An audio-visual review model enhanced one-year retention of cardiopulmonary resuscitation skills and knowledge: A randomized controlled trial

International Journal of Nursing Studies 102 (2020) 103451

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An audio-visual review model enhanced one-year retention of cardiopulmonary resuscitation skills and knowledge: A randomized controlled trial Yimin Xu1, Jia Li1, Ying Wu∗, Peng Yue, Fangqin Wu, Yahong Xu School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Fengtai District Beijing, 100069, China

article info

abstract

Article history: Received 8 March 2019 Received in revised form 8 October 2019 Accepted 12 October 2019

Background: As the majority of out-of-hospital cardiac arrest occur at patients’ homes, implementing high-quality cardiopulmonary resuscitation by family members is critical in improving patient outcomes. However, the survival rate remains low due to low bystander cardiopulmonary resuscitation rate and rapid skill deterioration in individuals who complete the training. Objectives: To evaluate the effectiveness of audio-visual review model and audio-visual-practice review model on cardiopulmonary resuscitation skill retention 12 months after training. Design: A randomized, double-blind, placebo controlled, and three-arm parallel study. Participants: A total of 641 family members of patients at high risk of out-of-hospital cardiac arrest enrolled in the study and 448 participants completed the follow-up. Methods: Family members from Beijing, China were recruited. All families underwent initial cardiopulmonary resuscitation training. Their cardiopulmonary resuscitation skill and knowledge were assessed immediately after training. Trainees who were rated “adequate skill and knowledge” were assigned randomly into one of three groups. The control group was given a cardiopulmonary resuscitation instruction booklet and a placebo-DVD without any reminders. Both audio-visual and audio-visual-practice groups were reinforced by a telephone reminder every 3 months. The audio-visual-practice group was also asked to simultaneously practice the skills while watching the instructional-DVD. The trainees’ cardiopulmonary resuscitation skills and knowledge were re-assessed 12 months after training. Results: The retention rates of cardiopulmonary resuscitation skills in both audio-visual-practice (N = 177) and audio-visual (N = 157) groups were higher than that in control group (N = 114) 12 months after training (all P-values < 0.001). The cardiopulmonary resuscitation skill retention rate in audio-visual-practice group was higher than that in audio-visual group (49.7% vs 36.9%, P = 0.019), but no difference was found in intention-to-treat analysis (32.1% vs 27.1%, P = 0.230). Both audio-visual-practice and audio-visual groups had higher correct rates on all skill elements than that in control group (all P-values < 0.05). The cardiopulmonary resuscitation knowledge scores in both audio-visual-practice and audio-visual groups were higher than that in control group (all P-values < 0.001). However, no significant difference was found between audio-visual-practice and audio-visual groups (P = 0.243). Conclusions: Both audio-visual-practice and audio-visual review models demonstrated better long-term retention of cardiopulmonary resuscitation skills for families of people at higher risk of out-of-hospital cardiac arrest. (Registration number: chiCTR-TRC-12002149) © 2019 Elsevier Ltd. All rights reserved.

Keywords: Bystander Cardiopulmonary resuscitation Retention Training Out-of-hospital cardiac arrest

What is already known about the topic? • Most of the out-of-hospital cardiac arrests occur at home and are witnessed by their family members who usually did not

∗

Corresponding author. E-mail address: [email protected] (Y. Wu). 1 These authors contributed equally to this work and should be considered cofirst authors. https://doi.org/10.1016/j.ijnurstu.2019.103451 0020-7489/© 2019 Elsevier Ltd. All rights reserved.

have the opportunity to attend cardiopulmonary resuscitation training. • Poor retention of cardiopulmonary resuscitation skills is an important contributing factor to low rescue rate of out-of-hospital cardiac arrest. What this paper adds • Audio-visual-practice and audio-visual review model were in favor of 12-month retention on cardiopulmonary resuscitation

