cpr instruction: modular versus lecture course

ORIGINAL CONTRIBUTION cardiopulmonary resuscitation, instruction

CPR Instruction: Modular Versus Lecture Course

A randomized prospective s tudy was done to examine long-term cardiopulmonary resuscitation (CPR) cognitive and motor skills retention and to compare the "self-taught" modular course with the standard lecture course. Both cognitive and motor skills were tested at one-, two- and four- year intervals after the initial course. Approximately half the students in both the modular and standard lecture courses also took a refresher course after one year. While there was no significant difference (P > .05) in retention based on the me thod of teaching (modular vs lecture course), students who took the refresher course after one year performed significantly better (P < .01) at the two-year interval. Results four years after the initial CPR course (three years after the refresher course) were uniformly poor in both groups. Only three of 104 students were able to mee t American Heart Asso- ciation standards for the performance of CPR. Refresher courses are vital if CPR is to be performed effectively and competently They should be available on a continuing basis with self-taught courses providing a good alterna- tive to the formal didactic'course as a means of providing instruction. [Nelson M, Brown CG: CPR instruction: Modular versus lecture course. Ann Emerg Med February 1984;13:118-121.]

INTRODUCTION Each year more than 750,000 Americans die from cardiac arrest. 1 In the

past 20 years tremendous strides have been made in the resuscitation of such victims, z along with the realization that respiratory and cardiac arrests are emergencies for which all persons, even children, should be able to initiate treatment.

This realization has led to an upsurge in the number of people desiring and required to be certified in basic life support. A Gallup poll taken in 1977 indicated that 12 million people had learned cardiopulmonary resuscitation (CPR), and that an additional 51 million people would like to learn ,it. 3

The demand for basic life support courses often exceeds their availability, and with more studies showing the importance of refresher courses, 4-8 the possibility of supplying the necessary instruction becomes increasingly diffi- cult.

One attempt to resolve this problem has been the self-taught modular approach to CPR training. In 1972, Safar et al 9 designed a CPR self-teaching system that consisted of a Recording Resusci-Anne manikin, flip charts, au- dio-cassette-recorded instruction, and a 10-minute training film. This system is not used by the American Heart Association (AHA), but a similar course has been given for some time by the American Red Cross (ARC). lo In addition, a number of articles have been written adapting modular courses to teaching basic life supporttl, tz as well as other first-aid skills.t3,14

Modular courses minimize the need for instructor time. Students practice in small groups and then return to the instructor with a manikin-recording tape that is used to evaluate their performance. The instructor's primary role is testing, although he must also organize the course, explain the equipment, and be available to answer questions.

In addition to reducing instructor time, the modular courses offer a number of other advantages. The courses are self-paced, enabling those students with prior experience to finish more quickly, while those students who need

Marc Nelson, MD Charles G Brown, MD Baltimore, Maryland

From the Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.

Presented at the University Association for Emergency Medicine Annual Meeting in Boston, June 1983.

Received for publication March 24, 1983. Revision received June 9, 1983. Accepted for publication August 25, 1983.

Address for reprints: Marc Nelson, MD, Department of Emergency Medicine, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, Maryland 21205.

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CPR INSTRUCTION Nelson & Brown

more time can work without fear of holding others back. In our experience, the modular course was com- pleted in six to eight hours, whereas the lecture course took approximately ten hours. More flexibility in t ime schedules is also possible, an impor- tant factor in retraining housestaff and nurses. Also, because students are ini- tially taught by observing tapes and films, variable and occasionally poor instructor performance is eliminated.

We a t tempted to discern any difference between the effects of the two approaches on CPR performance, and to study long-term retention in students. Modular and lecture refresher courses were also given and their effect evaluated.

MATERIALS AND METHODS Study par t ic ipants were medica l

students, hospital personnel, and lay people. Each course contained a similar mix of students. None of the students had any prior CPR training.

Approximately half of the trainees were taught CPR by the ARC modular course, and half were taught by a tra- ditional lecture course. All students passed the original modular and lecture courses. At the end of one year, all s tudents were tested again. All who passed the practical examination also passed the written examination at this time. Students who passed, as well as those who failed the examina- t ion at one year, were t h e n randomized into refresher and non-re- f r e she r g roups . S t u d e n t s in the modular course took a modular refresher course; students in the lecture course took a lecture refresher course. Students were then tested one and three years after the refresher course (two and four years after the original course). The practical part of the examination was administered first so that i n fo rma t ion inadver t en t ly re- vealed in the written part of the examination could not be used during the practical.

The practical part of the examination (Figure) was based on the AHA standards for performance of CPR. 15 This consisted of 12 items that were evaluated by observa t ion and data f rom an adul t Record ing Resusci - Anne manik in ' s pr in tout tape. The first seven items assess through obser- vation the ability of the rescuer to establish that card iopulmonary arrest has occurred, to correctly prepare and position the victim for the administra- tion of CPR, and to initiate CPR. The

Fig. AHA performance standards for CPR.15

last five items, which were recorded by the manikin, measure the actual performance of CPR.

