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Basic life support training into cardiac rehabilitation programs: A chance to give back. A community intervention controlled manikin study
Resuscitation 127 (2018) 14–20
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Clinical paper
Basic life support training into cardiac rehabilitation programs: A chance to give back. A community intervention controlled manikin study☆
T
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Violeta González-Salvadoa,b, , Cristian Abelairas-Gómezb,c,d, Carlos Peña-Gila,b, Carmen Neiro-Reya, Roberto Barcala-Furelosb,c,e,f, José Ramón González-Juanateya,b, Antonio Rodríguez-Núñezb,c,g,h,1 a
Cardiology Department, University Clinical Hospital of Santiago, Universidade de Santiago de Compostela, Santiago de Compostela, Spain Institute of Health Research of Santiago (IDIS), Spain c CLINURSID Research Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain d Faculty of Educational Sciences, Universidade de Santiago de Compostela, Santiago de Compostela, Spain e Faculty of Education and Sport Sciences, Universidade de Vigo, Pontevedra, Spain f REMOSS Research Group, Universidade de Vigo, Pontevedra, Spain g Paediatric Emergency and Critical Care Division, University Clinical Hospital of Santiago, Universidade de Santiago de Compostela, Santiago de Compostela, Spain h School of Nursing, Universidade de Santiago de Compostela, Santiago de Compostela, Spain b
A R T I C LE I N FO
A B S T R A C T
Keywords: Basic life support Cardiac rehabilitation Resuscitation Laypeople Bystander Cardiac arrest Learning
Aim: Early basic life support is crucial to enhance survival from out-of-hospital cardiac arrest but rates remain low, especially in households. High-risk groups’ training has been advocated, but the optimal method is unclear. The CArdiac REhabilitation and BAsic life Support (CAREBAS) project aims to compare the effectiveness of two basic life support educational strategies implemented in a cardiac rehabilitation program. Methods: A community intervention study including consecutive patients enrolled on an exercise-based cardiac rehabilitation program after acute coronary syndrome or revascularization was conducted. A standard basic life support training (G-Stan) and a novel approach integrating cardiopulmonary resuscitation hands-on rolling refreshers (G-CPR) were randomly assigned to each group and compared. Basic life support performance was assessed by means of simulation at baseline, following brief instruction and after the 2-month program. Results: 114 participants were included and 108 completed the final evaluation (G-Stan:58, G-CPR:50). Basic life support performance was equally poor at baseline and significantly improved following a brief instruction. A better skill retention was found after the 2-month program in G-CPR, significantly superior for safety and sending for an automated external defibrillator. Confidence and self-perceived preparation were also significantly greater in G-CPR after the program. Conclusions: Integrating cardiopulmonary resuscitation hands-on rolling refreshers in the training of an exercisebased cardiac rehabilitation program is feasible and improves patients’ skill retention and confidence to perform a basic life support sequence, compared to conventional training. Exporting this formula to other programs may result in increased numbers of trained citizens, enhanced social awareness and bystander resuscitation.
Introduction Although early cardiopulmonary resuscitation (CPR) and defibrillation are crucial for improving outcomes and survival of out-ofhospital cardiac arrest (OHCA) [1–3], less than half of victims receive bystander assistance [4,5]. Shortening the time to advanced care is also critical, which implies performing the sequence of actions that comprise the basic life support (BLS) sequence as part of the chain of survival [6].
Most of OHCA occur at home, with particularly low reported rates of survival [7] and bystander BLS [8] compared to other settings. Patients with a cardiac history −especially of coronary disease- are at increased risk of adverse events, including sudden cardiac death [5,9,10]. BLS training among patients and their families has been encouraged [11,12] but scarcely applied. Cardiac rehabilitation programs have demonstrated to improve quality of life after myocardial infarction and reduce readmissions, cardiovascular events and cardiovascular
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.03.018. Corresponding author at: Cardiology Department,University Clinical Hospital of Santiago,A Choupana s/n. 15706, Santiago de Compostela, A Coruña, Spain. E-mail address: [email protected] (V. González-Salvado). 1 SAMID-II Network, Spain, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), ref. RD12/0026. ⁎
https://doi.org/10.1016/j.resuscitation.2018.03.018 Received 27 September 2017; Received in revised form 12 January 2018; Accepted 10 March 2018 0300-9572/ © 2018 Elsevier B.V. All rights reserved.
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Fig. 1. Participants’ flow and study completion. Abbreviations: BLS: basic life support. CPR: cardiopulmonary resuscitation.
population area. It comprises 750 beds of which 64 are dedicated to cardiology, including 10 beds at the coronary care unit. A mean of 3000 patients per year are admitted in the cardiology department, with 1200 angioplasties performed per year. The Cardiac Rehabilitation Unit is run by one cardiologist, one endocrinologist, two rehabilitation doctors, two nurses, one physiotherapist and one psychologist. A mean of 225 patients per year enrol on the exercise-based program, mainly after suffering acute coronary syndromes. Inpatient phase I comprises individualized advise for risk factor modification and adherence to medication. Patients meeting inclusion criteria for phase II are comprehensively evaluated within 4 weeks after discharge to assess their lifestyle, psychological state, functional capacity and overall risk. Phase II consists of an outpatient structured educational program and supervised exercise training at the hospital gym, along 24 sessions distributed over 8 weeks (3 sessions/ week) in groups of 6 patients. Patients’ families often attend the educational module.