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skills and knowledge for family members of people at higher risk of out-of-hospital cardiac arrest. • Considering the cost, the audio-visual review model is more scalable than the audio-visual-practice review model for improving the 12-month retention rate of cardiopulmonary resuscitation skills. 1. Introduction Out-of-hospital cardiac arrest is one of the leading causes of death worldwide (Nichol et al., 2008). The incidence of out-ofhospital cardiac arrest is about 394 0 0 0 per year in the United States, 275 0 0 0 in Europe (Atwood et al., 2005; Mozaffarian et al., 2016). However, the survival rate is rarely beyond 10% (Berdowski et al., 2010; Fairbanks et al., 2007; Hollenberg et al., 2008; Sasson et al., 2010). Compared with North America and Europe, Asia has a lower survival rate (Ong et al., 2008; S C, 1994).The incidence of emergency medical service-assessed out-of-hospital cardiac arrest was about 71.2 per 100 000 inhabitants annually in urban areas in Beijing, and the survival rate is only 1.3% (Shao et al., 2014). Bystander cardiopulmonary resuscitation has been a very important and the initial step that could link the survival chain of out-of-hospital cardiac arrest victims. Worldwide two approaches have been used to increase the bystander rescue rate: training the public to perform cardiopulmonary resuscitation and dispatchers providing telephone instructions to witnesses (Fujie et al., 2014; Shimamoto et al., 2015; Tanaka et al., 2012). Globally, bystander rescue rates differ widely, 73% in Norway, and 11.4% in Beijing China (Chiang et al., 2014; Fujie et al., 2014; Fosbøl et al., 2014; Lindner et al., 2011). Mismatch of people who receive cardiopulmonary resuscitation training and the persons who witness the out-of-hospital cardiac arrest events are one of the main contributors of lower bystander rescue rate (Cartledge et al., 2016; 2019). The majority people who attended cardiopulmonary resuscitation training are required by their jobs, while about 80% of the out-of-hospital cardiac arrests occur at home and are witnessed by their family members who usually did not have the opportunity to attend cardiopulmonary resuscitation training (Mozaffarian et al., 2016). Only about 17.9% of bystanders in private locations received cardiopulmonary resuscitation training 5 years prior to the out-of-hospital cardiac arrest event (Bray et al., 2017; Hawkes et al., 2019; Swor et al., 2003). This number is even lower in China (Liu et al., 2012; Wang, 2015). Previous studies have shown the families have the capability to master the cardiopulmonary resuscitation performance immediately after training and are willing to perform cardiopulmonary resuscitation when witnessing an out-of-hospital cardiac arrest event (Blewer et al., 2012; Cokkinos et al., 2010; Hao et al., 2011). Poor retention of cardiopulmonary resuscitation skills is a contributing factor in low rescue rates. Deterioration of cardiopulmonary resuscitation skills occurs as early as three months after training if not used or reviewed, even for healthcare providers (Nolan et al., 2010). The American Heart Association recommends that healthcare provider should renew their cardiopulmonary resuscitation skills every two years. However, it is difficult to provide the public with renewal courses, especially in countries with large populations like China or low-income countries. Most of the family members often do not feel confident in performing cardiopulmonary resuscitation or cannot rescue effectively even though they received cardiopulmonary resuscitation training previously (Bobrow et al., 2010; Iwami et al., 2012; Rea et al., 2010). In order to close the gap between people who have cardiopulmonary resuscitation training and the persons who witness out-of-hospital cardiac arrest events, we chose families of patients at high risk of out-of-hospital cardiac arrest for training, and designed two different models to help them review cardiopulmonary