The second part of the examination was a wri t ten test consis t ing of 25 multiple-choice questions. The questions tested five basic areas of knowledge: recognition (two questions), airway (four questions), artificial respira- t ion (four questions), compress ions (seven questions), ven t i l a t i on / compression rat io (two questions), and obstructed airway (six questions). The same examination was given at each testing interval.

Students were also asked, "Do you feel confident in your ability to perform CPR, and if you are not confident, would you perform CPR anyway ?"

In addition, potentially deleterious per formances were specif ical ly recorded. These included failure to feel for a pulse before beginning compressions, incorrect hand position as indicated by the red light on the manikin and on the tape, excessive compression force (> 51 mm), and excessive ventilation volume (> 2,000 cc).

To m e e t the A H A standards, all i tems on the practical examina t ion had to be performed 'correctly. The manikin was checked after each test to ensure that it was functioning prop- erly. Students needed a score of 70% to pass the written test.

All the recording tapes were evaluated blindly. Unfortunately this was not possible during the observat ion part of the test.

RESULTS Sta t i s t ica l ana lys i s by the chi-

square test showed no significant difference (P > .05) in the number of po- tent ia l ly ha rmfu l pe r fo rmances by students between the modular and lecture course at one year (Table 1). At two years, s tudents who took a refresher course performed significantly better than those who did not (P < .01), although there was no difference (P > .05) in the number of potentially harmful performances between students taking the modular course and those taking the lecture course (Table 1). At four years, there was no significant difference (P > .05) between the methods of teaching (modular vs lecture course) or between refresher and no-refresher groups (Table 1).

Annals of Emergency Medicine

Practical Examination

1. Establish unresponsiveness and call for help.

2. Open airway. 3. Establish respiratory arrest. 4. Initiate respirations with four

quick breaths. 5. Check pulse. 6. Use carotid artery for above

(5). 7. Correct hand position. 8. Sixty or more compressions

per minute. 9. Correct compression depth

(38 to 51 mm). 10. Eight or more breaths (per

minute). 11. Each breath between 800 cc

and 2,000 cc. 12. Proper ratio of compressions

to breaths (15:2).

Similarly there was no statistically significant difference (P > .05) between the modular and lecture courses for both the practical and written examinat ions at one year {Tables 2 and 3). At two years, students who took the refresher course showed a statistically significant difference (P < .05) in pass rates on both the practical (P < .01) and written examination (P K .05) compared with students who did not take a refresher course (Tables 2 and 3). This was true for both the modular and lecture courses, although there was no statistically significant difference between these methods at the two-year interval.

At four years there was no statistically significant difference (P > .05) in pass rates on the practical examination between the modular and lecture courses, or between the refresher and no-refresher groups (Table 2). At the four-year interval there was a significant difference (P < .05) on the written examinat ion for those s tudents who took the refresher course (Table 3).

There was no significant difference (P > .05) between the modular and lecture courses at one, two, and four years with regard to the students' con- f idence in their abi l i ty to per form CPR (Table 4) or in the number of students who would perform CPR even if they were not confident. While there was no significant difference {P > .05) based on the type of refresher course taken (lecture vs modular), there was a significant difference (P < .05) be-

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TABLE l. Number of students with potentially harmful performances

Modular (N = 56)

1 yr 17 (30.3%)

Refresher (n = 30) No Refresher (n = 26)

2 yr 10 (33%) 21 (80.7%)


4 yr* 21 (75%) 23 (92%)

*Five students were tost to follow up between the first and fourth years,

Lecture (N = 48)

19 (39.5%)


10 (40%) 18 (78.2%)


20 (80%) 18 (85.7%)

TABLE 2. Number of students passing the practical examination

Modular (N = 56)

1 yr 30 (53.5%)


2 yr 16 (53.3%) 2 (7.6%)


4 yr* 2 (7.1%) 0 (0%)

*Five students were lost to follow up between the first and fourth years.

Lecture (N = 48)

24 (50%)


12 (48%) 1 (4.3%)


1 (4%) 0 (0%)

TABLE 3. Number of students passing the written examination

Modular (N = 56)

1 yr 43 (76.7%)


2 yr 22 (73.3%) 6 (23%)


4 yr* 8 (28.5%) 2 (8%)

*Five students were lost to follow up between the first and fourth years.

Lecture (N = 48)

38 (79.1%)


20 (80%) 7 (30,4%)


10 (40%) 1 (4.3%)

tween the refresher and no-refresher groups at two and four years.

DISCUSSION Although many of the students did

not meet AHA criteria for the performance of CPR, it does not appear that the type of course (or the type of refresher course) affects retention. How- ever, as has been stressed repeatedly, 4-8 without refresher courses retention is extremely poor. This study, which is the first to examine retention over this period of time (four years), also suggests that motor skills deteriorate more rapidly than do cognitive skills (Tables 2 and 3), emphasizing the importance of actual "hands on" practice

13:2 February 1984

during refresher courses. This disparity between cognitive

and motor skill retention may explain, in part, the students' "false" confidence in their ability to perform CPR. It is therefore not surprising, in spite of the large number of potentially harmful performances, to see how many students still felt confident in their ability to perform CPR. This discrepancy between perceived ability and actual skills emphasizes the need for refresher courses.