mortality. With a comprehensive approach including risk factor modification, medication adherence and physical exercise, they have been recognized as an essential component of care [13]. Moreover, they provide a valuable educational setting for patients and ability to disseminate knowledge in their familiar and social environment. Even if they appear to be a safe and feasible frame to implement such training [14], the optimal method is unclear. The CArdiac REhabilitation and BAsic life Support (CAREBAS) project is rooted in this concern for improving outcomes of OHCA by implementing BLS learning in a cardiac rehabilitation program at a tertiary University hospital. Even if the effectiveness of CPR rolling refreshers to achieve psychomotor competence by healthcare staff has been well characterized [15–18], no previous studies have assessed their usefulness to remind the complete BLS sequence. This 6-month project aims to compare a new training formula integrating these CPR refreshers to a standard course regarding performance, retention and self-perceived preparation in BLS depending on the strategy assigned. Methods
Participants
The project is conducted in the frame of an exercise-based cardiac rehabilitation program at a single centre in Santiago de Compostela, Galicia (Spain). The study complies with the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of our hospital.
All patients who joined the exercise-based cardiac rehabilitation program between February 2016 and February 2017 and their families were invited to participate in the study. Eligible participants were those aged > 18 years, medically stable and physically and psychologically able to participate in the training. All subjects gave their written consent to participate. Demographic characteristics, previous training in BLS and experience in witnessed OHCA were assessed at baseline, and anthropometric and functional features were collected before and after the program.
Setting The hospital serves around 500000 inhabitants in a scattered 15
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Training
Table 1 Participants’ characteristics. Total (N = 114) Demographic characteristics a Sex Women 10 (8.8) Men 104 (91.2) a Age 53.7 (6.4) Residence Rural 63 (55.3) Urban 51 (44.7) Education No studies 3 (2.6) Primary 43 (37.7) Secondary 48 (42.1) University 20 (17.5) Knowledge regarding basic life support Healthcare Yes 4 (3.5) background No 110 (96.5) Previous training in Yes 28 (24.6) basic life support No 86 (75.4) Last training Never 86 (75.4) Last year 6 (5.3) + 2 years 22 (19.3) Witnessed cardiac Yes 17 (14.9) arrest No 97 (85.1) Clinical, anthropometric and functional features Diagnosis at STEMI 50 (43.9) admission non-STEMI 33 (28.9) Unstable angina 29 (25.4) Others 2 (1.8) Cardiac arrest at Yes 2 (1.8) admission No 112 (98.2) Risk stratification Low 70 (61.4) Intermediate 35 (30.7) High 9 (7.9) a Weight (kg) Before program 85.2 (15.7) b
a
Body Mass Index (kg/m2) a Functional capacity (METs)
After program
84.6 (14.7)
Before program After program Before program c After program
29.4 (4.7) 29.2 (4.3) 9.6 (2.5) 12.2 (2.6)
b
G-Stan (n = 61)
G-CPR (n = 53)
3 (4.9) 58 (95.1) 53.7 (7.0) 36 (59.0) 25 (41.0) 2 (3.3) 19 (31.1) 30 (49.2) 10 (16.4)
7 (13.2) 46 (86.8) 53.6 (5.6) 27 (50.9) 26 (49.1) 1 (1.9) 24 (45.3) 18 (34.0) 10 (18.9)
1 (1.6) 60 (98.4) 14 (23.0) 47 (77.0) 47 (77.0) 3 (4.9) 11 (18.0) 7 (11.5) 54 (88.5)
3 (5.7) 50 (94.3) 14 (26.4) 39 (73.6) 39 (73.6) 3 (5.7) 11 (20.8) 10 (18.9) 43 (81.1)
21 (34.4) 23 (37.7) 17 (27.9) 0 (0.0) 2 (3.3) 59 (96.7) 42 (68.9) 15 (24.6) 4 (6.6) 87.0 (16.5) 86.0 (15.6) 29.6 (4.5) 29.4 (4.3) 9.8 (2.6) 12.7 (2.7)
29 (54.7) 10 (18.9) 12 (22.6) 2 (3.8) 0 (0.0) 53 (100.0) 28 (52.8) 20 (37.7) 5 (9.4) 83.3 (14.7)
The educational design was conducted according to the guidelines [6,12] and the results of a prior pilot study including 10 patients (7 men, 3 women; mean age 54.8 years) to assess their preferences and attitudes towards training. After baseline evaluation, a 20-min instruction on the subsequent steps to evaluate a collapsed victim and act accordingly following the BLS sequence [6] were provided. The instructor explained the steps as he/she performed them on a ResusciAnne® (Laerdal) manikin; an automated external defibrillator (AED) trainer was also use. Early recognition of the situation by checking the victim’s response and breathing−including gasping as a sign of cardiac arrest- were emphasized. Participants were motivated to act following the BLS sequence to facilitate early defibrillation and access to advanced care of the collapsed victim. Compression-only CPR performance and AED use were taught according to the guidelines [6]. A different training strategy was then applied in each group during the cardiac rehabilitation program. Patients in G-Stan attended a conventional aerobic endurance and strength training. Patients in G-CPR received a brief hands-on CPR rolling refresher on a MiniAnne© manikin integrated in the exercise sessions at increasing intervals of 30 s/2 weeks starting at 30 s, until they achieved a continuous 2-min compression-only CPR training at weeks 7 and 8. No specific reminders about the BLS protocol were provided to either of the groups during the program or afterwards. Evaluation Evaluation was individually performed by means of a simulation scenario. A ResusciAnne® manikin was placed on the floor and the participant was told to imagine passing amid a crosswalk when suddenly a middle-age person collapsed a few meters in front of him/her, and was required to “act as he/she would in that particular situation”. Proficiency to perform a complete BLS protocol was checked by directly observed procedural skills, including: 1) checking safety 2) checking response 3) opening the airway and checking breathing 4) alerting the emergency medical services (EMS) 5) sending for an AED and 6) initiating CPR. Whilst all variables were categorized as a yes/no answer (performed/not performed), response, breathing and alerting the EMS were evaluated in detail (correctly performed/with errors/not performed) and mistakes were reported. Additionally, AED use and chest compressions’ resumption afterwards were also assessed. (Supplementary material Appendix A, Table A1). The questionnaire was filled out during the simulation while observing performance. No feedback was provided by the evaluator, but if the participant called the EMS, he/she was given standardized dispatcher instructions according to the national EMS protocol [19]. If not, an actor who played the role of another bystander made the call and put him/her in contact with the EMS. Since only those actions accomplished on the participant’s own initiative were considered as “performed”, the item alerting the EMS would have been considered “not performed” if he/she had not made the call. Likewise, if the participant needed the dispatcher’s instructions to initiate CPR, it would have been considered as “not performed”. In all cases the simulated situation required delivering a shock, for which an AED trainer was provided after 2 min of compression-only CPR. This was applied independently of the participant having sent for an AED or not, to allow testing the ability to use the device and subsequently resume chest compressions. The shock was considered effective (“performed”) if the pads were correctly placed. The same evaluation protocol was followed independently of the group (G-CPR/G-Stan) or the stage of the study. In order to minimize inter and intra-observer variability, only four evaluators examined participants according to pre-established criteria. In case of discrepancy, decision was made by consensus.