resuscitation skills that did not involve any repetitive training. One is the audio-visual (AV) review model (watching a cardiopulmonary resuscitation video regularly), the other is the audio-visual-practice (AVP) review model (practicing the cardiopulmonary resuscitation skills while watching the video). We hypothesized that the audio-visual-practice review model would achieve a higher 12 months cardiopulmonary resuscitation skill retention rate when compared with the audio-visual review model and placebo control. 2. Methods 2.1. Study design and setting We conducted a randomized, double-blind, placebo controlled, and three-arm parallel study in Beijing, China, from November 2010 to May 2015. The team members are teachers of Nursing School of Capital Medical University. The study was approved by the institutional ethics committee (No. 2010SY26). Written informed consent was obtained from all participants. 2.2. Study participants Two team members were specifically responsible for recruiting participants. We recruited family members of patients at high risk of out-of-hospital cardiac arrests through flyers disseminated by residents’ committees and community nurses, and advertised regularly in a local newspaper. Recruiters contacted families about the training by telephone. Potential participants were informed about the research procedure, the intended benefit, and likelihood of complications. The family members who volunteered to participant in the study were asked to bring patient’s medical records to participate in the cardiopulmonary resuscitation training. So, the recruiters could verify relevant materials to ensure compliance with inclusion criteria. ‘High risk’ patients were defined as adults with coronary heart disease, hypertension, diabetes, hyperlipidemia, and obesity. The inclusion criteria for participants were: family members who reside with the patient, and aged 18–75 years. Families who received cardiopulmonary resuscitation training during the last 2 years and hold a job as healthcare professionals were excluded. After cardiopulmonary resuscitation training, participants having adequate cardiopulmonary resuscitation skills and knowledge were enrolled in the study. Baseline measures were also collected after training. 2.3. Instruments Cardiopulmonary resuscitation skill was assessed by a selfdeveloped cardiopulmonary resuscitation skill assessment scale according to 2010 the American Heart Association guidelines. The scale consists of 24 items, 11 are essential items (chest compression location, compression depth and compression rate, etc.). Each item is rated as correct (scored 1 point) or incorrect (scored 0 points). Raw scores were converted to percentages. Adequate skill is defined as a cardiopulmonary resuscitation skill score of 80 points or higher and correct performance of all essential items. The content validity index of each item is 0.75–1.00 and the total content validity index of the scale is 0.994. The inter-rater reliability is 0.861, the intra-class correlation coefficient is 0.916 (P < 0.01) and the inter-rater agreement on pass or fail decisions is 0.809 (P < 0.01). Cardiopulmonary resuscitation knowledge was assessed by a self-developed cardiopulmonary resuscitation knowledge questionnaire. The questionnaire consists of two parts: participant characteristics and 13 multiple-choice questions. Each question is rated as correct (scored 1 point) or incorrect (scored 0 points). Raw scores were converted to percentages.

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Adequate cardiopulmonary resuscitation knowledge is defined as a cardiopulmonary resuscitation knowledge score of 80 points or higher. The content validity index of each question is 0.75–1.00. The test-retest reliability is 0.880. The questionnaire was described in detail in a previous paper (Li et al., 2013). 2.4. Outcome measures The primary outcome of this study was cardiopulmonary resuscitation skill retention rate, which is defined as the percentage of subjects whose overall cardiopulmonary resuscitation performance was rated as adequate at 12 months after training. Our secondary outcome was cardiopulmonary resuscitation knowledge score, which was assessed immediately after training and 12 months later. 2.5. Cardiopulmonary resuscitation training and data collection To ensure the quality of cardiopulmonary resuscitation training, the two-hour sessions were designed based on the American Heart Association guidelines. The training sessions consisted of three parts: (1) watching the motivational scenarios and the whole process of cardiopulmonary resuscitation followed by step-by-step instruction, (2) practicing on the manikin while watching the instructional video, (3) cardiopulmonary resuscitation skill and knowledge assessment. We controlled the number of trainees of each session to no more than 30 persons with a minimum instructor-to-trainee ratio of 1:6 and at least one manikin for each six trainees. Participants had adequate time to practice cardiopulmonary resuscitation skills. Seven team members were specifically responsible for training and data collection. All training instructors were the American Heart Association certified basic life support instructors. The cardiopulmonary resuscitation training video was developed by the research team and verified by the Chinese Society of Pacing and Electrophysiology. Resusci Anne SkillReporterTM (310,025, Laerdal Medical) was used to measure the performance of cardiopulmonary resuscitation. Twelve months after training, all participants were re-assessed individually for their cardiopulmonary resuscitation skill and knowledge. The evaluators, the assessment procedure, and the manikin were identical to that of the initial assessment. Re-assessment was done at the same place of training and the participants were asked to complete the test without any extra training.

