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Heart & Lung 43 (2014) 66e71

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Heart & Lung

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Education and age affect skill acquisition and retention in lay rescuersafter a European Resuscitation Council CPR/AED course

Konstantina Papalexopoulou, MSc a,y, Athanasios Chalkias, PhD a,y,*, Ioannis Dontas, MSc a,Paraskevi Pliatsika, MSc a, Charalampos Giannakakos, MSc a, Panagiotis Papapanagiotou, MSc a,Afroditi Aggelina, MSc a, Theodoros Moumouris, MD a, Georgios Papadopoulos, PhD b,Theodoros Xanthos, PhD a

aNational and Kapodistrian University of Athens, Medical School, MSc “Cardiopulmonary Resuscitation”, Athens, GreecebUniversity of Ioannina, School of Medicine, Department of Anesthesiology, Ioannina, Greece

a r t i c l e i n f o

Article history:Received 14 May 2013Received in revised form29 September 2013Accepted 29 September 2013Available online 16 November 2013

Keywords:Basic life supportTrainingSkill acquisitionSkill retentionLay rescuers

Abbreviations: BLS, basic life support; AED, autoCPR, cardiopulmonary resuscitation; ERC, European R* Corresponding author. Tel.: þ30 210 4133992; fax

E-mail address: thanoschalkias@yahoo.gr (A. Chalky These authors contributed equally to the study.

0147-9563/$ e see front matter � 2014 Elsevier Inc.http://dx.doi.org/10.1016/j.hrtlng.2013.09.008

a b s t r a c t

Objectives: To examine whether education and age affect skill acquisition and retention in lay rescuersafter a European Resuscitation Council (ERC) CPR/AED course.Background: Because of the importance of bystander CPR/AED skills in the setting of cardiac arrest,acquisition and retention of resuscitation skills has gained a great amount of interest.Methods: The ERC CPR/AED course format for written and practical evaluation was used. Eighty laypeople were trained and evaluated at the end of the course, as well as at one, three, and six months.Results: Retention of CPR/AED skills improved over time, recording the lowest practical scores at onemonth after initial training and the lowest written scores at initial training. In practical evaluation scores,when examined longitudinally, age presented a significant adverse effect and higher background edu-cation presented a non-significant positive effect. Moreover, regarding written evaluation scores, whenexamined longitudinally, education presented a significant positive effect while age did not significantlycorrelate with written scores.Conclusions: Education and age affected retention of CPR/AED skills in lay rescuers. Also, our resultssuggest that the ERC CPR/AED course format may be poorly designed to discriminate between partici-pants with different levels of practical and written resuscitation skills and merit a thorough investigationin future studies.

� 2014 Elsevier Inc. All rights reserved.

Introduction

Cardiac arrest is a leading cause of death worldwide andthe most common cause of mortality over the age of 40.1 In caseof cardiac arrest, chances of survival are minimal, unless a layrescuer starts basic life support (BLS) and uses an automatedexternal defibrillator (AED), if present.2,3 Cardiopulmonaryresuscitation (CPR) improves the chances of successful resusci-tation from out-of-hospital cardiac arrest,4 while CPR/AED usefrom bystanders may double or triple survival of cardiac arrestvictims.5e7

mated external defibrillator;esuscitation Council.: þ30 210 6972396.ias).

All rights reserved.

Because of the importance of bystander CPR skills in the settingof cardiac arrest, CPR/AED skill acquisition and retention has gaineda great amount of interest and training of general population is ofoutmost importance.8,9 However, although the aim of educationalinterventions is to ensure that learners acquire and retain theresuscitation skills, BLS knowledge and skills deteriorate in as littleas three to six months.10 To our knowledge, only one study hasinvestigated potential factors affecting BLS acquisition. In thisstudy, the authors concluded that traditional BLS training is lesseffective in individuals aged 40 years or older.11 In addition,although first responders with higher qualification levels are morelikely to acquire the skill of defibrillation successfully,12 we haverecently showed that distribution of CPR/AED manuals one monthprior to the course has no effect on skill acquisition in lay-people.13

With this study, we aimed at examiningwhether education and ageaffect skill acquisition and retention in lay rescuers after a EuropeanResuscitation Council (ERC) CPR/AED course.