83.1 (13.6) 29.2 (4.9) 28.9 (4.4) 9.3 (2.3) 11.5 (2.2)
Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group; METs, metabolic equivalents of task; STEMI, ST-elevation myocardial infarction. a Quantitative variables [mean (SD)]. b Considering those who completed the program: n = 59 (G-Stan), n = 50 (G-CPR). c Considering those who completed the program and performed the exercise stress test: n = 58 (G-Stan), n = 50 (G-CPR). One patient in G-Stan could not perform exercise stress test due to an articular injury.
Study design CAREBAS is a 6-month prospective study assessing the effect of two educational interventions. Training both groups differently in parallel was unfeasible and this precluded individual randomisation. Instead, two convenience samples of participants were consecutively recruited as they enrolled on the program, and the training modality was arbitrarily assigned to each group. Hence, patients joining the program from February to June 2016 constituted the first group −randomly assigned to CPR-training (G-CPR)-, while those included from October 2016 to February 2017 formed the second group−randomly assigned to standard training (G-Stan)-. A 3-month washout period was left in between to prevent patients with different training modalities from overlapping at the gym. Family members were also invited to participate and provided their written consent. Patients’ performance of a BLS protocol was evaluated at baseline (T0), after brief instruction (T1) and after the 8-week exercise-based program (T2). Only those who attended a minimum 80% of exercise sessions were considered for evaluation at T2. Families and patients’ results at 6 months are currently undergoing evaluation.
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Fig. 2. Basic life support performance of groups over time. Hexagonal concentric lines from 0 to 100 represent the percentage of patients performing the action at each stage, without considering order of execution. Inter-group analysis with Chi-square test: * p < 0.05; ** p < 0.01. Abbreviations: as in Fig. 1. G-Stanstandard-training group; G-CPRCPR-training group; EMSemergency medical services; AEDautomated external defibrillator.
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analysed. McNemar test was carried out to compare the outcomes of dichotomous variables over time. When comparing categorical variables in the inter-group analysis, Chi-square statistic was performed, or Fisher’s Exact Test when the number of cells with expected values ≥5 was over 20%. For continuous variables, the Friedman test was used to assess intra-group differences at the three times, with post-hoc Wilcoxon Signed Rank Test to discern at which exact point significant differences occurred. Inter-group analyses for continuous variables were performed using the Mann-Whitney U Test. Statistical analyses were performed with IBM SPSS Statistics v.21 for Macintosh. A significance level of p < 0.05 was considered for all analyses. Results Participants’ characteristics A total of 114 patients were included in the study (G-Stan: 61, GCPR: 53). Of these, 3 in each group were excluded from T2 analysis because either they abandoned the program or did not fulfil the required minimum of 80% training sessions for any reason including work, illness or injuries (Fig. 1). Baseline characteristics are presented in Table 1. Diagnosis at admission was predominantly acute coronary syndrome (98.2%), with only two patients in G-CPR enrolling on the program after elective revascularization. According to pre-specified criteria, a predominant proportion of low-risk patients was found, followed by intermediate and high-risk patients. Only two patients in G-Stan presented with OHCA at admission. A great majority of participants were male and mean age was 53.7 years. Slightly more than half of patients lived in rural areas and most of them had at least primary and secondary education. Only 4 patients had a healthcare background (nurse, doctor, physiotherapist) and only one quarter reported previous BLS training, most of which had taken place > 2 years ago. A wide majority of participants had never witnessed an OHCA.
Fig. 3. Stringent analysis of the basic life support protocol’s fulfilment. Percentage of participants performing the complete sequence (above), and the complete sequence in the correct standard order (below) at each stage. Inter-group analysis with Chi-square test: * p < 0.05; ** p < 0.01; *** p < 0.001. Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group.