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in audio-visual group and 107 in audio-visual-practice group). We found that the cardiopulmonary resuscitation skill retention rates in both audio-visual and audio-visual-practice group were significantly higher than that of the control group, which indicates both interventions constantly favor cardiopulmonary resuscitation skill retention compared to the concurrent control group. As family members of patients at high risk of out-of-hospital cardiac arrests, trainees are more likely to experience sudden cardiac arrest than the general population. Because they have studied our cardiopulmonary resuscitation training course, they may not attend similar training afterwards. Once sudden cardiac arrest occurs, trainees in the control group may not be able to implement high-quality cardiopulmonary resuscitation (the skill retention rate was only 8.6%). The institutional board requested to stop recruiting control group and only randomize the subjects to two intervention groups (either audio-visual or audio-visualpractice group). After that, no control group was established, but people in the control group without follow-up were completed on time. 2.7. Sample size calculation The sample size was calculated using PASS statistical software. According to Mahoney’s study (Mahony et al., 2008), the cardiopulmonary resuscitation skill retention rate of non-professional personnel 12 months after training was only 5.7%. We expected the cardiopulmonary resuscitation skill retention rate achieved 30% at 12 months after training in audio-visual-practice group. The intracluster correlation coefficient is 0.1 and the sample size per cluster is about 24. We required 432 participates to give 80% power to detect the significant difference among groups. The sample size fully met the requirement. 2.8. Intervention 2.8.1. Control group The participants in control group received a cardiopulmonary resuscitation instruction booklet and a placebo-DVD without a telephone reminder and any further reinforcement. The content of booklet is the adult basic life support algorithm and the standard of operation. It was written by the research team and verified by the Chinese Society of Pacing and Electrophysiology (CSPE). The contents of the placebo-DVD published by the Medical AudioVisual Publishing House of PLA (China) addressed coronary disease prevention without any cardiopulmonary resuscitation skill or knowledge information.

2.6. Randomization and masking Randomizations were performed by a biostatistician who was not directly involved in this study. In order to avoid intervention contamination, the randomization was conducted at the training session (cluster) level instead of at the individual level. The enrolled subjects were then allocated to either the intervention or control group based upon the assignment of their training session. The number of subjects in each session varied from 18 to 30. Random numbers were generated using EXCEL software and the allocation of each training session was stored in an opaque sealed envelope. The participants, trainers and the evaluators were all blinded to the group assignment. The subjects were recruited between December 2010 and May 2014. There were 410 family members enrolled in the study till January 2013, 153 subjects in the control group, 120 subjects in audio-visual group and 137 subjects in audio-visual-practice group. We conducted ongoing interim analysis as requested by the institutional review board. The analysis included 330 people who completed the follow-up (120 in the control group, 103

2.8.2. Audio-visual group The participants in audio-visual group were given the cardiopulmonary resuscitation instruction booklet and a cardiopulmonary resuscitation instructional-DVD. The video was developed by the research team and was also verified by CSPE. Participants were told to review cardiopulmonary resuscitation skills every three months by reading the booklet and watching the instructional-DVD. Telephone calls were made every 3 months to remind participants to review the materials. Two team members were responsible for telephone follow-up who were blinded to the study allocation of each participant. 2.8.3. Audio-visual-practice group Besides the cardiopulmonary resuscitation instruction booklet and a cardiopulmonary resuscitation instruction-DVD, a humanshaped throw pillow was provided to the audio-visual-practice participants. The pillow was designed by the research team and has the landmarks of a sternum and two nipples. The participants in audio-visual-practice group were also told to review the

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Fig. 1. Flow diagram. Note. AVP group = audio-visual-practice group; AV group = audio-visual group; the institutional review board requested an interim review and recommended the cessation of recruitment into the control group in Jan 2013.

cardiopulmonary resuscitation skill every three months. Different from the audio-visual group, they were asked to practice the cardiopulmonary resuscitation skills on the throw pillow while watching the instruction-DVD. Telephone calls were made every 3 months to remind participants to review.

to deal with loss of follow-up of the participants. Two-sided p-value < 0.05 were considered significant for all statistical tests.