K. Papalexopoulou et al. / Heart & Lung 43 (2014) 66e71 67

Methods

The study was conducted in Athens, Greece between May 2011and May 2012, recruiting lay-people who had applied on their ownwill for CPR/AED training at a scientific society, namely the HellenicSociety of CPR, which was authorized to provide such accreditation.The study was additionally approved by the Postgraduate (MSc)Study Program “Cardiopulmonary Resuscitation” of the MedicalSchool of the National and Kapodistrian University of Athens. Par-ticipants were all individuals aged >18 years. Exclusion criteriawere previous training in CPR/AED and any health care profession.Participation to the study was voluntary with participants givinginformed consent.

Questionnaire development

A theoretical knowledge questionnaire consisting of multiplechoice questions according to the ERC 2010 guidelines were used toevaluate the level of candidates’ CPR/AED knowledge. All questionswere prepared by the authors of the present study. Any questionson which consensus about the correct answer was not easilyachieved were removed from the questionnaire. After receivinginstitutional review board approval, the questionnaire was initiallytested within a group of 12 CPR/AED course directors from atraining center in Athens, Greece. The questionnaire was also sentto local resuscitation experts for advice. The few questions thatwere not clear were removed from the questionnaire.

The questionnaire consisted of two parts, i.e. demographics and10 multiple choice theoretical knowledge questions (course test)with only one correct answer that surveyed familiarity with the2010 ERC CPR/AED guidelines (Appendix A). Each of the questionsof the course test surveying theoretical knowledge was followed byfour possible answers, one of which was correct. One point wasallocated to any correct answer with no negative marking; there-fore, the total maximum score was 10. The test was scored in orderto ensure a uniform theoretical knowledge among the participantsof the study, while competency was arbitrarily set and was indi-cated when the candidate answered correctly at least eight ques-tions (80%).

Course test reliability

A pilot survey among 25 lay rescuers, which was not included inthe results of the main study, was performed. All participants in thepilot survey found the course test clear; therefore, no furthermodifications were necessary. The reliability of the test was vali-dated using a testeretest procedure. Twelve of the previously sur-veyed respondents were randomly selected for another interviewone week later. The mean level of answer agreement was 97% be-tween the two sets of results (range, 90%e100%; standard devia-tion, 2%).

CPR/AED course format

During the study period, three ERC CPR/AED courses with lay-people were organized as previously described.14 Each course las-ted approximately half a day and consisted of skill demonstrationsand hands-on practice, with a minimum number of lectures. Theratio of instructor to candidates was approximately 1:6, with atleast one manikin and one AED for each group of six candidates.15

The manikin used was ‘Little Anne’ (Laerdal Medical Corporation,NY, USA). The AED used was the Lifepak 500T AED Training System(Medtronic Physio-Control, USA) with self-adhesive defibrillationpads. An AED connector that simulates different cardiac arrestrhythms was also used for training purposes.

The instructor group comprised of ERC-certified Course Di-rectors, while all lay-people were instructed by the same group toensure uniform training. All instructors were certified providers,nominated by the course faculty as having instructor potential, whohave successfully completed the CPR/AED instructor course andhave achieved instructor status after being successfully monitoredas instructor candidates for a minimum of two CPR/AED courses.The Course Directors had participated as instructors in more than15 CPR/AED courses and have achieved their status after beingmonitored in at least two courses as co-directors. The participantswere formally evaluated at the end of the course, while the eval-uation procedure consisted of two distinct parts: a 10-min writtentest (course teste Appendix A) which preceded a simulated cardiacarrest scenario.