Performance of a BLS protocol Fig. 2 shows the evolution of the BLS sequence performance by both groups over time. Variables were considered dichotomous (performed/ not performed, regardless of performance quality) for the elaboration of the graphics. When items were considered as “performed/not performed”, the intra-group analysis showed poor performance at baseline (T0), which significantly improved after brief instruction (T1, p < 0.001 for all analyses, except for G-CPR when alerting the EMS, p = 0.004). After the program results markedly differed. Although both groups did better with respect to baseline, skill deterioration from T1 to T2 was striking in G-Stan, whose proficiency significantly sank for the items safety (T1: 91.8% vs. T2: 77.6%; p = 0.036) and response (T1: 85.2% vs. T2: 53.4% p = 0.001). Conversely, G-CPR maintained similar results from T1 to T2 for response, breathing and initiating CPR. A slight although non-significant improvement regarding safety, alerting the EMS and sending for an AED was even shown in the latter group. The inter-group analysis revealed an overall poor performance at baseline, only better in G-CPR when checking response (T0: G-CPR: 41.5% vs. G-Stan: 23.0%; χ2(1) = 4.521, p = 0.033). After brief instruction both groups improved similarly, but participants in G-Stan remembered better to evaluate response this time (T1: G-Stan: 85.2% vs. G-CPR: 67.9%; χ2(1) = 4.833, p = 0.028). Finally, G-CPR showed better skill retention than G-Stan after the program. Except for comparable results when alerting the EMS (T2: G-Stan: 94.8%; G-CPR: 96.0%) and initiating CPR (T2: both groups 100.0%), participants in G-CPR remembered better to perform all other items. This superiority was statistically significant when checking safety (T2: G-Stan: 77.6%; G-CPR:
Fig. 4. Self-rated preparation and confidence. Values are reported in each group over time and expressed as median with interquartile range Inter-group analysis with Mann-Whitney U Test: *** p < 0.001 Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group.
Additionally, patients rated their confidence and preparation to encounter a hypothetical situation of OHCA at the three time points (T0, T1, T2), by means of a 10 cm visual analogue scale.
Statistical analysis Continuous variables are expressed as mean with standard deviation or median with interquartile range (IQR) as appropriate. Categorical variables are described using proportions. The effect of both an intra-group (evaluation of each group over time: T0 vs. T1 vs. T2) and an inter-group (G-Stan vs. G-CPR) factor was 18
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98.0%; χ2(1) = 9.918, p = 0.002) and sending for an AED (T2: G-Stan: 79.3%; G-CPR: 94.0%; χ2(1) = 4.845, p = 0.028). The items response, breathing and alerting the EMS were further examined considering a three-grade score (correctly performed/with errors/not performed), with two differentiated trends. On the one hand, barely one quarter of participants and < 10% in each group respectively checked response and breathing correctly at baseline, with substantial improvement to somewhat over 80% after instruction. After the program, proficient performance declined in G-Stan (< 50%) and was reasonably maintained in G-CPR, whose ability to adequately check breathing was significantly superior to that of G-Stan (G-Stan: 43.1%; GCPR: 74.0%; χ2(2) = 10.856, p = 0.004). Recurrent errors were respectively omitting one of the two steps to check response (verbally and shaking) and inadequately opening the airway to check breathing. Accordingly, the latter error was significantly minimized in G-CPR after training (G-Stan: 48.3%; G-CPR: 74.0%; χ2(1) = 7.415, p = 0.006). On the other hand, nearly 60% of participants succeeded alerting the EMS at baseline; 90% did after the course and up to 95% after the program. Contacting the police was the most frequent mistake among those who did the call. A stringent analysis to determine how many patients in each group executed the complete sequence and how many additionally followed the correct order was performed (Fig. 3). A significantly higher percentage of patients in G-CPR performed all items after the program (T2: G-Stan: 36.2%; G-CPR: 58.0%; χ2(1) = 5.129, p = 0.024), even if G-Stan had performed slightly better at the previous test (T1: G-Stan: 73.8%; GCPR: 52.8%; χ2(1) = 5.400, p = 0.020). Besides, more patients in G-CPR remembered the correct order of the sequence (T2: G-Stan: 20.7%; GCPR: 54.0%; χ2(1) = 12.914, p < 0.001). AED use and CPR resumption after defibrillation were additionally assessed. Hardly half of participants were able to deliver an effective shock at baseline despite the device’s acoustic direction (T0: G-Stan: 44.3%; G-CPR: 50.9%; χ2(1) = 1.275, p = 0.529), whereas a wide majority accomplished it following brief instruction (T1: G-Stan: 91.8%; GCPR: 100.0% Fisher’s Exact Test, p = 0.060). A fall in quality was observed in both groups after the program, although less pronounced in GCPR (T2: G-Stan: 79.3%; G-CPR: 90.0%; χ2(1) = 2.313, p = 0.128). Likewise, < 50% of patients resumed chest compressions after the shock at T0, with substantial improvement at T1 (G-Stan: 95.1%; GCPR: 84.9%) and opposite trends at T2 (G-Stan: 82.8%; G-CPR: 94.0%).
