Evolving CPR Training Through Improved Technology: An Unexpected Research Program

It is well documented that CPR skills decay shortly after taught, if they are not used. In an effort to ameliorate this finding, a research team was formed to conduct testing of a new CPR Voice Advisory Manikin (VAM) with refresher training and retention testing. VAMS provide accurate verbal non-biased feedback during compressions and ventilations such as “compress a little faster” or “ bag more slowly”. Six hundred six nursing students from 10 prelicensure programs around the country were divided into an experimental and control group, which did not practice. The experimental group used the new VAM manikin program by practicing 6 minutes a month (2 minutes compressions, 2 minutes bag, valve, mask, and 2 minutes of single rescuer CPR.) Twenty percent of students in both groups were randomly tested and dropped from the study every 3 months over a year. At the one-year point, the remaining 20% of students completed a second CPR course and were tested once again with the VAM. Findings indicated that students in the experimental group who completed brief deliberate practice (6 minutes a month) performed statistically better than those in the control group, in all measures.

A second study using an enhanced CPR training system was developed based on findings from the first study. The investigators were invited to lead a second multisite study, testing an algorithm developed by the USAF that predicted skill decay rates. This enhanced system included visual feedback on a laptop computer in addition to the VAM CPR manikin tested previously. In this second 10 site study, two schools and site coordinators from our previous study participated again in addition to 8 new programs. Students were randomized twice, once to training time (once a day for 4 days in a row, once a week for 4 weeks in arrow, once a month for 4 months in arrow, or once a quarter for quarters in a row). Students were then randomized into retention testing times (at 3 months X 4 visits, 6 months X 2 visits, or a performance predictor optimizer (PPO) group that used the USAF algorithm. Students might be asked to come back 6 times over the next year. Based on prior student training performance, the algorithm predicted when the students' skills would decay and when a student needed to return for training. Training and retention visits were performed in the same manner. Students performed one minute of compressions and one minute of bag valve mask without feedback. They then viewed brief refresher videos on proper compression and ventilation skills. Students completed a final round of one minute each of compression and ventilations with no feedback. Results indicated the prediction models for the 3 and 6 month groups were accurate. Inial data indicated that the PPO prediction algorithm was not stable. Some students were not consistent in their skill retention. Modifications to the protocol were added at the one year point of the study, because of these findings. Students in the PPO group with inconsistent skills, as determined by the manikin software, were provided up to an additional 4 practice visits.

Implications for nurses in practice and education include: skill decay is inevitable for rarely used skills such as CPR. Brief spaced practice with consistent computer based feedback is effective in refreshing and maintaining CPR skills. These findings may be generalizable to other psychomotor skills. Further research is warranted.