3. Results 3.1. Study population

2.9. Statistical analysis Statistical analysis was performed using IBM SPSS statistics for Windows version 19.0 (Armonk, NY, IBM Corp., USA). Continuous variables were compared using the Kruskal–Wallis test or MannWhitney U test. Categorical variables were reported as frequencies and proportions. The comparisons across groups were conducted using χ 2 test. A mixed effect logistic regression model was used to compare the knowledge and skill retention among the three groups 12 months after training. In all models, age, gender and education level were adjusted as covariates and cluster (different training sessions) was treated as random effect to accommodate for the correlation between participants within the same training session. In order to preserve the benefit of randomization fully and avoid the bias, intention-to-treat analysis was performed

A total of 820 family members attended the initial cardiopulmonary resuscitation training. As shown in Fig. 1, 112 did not meet the inclusive criteria, and 67 did not reach adequate cardiopulmonary resuscitation skills after training. There was a total of 31 training sessions and 7 sessions were randomly assigned to control group and 12 sessions were randomly assigned to each of two intervention groups respectively. There were 641 family members who were included in the intention-to-treat analysis. 193 were lost to follow-up, and 448 participants who completed the entire study process were included in the per-protocol analysis. At the end of recruitment and randomization there were 153 subjects in the control group, 214 subjects in audio-visual group and 274 subjects in audio-visual-practice group. There were no statistical differences in demographic data - neither among three study

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Fig. 2. Comparison of retention rates of cardiopulmonary resuscitation skills 12 months after training (N = 448).

Table 1 Demographic characteristics of the participants (N = 448).

Age, median (IQR) Gender, n (%) Male Female Education, n (%) Junior school and below High school College and above

Table 2 Comparison of knowledge and skill retention at 12 months after training (N = 448).

Control (n = 114)

AV group (n = 157)

AVP group (n = 177)

P-value

54(45, 60)

51(38, 59)

54(44, 60)

0.15∗ 0.05

25(21.9) 89(78.1)

55(35.0) 102(65.0)

48(27.4) 129(72.9)

18(15.8) 47(41.2) 49(43.0)

18(11.5) 57(36.3) 82(52.2)

28(15.8) 64(36.2) 85(48.0)

Knowledge retention

AV: Control AVP: Control AVP: AV

Skill retention

OR

95% CI

P-value

OR

95% CI

P-value

2.76 5.13 1.86

(1.32, 5.74) (2.47, 10.65) (0.98, 3.52)

0.007 <0.001 0.058

3.67 8.07 2.20

(1.86, 7.22) (4.16, 15.66) (1.37, 3.53)

<0.001 <0.001 0.001

0.54

∗ The Kruskal-Wallis test used to compare the age of three groups.Abbreviation: AVP group = audio-visual-practice group AV group = audio-visual group.

groups nor between follow-up and lost family members (Tables 1 and Supplementary s1).

3.2. The effects of audio-visual and audio-visual-practice on cardiopulmonary resuscitation retention Significant deterioration of cardiopulmonary resuscitation skill was observed in all three groups 12 months after training (all P-values < 0.001), but the retention rate differed significantly among three groups (P-values < 0.001). Comparison of retention rates of cardiopulmonary resuscitation skills 12 months after training is shown in Fig. 2. The retention rates of cardiopulmonary resuscitation skills in both audio-visual-practice and audio-visual groups were higher than that in control group (all P-values < 0.001 for per-protocol and intention-to-treat analysis). The retention rate of cardiopulmonary resuscitation skills in audio-visual-practice group was higher than that in audio-visual group (P = 0.019), no significant difference, however, was found for intention-to-treat analysis (P = 0.230). Given the clustered nature of our data and reasonable number of clusters in this study, a linear mixed model was used to compare the knowledge and skill retention among the three groups 12 months after training. Odds ratio (OR), 95% confidence interval and P-value are reported in Table 2. Post hoc sensitivity analyses were performed to assess the robustness of the results to protocol deviations. When taking