of a BLS protocol and confidence, compared to conventional training. The profile of those more likely to witness an OHCA −middle-aged woman in a family setting- is far from that of usual participants in BLS courses [20,21], thus selective training of high-risk populations −such as families of cardiac patients- has been advocated [22,23]. Although they are unlikely to seek out training on their own [24], there are reasonable grounds to believe they may present a positive attitude towards training [25]. Extending CPR training to cardiac patients has been encouraged; far from causing psychological distress, it has shown to reduce anxiety and increase their relatives’ participation and engagement [26]. Accordingly, patients in our study showed high motivation to participate, with no reported cases of serious concerns or rejection. Given its multidisciplinary character and educational vocation, cardiac rehabilitation may represent an optimal frame to implement such training [24]. Previous works have applied single interventions consisting of 2.5–4 h courses [25,26], but a growing trend to find innovative learning tools has been observed over the last decade, including self-instruction [27], gamification [28], simulation [16] and CPR rolling refreshers [15,17]. The latter have proven to be effective at improving paediatric CPR skills among healthcare staff.15 Similarly, different formulas providing low-dose, high-frequency CPR training have shown to enhance their skill retention [17]. Regarding cardiac patients, Cartledge et al. recently assessed the feasibility of introducing self-instructed CPR learning in a cardiac rehabilitation program, with encouraging results [14]. However, fewer studies have analysed the BLS sequence in detail [29–31] and none to our knowledge have assessed the usefulness of CPR rolling refreshers to retain it. Consistently with previous studies [24–26], baseline skills in our sample were overall poor. Participants especially failed to check safety −which may be a limitation of the simulation setting- and did not consider sending for an AED, reflecting low awareness of bystander defibrillation despite mass social campaigns. As expected, substantial improvement was achieved in both groups at T1, particularly remarkable for localizing an AED, suggesting that simple instruction may be enough to remind it. After the program, checking response was frequently forgotten, but checking breathing achieved acceptable accomplishment, which could make it possible to recognize cardiac arrest if performed correctly. However, opening the airway was frequently missed or incorrectly performed, as previously described [31], suggesting this aspect should be stressed in BLS courses. The superior results achieved by G-CPR at T2 make the difference between strategies. The sole incorporation of CPR rolling refreshers, without specific reminders of the BLS sequence, improved patients’ performance and confidence two months after. Our finding that “providing a single piece helps complete the whole puzzle” may be interesting for further studies in this field. Exercise-based cardiac rehabilitation programs are more successful than those simply providing risk factor counseling [13,32], and it is expected that the trend will be moving towards the former model, which may allow implementing BLS training formulas such as the proposed. Being at higher risk of adverse events does not preclude cardiac patients to help in an emergency situation. Furthermore, this chance to “give back” may help them to move from a vulnerable position following myocardial infarction to a state of regained control. In the same way they are motivated to promote healthy lifestyles in their environment, they may share their knowledge with others [14], becoming a lever for social awareness. Our study has some limitations. First, although no important baseline differences were found between groups, we cannot guarantee that other factors did not influence their skills. For instance, two patients in G-Stan presented with OHCA at admission, which might have influenced their attitude towards learning. Likewise, patients’ access to information about BLS from other sources was not controlled throughout the study, but investigators avoided favouring different access to such information between groups. Secondly, the CPR-training strategy
Self-perceived preparation Confidence and self-rated preparation to confront a situation of OHCA showed significant differences in both groups over time (Friedman test: p < 0.001) (Fig. 4). Initial values ranged from a very low basis (15%) in both groups. Further analyses carried out with Wilcoxon Signed Rank Test detected significant improvement to over 80% in self-perceived preparation after instruction (p < 0.001 in both cases). However, even if there was a significant confidence decline from T1 to T2 (p < 0.001 in both groups), this was substantially lessened in G-CPR, whose reported selfrated preparation was 20% higher than G-Stan after the program (p < 0.001). Discussion In this sample of patients with coronary disease undertaking a cardiac rehabilitation program skills to perform a BLS sequence were poor at baseline, improved substantially after brief instruction and showed opposite trends after the program, with marked deterioration in the standard-training group and reasonably maintenance in the CPRtraining group. In addition, confidence and self-perceived preparation to act in a hypothetical situation of OHCA were also enhanced in the latter group. Our results suggest that implementing this new CPRtraining model is feasible and significantly improves patients’ retention 19
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proposed in this study would not apply to cardiac rehabilitation programs excluding the exercise component. Thirdly, the encouraging results achieved by means of simulation may not apply to an actual scenario of OHCA; however, interventions removing psychological and knowledge barriers have shown to make people more likely to act in a real setting [33]. Finally, as a shared limitation with this type of studies, no conclusions about the impact of training on survival from OHCA can be drawn, given its low incidence that would require an enormous sample size to detect differences.
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[21] Vaillancourt C, Kasaboski A, Charette M, Islam R, Osmond M, Wells GA, et al. Barriers and facilitators to CPR training and performing CPR in an older population most likely to witness cardiac arrest: a national survey. Resuscitation 2013;84:1747–52. [22] Swor RA, Jackson RE, Compton S, Domeier R, Zalenski R, Honeycutt L, et al. Cardiac arrest in private locations: different strategies are needed to improve outcome. Resuscitation 2003;58:171–6. [23] Blewer AL, Putt ME, Becker LB, Riegel BJ, Li J, Leary M, et al. Video-only cardiopulmonary resuscitation education for high-risk families before hospital discharge: a multicenter pragmatic trial. Circ Cardiovasc Qual Outcomes 2016;9:740–8. [24] Richardson ME, Lie KG. Cardiopulmonary resuscitation training for family members of patients on cardiac rehabilitation programmes in Scotland. Resuscitation 1999;40:11–9. [25] Cartledge S, Bray JE, Leary M, Stub D, Finn J. A systematic review of basic life support training targeted to family members of high-risk cardiac patients. Resuscitation 2016;105:70–8. [26] Ingram S, Maher V, Bennett K, Gormley J. The effect of cardiopulmonary resuscitation training on psychological variables of cardiac rehabilitation patients. Resuscitation 2006;71:89–96. [27] Hsieh M-J, Bhanji F, Chiang W-C, Yang C-W, Chien K-L, Ma MH-M. Comparing the effect of self-instruction with that of traditional instruction in basic life support courses—a systematic review. Resuscitation 2016;108:8–19. [28] MacKinnon RJ, Stoeter R, Doherty C, Fullwood C, Cheng A, Nadkarni V, et al. Selfmotivated learning with gamification improves infant CPR performance, a randomised controlled trial. BMJ Simul Technol Enhanc Learn 2015;1:71–6. [29] Meissner TM, Kloppe C, Hanefeld C. Basic life support skills of high school students before and after cardiopulmonary resuscitation training: a longitudinal investigation. Scand J Trauma Resusc Emerg Med 2012;20:31. [30] de Ruijter PA, Biersteker HA, Biert J, van Goor H, Tan EC. Retention of first aid and basic life support skills in undergraduate medical students. Med Educ Online 2014;19:24841. [31] Van Raemdonck V, Aerenhouts D, Monsieurs K, De Martelaer K. A pilot study of flipped cardiopulmonary resuscitation training: which items can be self-trained? Health Educ J 2017;76:946–55. [32] Corra U, Piepoli MF, Carre F, Heuschmann P, Hoffmann U, Verschuren M, et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the cardiac rehabilitation section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010;31:1967–74. [33] Oliver E, Cooper J, McKinney D. Can first aid training encourage individuals’ propensity to act in an emergency situation? A pilot study. Emerg Med J 2014;31:518–20.