After a 2 min introduction by two instructors, the trainee tookthe role of the rescuer and had to recognize cardiac arrest andeffectively provide CPR according to CPR/AED algorithms and rec-ommendations. The scenario given to each participant was a pa-tient, found unconscious, who required the use of an AED in apublic place. The initial cardiac rhythmwhen the AEDwas attachedwas ventricular fibrillation. The same scenario was used for eachparticipant, whowas then asked to perform the CPR/AED algorithmin real time (defibrillation e 2 min CPRedefibrillation), until pro-fessional care arrived. Forty four parameters were evaluated totallyby the two instructors (Appendix B). These points have beendescribed in a previous study,14 but we excluded the check for signsof circulation or carotid pulse, because the trainees were not healthcare professionals. The instructors used skills testing sheet criteriato determine if the trainee has demonstrated each step of the skillcorrectly and to record the student’s results. Each parameter in thechecked list (Appendix B) was considered to be completed suc-cessfully, only if both of the instructors agreed, while individualwritten feedback was given to the participants after the end ofthe tests.

One, three, and six months after completing their initialtraining, the participants were re-evaluated in predeterminedsessions. A written remainder was given at the end of the courseand was also send via email one month prior to the second andthird re-evaluation. We chose these time intervals for performingthe re-evaluation considering that BLS knowledge and skills dete-riorate in as little as three to six months,10 while traditional BLStraining is less effective in individuals aged 40 years or older.11

The group of instructors and the evaluation procedure wasidentical to that of the initial course. The assessments were per-formed by two investigators who did not instruct in any of thecourses. Each re-evaluation was done at the same venue and theparticipants had to complete the same course test without havingany complementary CPR/AED training in the meantime. The sce-nario, the manikin, and the AED were also identical to thesementioned above, while the participants were evaluated with thesame check list.

Statistical analysis

Statistical analysis was conducted using Stata version 9.0(StataCorp LP, College Station, TX, USA), and SPSS version 15.0 (SPSSInc, Chicago, IL, USA). Due to insufficient normality in distributionand small sample size, we compared overall evaluation scores be-tween the four different sessions (time-points) using the non-parametric Wilcoxon sign-rank test. We also analyzed evaluationscores in relation to trainee characteristics for each of the evalua-tion sessions, either by using the non-parametric ManneWhitneytest, due to insufficient normality and small sample size, for cate-gorical factors, or by using simple linear regression for age, whichwas measured in a continuous manner. Finally, we further analyzed

Table 1Demographic characteristics of subjects in the study (N ¼ 80).

Characteristic Mean (SD)/N (%)

Age (years) 41.8/(9.63)Age group�40 years old 36/(45)>40 years old 44/(55)

GenderMale 54/(67.5)Female 26/(32.5)

EducationSecondary 52/(65)Higher 28/(35)

K. Papalexopoulou et al. / Heart & Lung 43 (2014) 66e7168

our sample investigating a possible association between traineecharacteristics and scores in a longitudinal manner, using gener-alized population-averaged linear regression models, adjusting forall possible predictors at the same time. In order to select the mosteffective correlation structure in our regression models and toexamine the need for adding random effects, we incorporatedthe quasi-likelihood information criterion (QIC). QIC is a model-selection criterion for selecting model parameters (covariates)and variance/covariance structure in repeated measures regressionmodels, originating in Akaike’s information criterion (AIC) asmodified by Pan.16 QIC selects the most parsimonious model thatprovides an efficient level of goodness-of-fit to the data. Differenceswere considered to be statistically significant when p < 0.05.

Approximate achieved power for comparisons, assuming amedium effect and a significance level of a¼ 0.05, would be 0.99 fortime-point, 0.52 for gender and 0.54 for education, all univariatelyand in categorical form. Approximate power for detecting a linearregression effect for age alone, also assuming amedium effect and asignificance level of a ¼ 0.05, would be 0.92. Approximate powerfor detecting an effect assuming a medium effect of each factor,when using generalized multiple regression analysis, and a signif-icance level of a ¼ 0.05, would be 0.99 for each parameter.

Results

Eighty adult trainees were selected and followed throughout thestudy. The trainees participating in the study were mostly male(67.5%), most had only completed secondary education (65%), whilemean age (�SD) was 41.8 (�9.63) years, ranging from 22 to 58years; age values were normally distributed among subjects, ac-cording to the ShapiroeWilk test for normality. Demographiccharacteristics of our sample are summed up in Table 1.

Table 2Comparison of scores at each time-point (for all patients), and between groups (at each timfor effect of age on score (at each time-point separately).