clustering into account, the results are similar to those of the primary analysis. There were no significant differences in cardiopulmonary resuscitation knowledge scores immediately after the initial cardiopulmonary resuscitation training among the three groups. Significant decline was observed in cardiopulmonary resuscitation knowledge score in all three groups 12 months after training (all P-values < 0.001). The cardiopulmonary resuscitation knowledge scores in both audio-visual and audio-visual-practice groups were higher than in control group (all P-values < 0.001). However, no differences were observed between audio-visual and audio-visual-practice groups (P = 0.243) (Supplementary s2). In order to explore the cardiopulmonary resuscitation skill retention of each single skill item, all elements were compared. Fig. 3 shows the retention rates of each cardiopulmonary resuscitation skill item 12 months after training. Except for two skill items (airway opening and effective ventilation), the audio-visualpractice and audio-visual group displayed good skill retention. Both audio-visual-practice and audio-visual groups had higher correct rates on all items than in control group (all P-values < 0.05), however, no differences were found between audio-visual-practice and audio-visual groups (all P-values > 0.05). 4. Discussion This randomized placebo controlled clinical trial was designed to test the effectiveness of the two review models on the retention of cardiopulmonary resuscitation skill and knowledge. We found that both audio-visual and audio-visual-practice review models had a relative increased 12-month cardiopulmonary resuscitation retention rate of 36.9% and 49.7%, respectively. Our findings indicate that in the event of out-of-hospital cardiac arrest, witnesses

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Fig. 3. Retention rates of cardiopulmonary resuscitation skills 12 months after training.

who received both audio-visual review and audio-visual-practice review could rescue more effectively and therefore improve chances for survival. Cardiopulmonary resuscitation skill is a psychomotor skill that can only be maintained through repetitive practice. As a small probability event, it is difficult for the lay person to review and use cardiopulmonary resuscitation skills regularly in daily life (Dracup et al., 1994; Sanna et al., 2006). A previous study confirmed that repeated viewing of a reminder video clip on a mobile phone can increase the cardiopulmonary resuscitation skill retention three months after training (Ahn et al., 2011). Our study supports this finding that regular review either through watching cardiopulmonary resuscitation video only or practicing the cardiopulmonary resuscitation skills while watching the cardiopulmonary resuscitation video every three months can effectively improve long-term retention rate of cardiopulmonary resuscitation skills and audio-visual-practice might be more effective in terms of cardiopulmonary resuscitation skill retention. Repetitive practice is critical for some cardiopulmonary resuscitation skills such as adequate compression depth and compression rate (Bilger et al., 1997; Hornstein and Mulligan, 2001). These skills can only be mastered through practice to obtain the feeling and experience of appropriate depth and frequency (Ahn et al., 2011). For cost consideration, the portable manikin or the American Heart Association cardiopulmonary resuscitation Anytime Training Kits is not feasible in China. Our throw pillow (only costs $7) could be put on a sofa and used every day so that it could serve both as a reminder to review and a mannequin to practice. Although a relative higher 12-month retention rate was found in audio-visual-practice group (32.1%), we did not confirm that audio-visual-practice review model was more effective on 12-months cardiopulmonary resuscitation skill retention on intention-to-treat analysis. We also failed to confirm that the audio-visual-practice review model assisted with the throw pillow could improve the 12-month retention rate of each skill element. Although the absolute retention rates in audio-visual-practice group were higher than that of audio-visual group in some skill elements such as “compression location”, “compression depth”. Several reasons could explain these findings. First, the trainees might habitually put their hands on the

landmark rather than really remember the compression location. Second, the resistance of our throw pillow is much lower than resuscitation mannequin. The force required to achieve adequate compression depth on the pillow could not ensure the same effect on mannequin. Third, our throw pillow does not provide real-time feedback to correct learner’s mistakes when practicing cardiopulmonary resuscitation skills. Fourth, the throw pillow cannot practice airway opening and breathing skills. Finally, the audiovisual-practice group had a higher rate of lost follow-up (35.4%), which might be one of the reasons for no significant difference in 12-month retention rate of both overall cardiopulmonary resuscitation skill and each skill element on the intention-to-treat analysis. The reason for this higher rate of lost follow-up is unclear. According to the American Heart Association guidelines, ventilation skills are an important part of cardiopulmonary resuscitation in the research design phase. In our study, the family members were trained and assessed with traditional cardiopulmonary resuscitation. Among all cardiopulmonary resuscitation skills, ventilation skills had the lowest retention rate 12 months after training. Ventilation skills are difficult for the families to master. And to some extent, this skill affected the overall cardiopulmonary resuscitation skill retention. In 2008, the American Heart Association emphasized quality “hard and fast” chest compressions (Sayre et al., 2008). In 2010, the AHA guidelines recommended the lay rescuers to begin chest compression as quickly as possible, and deemphasized the ventilation skills for the untrained lay rescuer or the trained lay rescuer lacking confident resuscitation skills (Hazinski et al., 2010). Participants were notified of these guideline changes after follow-up assessment. In contrast to cardiopulmonary resuscitation skills, the 12month cardiopulmonary resuscitation knowledge scores were much higher in three groups and the two review models could also effectively help participants retain cardiopulmonary resuscitation knowledge. Our findings indicate that the retention of knowledge does not insure skill retention. Only half of the people with adequate cardiopulmonary resuscitation knowledge (50.6%) had adequate cardiopulmonary resuscitation skills. Our study has some limitations. First, the drop-out rate was high. Participants were lost to follow-up due to different reasons.