Conclusions Exercise-based cardiac rehabilitation programs provide an optimal frame to implement BLS learning among cardiac patients and their families, taking advantage of the existing resources. The integration of CPR hands-on rolling refreshers into exercise training enhanced patients’ retention of a BLS protocol, as well as their confidence and selfperceived preparation to act. This formula could be exportable to other programs on an affordable inversion, resulting in increased numbers of trained citizens and bystander initiated BLS. Further studies are needed to assess long-time retention of skills and the impact of such strategies on the patient’s familiar setting. Conflicts of interest None. Acknowledgements The authors thank all those who voluntarily contributed to the realization of this project, especially C. Gómez-González for her excellent collaboration during the data collection, M. Sestayo-Fernández for her language editing and F. Gude-Sampedro and G. Prada-Ramallal for their statistical assessment. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.resuscitation.2018.03.018. References [1] Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander efforts and 1-Year outcomes in out-of-hospital cardiac arrest. N Engl J Med 2017;376:1737–47. [2] Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-ofhospital cardiac arrest in North Carolina, 2010–2013. JAMA 2015;314:255–64. [3] Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307–15. [4] Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81. [5] Gräsner J-T, Lefering R, Koster RW, Masterson S, Böttiger BW, Herlitz J, et al. EuReCa ONE—27 Nations, ONE Europe, ONE Registry. Resuscitation 2016;105:188–95. [6] Perkins GD, Handley AJ, Koster RW, Castrén M, Smyth MA, Olasveengen T, et al. European resuscitation council guidelines for resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99. [7] Herlitz J, Eek M, Holmberg M, Engdahl J, Holmberg S. Characteristics and outcome among patients having out of hospital cardiac arrest at home compared with elsewhere. Heart Br Card Soc 2002;88:579–82. [8] Fujie K, Nakata Y, Yasuda S, Mizutani T, Hashimoto K. Do dispatcher instructions facilitate bystander-initiated cardiopulmonary resuscitation and improve outcomes in patients with out-of-hospital cardiac arrest? A comparison of family and nonfamily bystanders. Resuscitation 2014;85:315–9. [9] Hayashi M, Shimizu W, Albert CM. The spectrum of epidemiology underlying
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Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Basic life support training into cardiac rehabilitation programs: A chance to give back. A community intervention controlled manikin study☆
T
⁎
Violeta González-Salvadoa,b, , Cristian Abelairas-Gómezb,c,d, Carlos Peña-Gila,b, Carmen Neiro-Reya, Roberto Barcala-Furelosb,c,e,f, José Ramón González-Juanateya,b, Antonio Rodríguez-Núñezb,c,g,h,1 a
Cardiology Department, University Clinical Hospital of Santiago, Universidade de Santiago de Compostela, Santiago de Compostela, Spain Institute of Health Research of Santiago (IDIS), Spain c CLINURSID Research Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain d Faculty of Educational Sciences, Universidade de Santiago de Compostela, Santiago de Compostela, Spain e Faculty of Education and Sport Sciences, Universidade de Vigo, Pontevedra, Spain f REMOSS Research Group, Universidade de Vigo, Pontevedra, Spain g Paediatric Emergency and Critical Care Division, University Clinical Hospital of Santiago, Universidade de Santiago de Compostela, Santiago de Compostela, Spain h School of Nursing, Universidade de Santiago de Compostela, Santiago de Compostela, Spain b
A R T I C LE I N FO
A B S T R A C T
Keywords: Basic life support Cardiac rehabilitation Resuscitation Laypeople Bystander Cardiac arrest Learning
Aim: Early basic life support is crucial to enhance survival from out-of-hospital cardiac arrest but rates remain low, especially in households. High-risk groups’ training has been advocated, but the optimal method is unclear. The CArdiac REhabilitation and BAsic life Support (CAREBAS) project aims to compare the effectiveness of two basic life support educational strategies implemented in a cardiac rehabilitation program. Methods: A community intervention study including consecutive patients enrolled on an exercise-based cardiac rehabilitation program after acute coronary syndrome or revascularization was conducted. A standard basic life support training (G-Stan) and a novel approach integrating cardiopulmonary resuscitation hands-on rolling refreshers (G-CPR) were randomly assigned to each group and compared. Basic life support performance was assessed by means of simulation at baseline, following brief instruction and after the 2-month program. Results: 114 participants were included and 108 completed the final evaluation (G-Stan:58, G-CPR:50). Basic life support performance was equally poor at baseline and significantly improved following a brief instruction. A better skill retention was found after the 2-month program in G-CPR, significantly superior for safety and sending for an automated external defibrillator. Confidence and self-perceived preparation were also significantly greater in G-CPR after the program. Conclusions: Integrating cardiopulmonary resuscitation hands-on rolling refreshers in the training of an exercisebased cardiac rehabilitation program is feasible and improves patients’ skill retention and confidence to perform a basic life support sequence, compared to conventional training. Exporting this formula to other programs may result in increased numbers of trained citizens, enhanced social awareness and bystander resuscitation.