Evaluation Time-point Mean score(SD)a

Scorerange

Gender, mean score (SD) p-v

Male(N ¼ 54)

Female(N ¼ 26)

Practical Initial training 40.6 (5.08) 19e44 40.4 (5.09) 41.0 (5.28) 0.4After 1 month 39.1 (5.53) 20e44 38.9 (5.61) 39.5 (5.56) 0.7After 3 months 40.4 (5.10) 20e44 40.0 (5.88) 41.3 (2.93) 0.8After 6 months 40.8 (4.66) 20e44 40.3 (5.39) 41.8 (2.42) 0.4

Written Initial training 8.15 (1.477) 5e10 8.00 (1.617) 8.46 (1.127) 0.5After 1 month 8.68 (1.248) 6e10 8.78 (1.220) 8.46 (1.330) 0.4After 3 months 8.73 (1.320) 6e10 8.67 (1.301) 8.85 (1.405) 0.6After 6 months 9.00 (1.281) 5e10 9.11 (1.121) 8.77 (1.589) 0.5

a Practical scores: significant difference between evaluation after 1 month vs. scores atrespectively). Written scores: significant differences between initial evaluation vs. scorerespectively), and between evaluation after 6 months vs. scores after 1 month and aftesignificant (p-value >0.05).

From the original 80 participants, all of them return for re-evaluation at one, three, and six months and were included in thedata analysis of the study. Trainees presented a sufficient overallperformance in important CPR/AED practical skills at all time-points; practical and written evaluation scores at different time-points are presented in Table 2. Practical evaluation presentedlower mean scores at the first re-evaluation point, while writtenevaluation presented lower mean scores at initial training andhigher mean scores at 6 months. Univariately, gender had no sig-nificant effect on scores, while higher education and increase of ageboth presented a positive effect, mainly on mean practical evalua-tion scores, at all time-points, and at initial training written scores(corresponding effects and p-values shown in Table 2).

Subsequent analysis proceeded with fitting generalized multi-ple linear regression models for repeated measurements. The QICmodel selection criterion led us into assuming random effects forthe intercept and a uniform autocorrelation structure; gender, ed-ucation and time were included in a categorical manner, while agewas included in a continuous form as a covariate; no interaction orquadratic term improved the fit of the generalized regressionmodels (Table 3). Lowest mean practical scoring was observed atone month after initial training and lowest mean written scoringwas observed at initial training. In practical evaluation scores, agepresented a significant adverse effect (p ¼ 0.02) and educationpresented an almost-significant positive effect (p ¼ 0.07). On thecontrary, regarding written evaluation scores, education presenteda significant positive effect (p ¼ 0.03), while age did not present asignificant effect.

Discussion

Bystander-initiated CPR is of paramount importance and shouldbe provided immediately after recognition of cardiac arrest as thishas shown to increase survival rates.17e19 Ideally, all citizens shouldbe trained in standard CPR that includes compressions and venti-lations. However, although the aim of education is to ensure thatlearners acquire and retain the skills and knowledge that willenable them to act correctly in actual cardiac arrests and improvepatient outcomes, most studies show that CPR skills decay overtime.13,20,21

Of note, most studies regarding BLS skill acquisition and reten-tion have been performed using health care personnel as partici-pants. Our study is, to our knowledge, the first that tries to identifyfactors that may affect CPR/AED skill acquisition and retention inthe general population. In particular, the results of our study indi-cate that practical performance during the CPR/AED scenario was

e-point separately) according to gender and education, and simple regression results

alue Education, mean score(SD)

p-value Age, b coefficient for scoreper year increase (95% CI)

p-value

Secondary(N ¼ 52)

Higher(N ¼ 28)