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Intention-to-treat analysis, however, was used to evaluate the real effect of interventions. Second, we did not measure the compliance rate of cardiopulmonary resuscitation skill review. Although the audio-visual and audio-visual-practice group received telephone reminders every 3 months, we do not know the true states of the trainee’s review at home. Even so, the cardiopulmonary resuscitation skill retention rates of two review models were still higher than the control group. With the popularity of smart phone and instant communication applications such as WeChat in China, future studies may explore the possibility of automatic reminder for cardiopulmonary resuscitation skill review and monitoring of adherence by developing a special application or simply using the self-contained function of smart phones to test its effectiveness on cardiopulmonary resuscitation skill retention. Third, the cardiopulmonary resuscitation training experience of trainees two years ago was not collected. Previous cardiopulmonary resuscitation training may make it easier to maintain skills. Fourth, this study only observed the retention rate 12 months after cardiopulmonary resuscitation training. Further studies are needed to evaluate the longer term cardiopulmonary resuscitation skill retention rates of audio-visual-practice and audio-visual review model. 5. Conclusion Both audio-visual and audio-visual-practice review models revealed better 12-month retention on cardiopulmonary resuscitation skills and knowledge for family members of people at higher risk of out-of-hospital cardiac arrest. Further studies are needed to test the long-term cardiopulmonary resuscitation skill retention in combination with mobile information technology. Conflict of interest None. Funding This study was supported by a scientific research grant from the Ministry of Health of China (grant no. 20 09020 01). Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnurstu.2019.103451. References Ahn, J.Y., Cho, G.C., Shon, Y.D., Park, S.M., Kang, K.H., 2011. Effect of a reminder video using a mobile phone on the retention of CPR and AED skills in lay responders. Resuscitation 82 (12), 1543–1547. doi:10.1016/j.resuscitation.2011.08.029. Atwood, C., Eisenberg, M.S., Herlitz, J., Rea, T.D., 2005. Incidence of EMS-treated outof-hospital cardiac arrest in Europe. Resuscitation 67 (1), 75–80. doi:10.1016/j. resuscitation.2005.03.021. Berdowski, J., Berg, R.A., Tijssen, J.G., Koster, R.W., 2010. Global incidences of outof-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 81 (11), 1479–1487. doi:10.1016/j.resuscitation.2010. 08.006. Bilger, M.C., Giesen, B.C., Wollan, P.C., White, R.D., 1997. Improved retention of the ems activation component (EMSAC) in adult CPR education. Resuscitation 35 (3), 219–224. Blewer, A.L., Leary, M., Esposito, E.C., Gonzalez, M., Riegel, B., Bobrow, B.J., Abella, B.S., 2012. Continuous chest compression cardiopulmonary resuscitation training promotes rescuer self-confidence and increased secondary training: a hospital-based randomized controlled trial∗ . Crit. Care Med. 40 (3), 787–792. doi:10.1097/CCM.0b013e318236f2ca. Bobrow, B.J., Spaite, D.W., Berg, R.A., Stolz, U., Sanders, A.B., Kern, K.B., Vadeboncoeur, T.F., Clark, L.L., Gallagher, J.V., Stapczynski, J.S., LoVecchio, F., Mullins, T.J., Humble, W.O., Ewy, G.A., 2010. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. Jama 304 (13), 1447–1454. doi:10.1001/jama.2010.1392.

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