Introduction Although early cardiopulmonary resuscitation (CPR) and defibrillation are crucial for improving outcomes and survival of out-ofhospital cardiac arrest (OHCA) [1–3], less than half of victims receive bystander assistance [4,5]. Shortening the time to advanced care is also critical, which implies performing the sequence of actions that comprise the basic life support (BLS) sequence as part of the chain of survival [6].
Most of OHCA occur at home, with particularly low reported rates of survival [7] and bystander BLS [8] compared to other settings. Patients with a cardiac history −especially of coronary disease- are at increased risk of adverse events, including sudden cardiac death [5,9,10]. BLS training among patients and their families has been encouraged [11,12] but scarcely applied. Cardiac rehabilitation programs have demonstrated to improve quality of life after myocardial infarction and reduce readmissions, cardiovascular events and cardiovascular
☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.03.018. Corresponding author at: Cardiology Department,University Clinical Hospital of Santiago,A Choupana s/n. 15706, Santiago de Compostela, A Coruña, Spain. E-mail address: [email protected] (V. González-Salvado). 1 SAMID-II Network, Spain, ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), ref. RD12/0026. ⁎
https://doi.org/10.1016/j.resuscitation.2018.03.018 Received 27 September 2017; Received in revised form 12 January 2018; Accepted 10 March 2018 0300-9572/ © 2018 Elsevier B.V. All rights reserved.
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Fig. 1. Participants’ flow and study completion. Abbreviations: BLS: basic life support. CPR: cardiopulmonary resuscitation.
population area. It comprises 750 beds of which 64 are dedicated to cardiology, including 10 beds at the coronary care unit. A mean of 3000 patients per year are admitted in the cardiology department, with 1200 angioplasties performed per year. The Cardiac Rehabilitation Unit is run by one cardiologist, one endocrinologist, two rehabilitation doctors, two nurses, one physiotherapist and one psychologist. A mean of 225 patients per year enrol on the exercise-based program, mainly after suffering acute coronary syndromes. Inpatient phase I comprises individualized advise for risk factor modification and adherence to medication. Patients meeting inclusion criteria for phase II are comprehensively evaluated within 4 weeks after discharge to assess their lifestyle, psychological state, functional capacity and overall risk. Phase II consists of an outpatient structured educational program and supervised exercise training at the hospital gym, along 24 sessions distributed over 8 weeks (3 sessions/ week) in groups of 6 patients. Patients’ families often attend the educational module.
mortality. With a comprehensive approach including risk factor modification, medication adherence and physical exercise, they have been recognized as an essential component of care [13]. Moreover, they provide a valuable educational setting for patients and ability to disseminate knowledge in their familiar and social environment. Even if they appear to be a safe and feasible frame to implement such training [14], the optimal method is unclear. The CArdiac REhabilitation and BAsic life Support (CAREBAS) project is rooted in this concern for improving outcomes of OHCA by implementing BLS learning in a cardiac rehabilitation program at a tertiary University hospital. Even if the effectiveness of CPR rolling refreshers to achieve psychomotor competence by healthcare staff has been well characterized [15–18], no previous studies have assessed their usefulness to remind the complete BLS sequence. This 6-month project aims to compare a new training formula integrating these CPR refreshers to a standard course regarding performance, retention and self-perceived preparation in BLS depending on the strategy assigned. Methods
Participants
The project is conducted in the frame of an exercise-based cardiac rehabilitation program at a single centre in Santiago de Compostela, Galicia (Spain). The study complies with the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of our hospital.
All patients who joined the exercise-based cardiac rehabilitation program between February 2016 and February 2017 and their families were invited to participate in the study. Eligible participants were those aged > 18 years, medically stable and physically and psychologically able to participate in the training. All subjects gave their written consent to participate. Demographic characteristics, previous training in BLS and experience in witnessed OHCA were assessed at baseline, and anthropometric and functional features were collected before and after the program.