3 39.4 (5.92) 42.8 (1.48) 0.006 �0.16 (�0.33 to �0.01) 0.057 37.7 (6.30) 41.6 (2.17) 0.02 �0.19 (�0.37 to �0.01) 0.048 39.5 (5.39) 42.1 (4.17) 0.006 �0.20 (�0.36 to �0.04) 0.029 40.1 (4.84) 42.0 (4.19) 0.01 �0.15 (�0.30 to 0.01) 0.050 7.65 (1.522) 9.07 (0.829) 0.003 �0.06 (�0.11 to �0.01) 0.019 8.58 (1.391) 8.86 (0.949) 0.71 �0.01 (�0.05 to 0.04) 0.801 8.46 (1.476) 9.21 (0.802) 0.16 �0.02 (�0.07 to 0.02) 0.329 8.81 (1.443) 9.36 (0.842) 0.32 0.01 (�0.04 to 0.05) 0.78

initial training, after 3 months and after 6 months (p-values 0.005, 0.003 and 0.001,s after 1 month, after 3 months and after 6 months (p-values 0.04, 0.01 and 0.001,r 3 months (p-values 0.05 and 0.02, respectively). All other comparisons are non-

Table 3Effect of age, education, gender, and time on evaluation scores using generalizedregression models for longitudinal data.

Evaluation Factor Estimated b coefficient(effect of factor onmean score) (95% CI)

p-value

Practical Age (per year increase) �0.161 (�0.299 to �0.023) 0.02Education (higher vs.secondary)

2.534 (�0.213 to 5.281) 0.07

Gender (female vs. male) �0.599 (�3.461 to 2.264) 0.68After 1 month vs. initiala �1.475 (�2.601 to �0.349) 0.01After 3 months vs. initialscore

�0.150 (�1.275 to 0.976) 0.79

After 6 months vs. initialscore

0.200 (�0.926 to 1.326) 0.73

Written Age (per year increase) �0.017 (�0.053 to 0.018) 0.34Education (higher vs.secondary)

0.772 (0.063e1.481) 0.03

Gender (female vs. male) �0.318 (�1.057 to 0.420) 0.40After 1 month vs. initialscoreb

0.525 (0.172e0.878) 0.004

After 3 months vs. initialscore

0.575 (0.222e0.928) 0.001

After 6 months vs. initialscore

0.850 (0.497e1.203) <0.001

a Practical evaluation score according to time: after 3 months vs. after 1 monthestimated b¼ 1.325 (0.199e2.451), p-value¼ 0.02; after 6 months vs. after 1 monthestimated b ¼ 1.675 (0.549e2.801), p-value ¼ 0.004; after 6 months vs. after 3months estimated b ¼ �0.350 (�0.776 to 1.476) p-value ¼ NS; global time p-value(for inclusion of time categorically) ¼ 0.02.

b Written evaluation score according to time: after 3 months vs. after 1 monthestimated b ¼ 0.050 (�0.303 to 0.403), p-value ¼ NS; after 6 months vs. after 1month estimated b ¼ 0.325 (�0.028 to 0.678), p-value ¼ 0.07; after 6 months vs.after 3 months estimated b ¼ 0.275 (�0.078 to 0.628), p-value ¼ NS; global time p-value (for inclusion of time categorically) < 0.001.

K. Papalexopoulou et al. / Heart & Lung 43 (2014) 66e71 69

worse in the first month of re-evaluation. This observation could beexplained if one considers the fact that each subject has a tendencyto make the same mistakes every time; however, due to frequentrepetition of the algorithm there was a decrease in mistakes inconsequent re-evaluations.22 Regarding written evaluation, wefound that mean scores improved over time. Perhaps the betterunderstanding of the importance of following the steps of the al-gorithm precisely and familiarization with the questions in theexamination might have led to this result. Of note, one of the mostinteresting results in our study is the very small difference in thewritten or practical evaluation scores at any of the time points. Thedifference in the mean written and practical evaluation betweenany of the time points suggests that the ERC CPR/AED course testmay be poorly designed to discriminate between participants withdiffering levels of practical and written resuscitation skill, meritinga thoroughly investigation in future studies.