There are several possible sources of error in this study. The majority of the trainees were first-year medical students who, unlike most lay people, al- most certainly were exposed to a

Annals of Emergency Medicine

number of cardiac arrests during their medical school training. While one might postulate that this would improve their performance, this was ap- parently not the case, for wi thout proper feedback they were probably just reinforcing poor technique. The testing tapes were run for only one minute, and while some people may improve with time, most tend to deteriorate after a few minutes. In addition, some did not take the test se- riously and under real conditions may have performed better. Of course, under the stress of a real cardiac arrest, they may also have performed less well.

It has been more than ten years

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CPR INSTRUCTION Nelson & Brown

TABLE 4. Students' confidence in ability to perform CPR

Confident

If not confident

Confident

If not confident

would perform it anyway

would perform it anyway

ModuLar

Refresher

1 yr 2 yr 4 yr

83% 87% 60%

93% 97% 75% Lectu re

No Refresher

1 yr 2 yr 4 yr

85% 50% 25%

91% 60% 42%

Refresher

1 yr 2 yr 4 yr

80% 84% 52%

92% 92% 68%

No Refresher

1 yr 2 yr 4 yr

83% 48% 28%

91% 65% 48%

since Safar et al first designed a self- taught CPR course,9 and the need for such courses cont inues to grow. Im- provements in audiovisual aids are making self-taught courses more effec- tive. In fact, early tests by one group us ing a compute r videodisc sys tem showed that s tudents were certified more quickly and with higher standards t han a l ive i n s t r u c t o r could achieve. 16

In the future, instructors may be- come obsolete. In the meantime, how- ever, the self-taught modular and refresher courses r ema in an excel lent option for teaching CPR to large num- bers of people.

C O N C L U S I O N A randomized, prospective s tudy

was done to evaluate retention of cog- ni t ive and psychomotor CPR skills based on the method of teaching. The effect of a refresher course on retention also was evaluated.

While there was no significant difference based on the method of teaching (modular vs lecture course), students who took a refresher course one year after the initial course performed significantly better at the two-year interval.

Results four years after the ini t ial

CPR course (three years after the refresher course) were uniformly poor.

REFERENCES 1. Grant H, Murray P: In Emergency Care, ed 2. Bowie, Maryland, Robert J Brady Co, 1978, p 341.

2. Lemire JG, Johnson AL: Is cardiac resuscitation worthwhile? A decade of experience. N Engl J Med 1972;282:970-972.

3. CPR Lifesaving Techniques. Gallup Poll, June 30, 1977. Copyright Field Enter- prise, Inc, Chicago.

4. Tweed WA, Wilson E, Isfeld B: Reten- tion of cardiopulmonary resuscitation skills after initial overtraining. Crit Care Med 1980;8:651-653. '

5. Nelson M: Evaluation of CPR performance among medical students, resi- dents, and attendings at the Mount Sinai School of Medicine. Mt Sinai J Med 1981;48:89-94.

6. Weaver FJ, Ramirez AG, Dorfinan SB, et ah Trainees' retention of cardiopulmonary resuscitation - - How quickly they forget. JAMA 1979;241:901-903.

7. Latman NS, Wooley K: Knowledge and skill retention of emergency care atten- dants, EMT-As, and EMT-Ps. Ann Emerg Med 1980;9:183-189.

8. Deliere HM, Schneider LE: A study of cardiopulmonary resuscitation technical skill retention among trained EMT-As.

EMT Journal 1980;4:57-60.

9. 8afar P, Benson DM, Berkebile PE, et al: Teaching and organizing CPR, in Safar P (ed): Public Health Aspects of Critical Care Medicine and Anesthesiology. Phila- delphia, FA Davis Co, 1974, p 162-191.

10. Modular Course in Cardiopulmo- nary Resuscitation. Washington, DC, American Red Cross, 1975.

11. Berkebile PE, Benson DM, Ensoy CJ, et ah Public education in CPR: Evalua- tion of three teaching methods (abstract). Proceedings of the AHA/NRC CPR/ECC conference. National Academy .of Sci- ences, Washington, DC, May 1973. Crit Care Med 1973;1:15.

12. Herrin TJ, Norman PF, Hill C, et ah Modular approach to CPR training. South Med J 1980;73:742-744.

13. Safar P, Berkebile PE, Scott MA, et al: Education research on life-supporting first aid (LSFA) and CPR self-training systems (STS). Crit Care Med 1981;9:403-404.

14. Breivik H, Ulvik NM, Btikra G, et ah Life-supporting first aid training. Crit Care Med 1980;8:654-658.

15. American Heart Association: Stan- dards for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1980;244(suppl):453-509.

16. Hon D: Interactive training in cardiopulmonary resuscitation. BYTE 1972; 7(6):108-120,130-138.

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cpr instruction: modular versus lecture course

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