-
ation of Pediatric Intensive and Critical Care Societies. 2011; 12(3):
e116. PMid:20625336
https://doi.org/10.1097/PCC.0b013e
3181e91271
[29]
Yeung J, Meeks R, Edelson D, et al. Review: The use of
CPR feedback/prompt devices during training and CPR perfor-
mance: A systematic review. Resuscitation. 2009; 80: 743-751.
PMid:19477574
https://doi.org/10.1016/j.resuscitatio
n.2009.04.012
[30]
Gonzi G, Sestigiani F, D’Errico A, et al. Correlation between quality
of cardiopulmonary resuscitation and self-efficacy measured dur-
ing in-hospital cardiac arrest simulation; preliminary results. Acta
Bio-Medica: Atenei Parmensis. 2015; 86 Suppl 1: 40-45.
[31]
Kaye W, Wynne G, Marteau T, et al. An advanced resuscitation train-
ing course for preregistration house officers. Journal of the Royal
College of Physicians of London. 1990; 24(1): 51-54.
[32]
Sullivan NJ, Duval-Arnould J, Twilley M, et al. Simulation and edu-
cation: Simulation exercise to improve retention of cardiopulmonary
resuscitation priorities for in-hospital cardiac arrests: A randomized
controlled trial. Resuscitation. 2015; 86: 6-13. PMid:25447038
ht
tps://doi.org/10.1016/j.resuscitation.2014.10.021
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