Interestingly, educationwas a factor which positively influencedthe performance in written evaluation. This could be explained bythe fact that well educated individuals are familiar with writtenexaminations. Considering the above results, individuals withlower educational level seem to have the need for more suitableand repeated CPR/AED training, in order to demonstrate perfor-mance equal to highly educated individuals. Thus, internationalorganizations studying resuscitation may consider altering the wayindividuals with secondary education are being trained and eval-uated. Some suggestions would be simplification of the courseformat or design of an internet-based presentation and self-evaluation program. Moreover, literacy may also be an issuerather than education per se. Those with less education could beavailed by web-based interactive programs or reciprocal learningwith task cards.23,24 Alterations like the aforementioned mayimprove the quality of resuscitation performed by this group ofpeople for a longer time period and may ultimately increase thesurvival rates after cardiac arrest.

In our study, age had a negative effect on rescuers’ performanceper year of increase, mainly in practical evaluations, in both simpleand longitudinal analyses. As age progresses, one may becomemore and more unfamiliar with computer-based presentations, aswell as with the use of technical equipment, such as the manikinsor the AED. Moreover, physical stamina may weaken with age,hence making it more difficult for elderly bystanders to performCPR. Nevertheless, there is evidence that age does not significantlyaffect quality of CPR. Neset et al25 studied the capability of lay-persons aged 50e76 to perform 10min of CPR on a realisticmanikinwith continuous chest compressions and conventional CPR (30:2)and they found that they were able to perform chest compressionswith acceptable quality for ten minutes and with very slight tem-poral quality deterioration. In another study, the same researchgroup sought to determine whether laypersons aged 50e75perform CPR poorer in a realistic cardiac arrest simulation,compared to a traditional test and they found that they werecapable of performing chest compressions with acceptable qualityfor ten minutes, although ventilation quality and hands-off timewere not adequate.26 Ochoa et al27 evaluated the influence ofrescuer fatigue on the quality of chest compressions andthe influence of the rescuer’s gender and age on the reduction ofquality of chest compressions caused by fatigue and found that adecrease of compressions quality after the first minute of CPRis produced. However, this effect did not depend on gender orage. Heidenreich et al28 compared the elderly rescuers’ ability tomaintain adequate compression rate and depth during hands-onlyCPR and standard CPR in a manikin model and found that hand-only CPR resulted in a greater number of overall compressionsthan standard CPR. However, standard CPR resulted in a greaternumber of adequate compressions in all but the first minute ofresuscitation. In either case, elderly CPR providers with decreasedstamina may benefit from specifically designed fitness programs,such as muscle strength exercises, in order to remain competent.29

One limitation of this study is the small number of the partici-pants; therefore our study might have been underpowered, espe-cially regarding the non-parametric part of group comparisons inthe analysis where achieved power was fairly low. Furthermore,not knowing the true effect of each of the factors, the actualpower could have been lower than its computed approximation, atthe longitudinal regression level as well. In either case, a largercohort study is necessary for drawing safe conclusions. Secondly,the environment of a cardiac arrest scenario is controlled and use ofthe same questionnaire over time might have artificially increa-sed overall CPR success; in a “real-life” cardiac arrest many factorscould complicate the process of resuscitation and some lay rescuersmight panic easily,15 with unpredicted outcomes on victims’ sur-vival rates. In addition, prior studies have shown that knowledgeretention is improved by repeated testing alone, so having allthe participants repeat testing at one, three, and six months likelyactually improved knowledge retention of the participants ratherthan simply measuring an anticipated deterioration in knowledgeretention at different time points, a phenomenon known as thetesting effect.30 This may have biased our findings. Finally our studyexamined short-term skill and knowledge retention of the studygroup and did not follow the subjects for a longer time period.Future studies may elucidate long-term retention of CPR/AED skills.

Our study showed that frequent re-evaluation of CPR/AED skillsmay be essential for lay-people, in order to maintain the level oftheir competence.10,11 Gender did not seem to play a role, whileeducational level affected positively and age had an adverse effecton both acquisition and retention of CPR/AED skills. The ERC andthe other international resuscitation organizations might want toreconsider the format of CPR/AED courses tests and design theseaccording to the level of literacy of candidates. This will increase

K. Papalexopoulou et al. / Heart & Lung 43 (2014) 66e7170

discrimination between participants with differing levels of prac-tical and written resuscitation skills. Future and larger studiesshould be performed to clarify possible factors that might correlatewith retention of CPR skills.

Acknowledgments

Nothing to acknowledge.Conflicts of interest: None declared.

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Appendix A

1. Which of the following is the best indicator that a person isexperiencing cardiac arrest?

a. Severe chest pain.b. Difficulty in breathing.c. Choking.d. Absence of breath.

2. What should you do to check responsiveness?

a. Call 112.b. Shake his/her shoulder and ask loudly: ‘‘Are you okay?’’c. Get an AED.d. Perform two rounds of CPR and see if the person responds.

3. What is the first thing you should do when a person isunresponsive?

a. Do nothing until someone brings an AED.b. Check the person’s breathing and start CPR if she/he is not

breathing.c. Call 112.d. Shout for help.

4. When you call 112, what information should you be preparedto give them?

a. Your name.b. The type of emergency.c. Your location.d. All of the above.

5. What is the correct pattern used while performing CPR on anadult?

a. Thirty chest compressions, 2 rescue breaths, repeat.b. Five chest compressions, 1 rescue breath, repeat.c. Fifteen chest compressions, 5 breaths, repeat.d. Ten chest compressions, 2 breaths, repeat.

6. How can you ensure the adequacy of each rescue breath?

a. Easy air passage.b. Breathing sounds are heard.c. The person’s chest rises as you deliver each breath.d. The person turns blue.

7. For which of the following conditions will you use an AED?

a. Heart attack.b. Cardiac arrest.c. Choking.d. Seizure or convulsion.

8. What is your first priority when using an AED?

a. Plug the AED in an electrical socket.b. Turn on the AED.c. Put the pads on the person’s chest.d. Take 5e10 deep breaths to calm yourself.

9. Why should everybody stand clear when pressing the AEDSHOCK button?

a. So that the AED does an accurate reading.b. So that the AED gives the shock.c. So that no one else is shocked by mistake.d. All of the above.

K. Papalexopoulou et al. / Heart & Lung 43 (2014) 66e71 71

10. When someone is not breathing, what is the WORST thing youcan do?

a. Perform CPR even though you are not sure you remember

how.b. Use an AED even though you are not sure you remember

how.c. Wait for someone more qualified to handle the situation.d. a and b.

Appendix B

1. Checks for safety2. Addresses and simultaneously shakes the patient3. Shakes the patient from the shoulders strongly enough4. Shouts for help without delay5. Opens airway, gently tilts the head back and lifts the patient’s

chin6. Positions head close to the victims face7. Feels for breathing and listens for air movement8. Looks for chest movement9. Uses no more than 10 s to check breathing and signs of

circulation10. Activates EMS (emergency medical service)11. Gives name to the operator of EMS12. Gives exact location13. States that the victim is not breathing14. Ensures that all information has been received by operator15. Brings AED on the scene16. Demonstrates pulling the shirt towards the patient’s head and

bares the chest enough to attach electrodes properly17. Opens the cover

18. Attaches electrodes/defibrillation pads correctly by pressingthe electrodes firmly

19. Attaches upper electrode below right clavicle without coveringthe nipple

20. Attaches lower electrode 10 cm below left axilla21. Demonstrates switching on AED22. When AED is analyzing, asks that nobody touches the victim23. Ensures using appropriate gestures that nobody touches the

victim24. Ensures safety when attempting defibrillation25. Delivers shock in less than 60 s26. Immediately starts CPR27. Positions hands in the center of the chest28. Places heel of the other hand on top of the first and interlocks

fingers29. Keeps elbows straight30. Depresses chest 4e5 cm31. Allows chest to recoil32. Uses correct compression rate (100/min)33. Ensures correct ratio (30:2) of compressions to rescue breaths34. Opens airway by tilting the patient’s head and lifting chin35. Takes normal breath36. Places lips around victim’s mouth37. Closes the nostrils38. Blows steadily for 1 s39. Demonstrates efficient rescue breath causing the chest to rise40. Notes that the patient’s chest rises and falls with ventilation,

and if not, opens airway more and successfully ventilates41. Does not attempt more than two rescue breaths42. Minimizes interruption in chest compressions43. Stops performing CPR when AED asks so44. Continues the whole process effectively until professional help

arrives