Setting The hospital serves around 500000 inhabitants in a scattered 15
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Training
Table 1 Participants’ characteristics. Total (N = 114) Demographic characteristics a Sex Women 10 (8.8) Men 104 (91.2) a Age 53.7 (6.4) Residence Rural 63 (55.3) Urban 51 (44.7) Education No studies 3 (2.6) Primary 43 (37.7) Secondary 48 (42.1) University 20 (17.5) Knowledge regarding basic life support Healthcare Yes 4 (3.5) background No 110 (96.5) Previous training in Yes 28 (24.6) basic life support No 86 (75.4) Last training Never 86 (75.4) Last year 6 (5.3) + 2 years 22 (19.3) Witnessed cardiac Yes 17 (14.9) arrest No 97 (85.1) Clinical, anthropometric and functional features Diagnosis at STEMI 50 (43.9) admission non-STEMI 33 (28.9) Unstable angina 29 (25.4) Others 2 (1.8) Cardiac arrest at Yes 2 (1.8) admission No 112 (98.2) Risk stratification Low 70 (61.4) Intermediate 35 (30.7) High 9 (7.9) a Weight (kg) Before program 85.2 (15.7) b
a
Body Mass Index (kg/m2) a Functional capacity (METs)
After program
84.6 (14.7)
Before program After program Before program c After program
29.4 (4.7) 29.2 (4.3) 9.6 (2.5) 12.2 (2.6)
b
G-Stan (n = 61)
G-CPR (n = 53)
3 (4.9) 58 (95.1) 53.7 (7.0) 36 (59.0) 25 (41.0) 2 (3.3) 19 (31.1) 30 (49.2) 10 (16.4)
7 (13.2) 46 (86.8) 53.6 (5.6) 27 (50.9) 26 (49.1) 1 (1.9) 24 (45.3) 18 (34.0) 10 (18.9)
1 (1.6) 60 (98.4) 14 (23.0) 47 (77.0) 47 (77.0) 3 (4.9) 11 (18.0) 7 (11.5) 54 (88.5)
3 (5.7) 50 (94.3) 14 (26.4) 39 (73.6) 39 (73.6) 3 (5.7) 11 (20.8) 10 (18.9) 43 (81.1)
21 (34.4) 23 (37.7) 17 (27.9) 0 (0.0) 2 (3.3) 59 (96.7) 42 (68.9) 15 (24.6) 4 (6.6) 87.0 (16.5) 86.0 (15.6) 29.6 (4.5) 29.4 (4.3) 9.8 (2.6) 12.7 (2.7)
29 (54.7) 10 (18.9) 12 (22.6) 2 (3.8) 0 (0.0) 53 (100.0) 28 (52.8) 20 (37.7) 5 (9.4) 83.3 (14.7)
The educational design was conducted according to the guidelines [6,12] and the results of a prior pilot study including 10 patients (7 men, 3 women; mean age 54.8 years) to assess their preferences and attitudes towards training. After baseline evaluation, a 20-min instruction on the subsequent steps to evaluate a collapsed victim and act accordingly following the BLS sequence [6] were provided. The instructor explained the steps as he/she performed them on a ResusciAnne® (Laerdal) manikin; an automated external defibrillator (AED) trainer was also use. Early recognition of the situation by checking the victim’s response and breathing−including gasping as a sign of cardiac arrest- were emphasized. Participants were motivated to act following the BLS sequence to facilitate early defibrillation and access to advanced care of the collapsed victim. Compression-only CPR performance and AED use were taught according to the guidelines [6]. A different training strategy was then applied in each group during the cardiac rehabilitation program. Patients in G-Stan attended a conventional aerobic endurance and strength training. Patients in G-CPR received a brief hands-on CPR rolling refresher on a MiniAnne© manikin integrated in the exercise sessions at increasing intervals of 30 s/2 weeks starting at 30 s, until they achieved a continuous 2-min compression-only CPR training at weeks 7 and 8. No specific reminders about the BLS protocol were provided to either of the groups during the program or afterwards. Evaluation Evaluation was individually performed by means of a simulation scenario. A ResusciAnne® manikin was placed on the floor and the participant was told to imagine passing amid a crosswalk when suddenly a middle-age person collapsed a few meters in front of him/her, and was required to “act as he/she would in that particular situation”. Proficiency to perform a complete BLS protocol was checked by directly observed procedural skills, including: 1) checking safety 2) checking response 3) opening the airway and checking breathing 4) alerting the emergency medical services (EMS) 5) sending for an AED and 6) initiating CPR. Whilst all variables were categorized as a yes/no answer (performed/not performed), response, breathing and alerting the EMS were evaluated in detail (correctly performed/with errors/not performed) and mistakes were reported. Additionally, AED use and chest compressions’ resumption afterwards were also assessed. (Supplementary material Appendix A, Table A1). The questionnaire was filled out during the simulation while observing performance. No feedback was provided by the evaluator, but if the participant called the EMS, he/she was given standardized dispatcher instructions according to the national EMS protocol [19]. If not, an actor who played the role of another bystander made the call and put him/her in contact with the EMS. Since only those actions accomplished on the participant’s own initiative were considered as “performed”, the item alerting the EMS would have been considered “not performed” if he/she had not made the call. Likewise, if the participant needed the dispatcher’s instructions to initiate CPR, it would have been considered as “not performed”. In all cases the simulated situation required delivering a shock, for which an AED trainer was provided after 2 min of compression-only CPR. This was applied independently of the participant having sent for an AED or not, to allow testing the ability to use the device and subsequently resume chest compressions. The shock was considered effective (“performed”) if the pads were correctly placed. The same evaluation protocol was followed independently of the group (G-CPR/G-Stan) or the stage of the study. In order to minimize inter and intra-observer variability, only four evaluators examined participants according to pre-established criteria. In case of discrepancy, decision was made by consensus.
83.1 (13.6) 29.2 (4.9) 28.9 (4.4) 9.3 (2.3) 11.5 (2.2)
Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group; METs, metabolic equivalents of task; STEMI, ST-elevation myocardial infarction. a Quantitative variables [mean (SD)]. b Considering those who completed the program: n = 59 (G-Stan), n = 50 (G-CPR). c Considering those who completed the program and performed the exercise stress test: n = 58 (G-Stan), n = 50 (G-CPR). One patient in G-Stan could not perform exercise stress test due to an articular injury.
Study design CAREBAS is a 6-month prospective study assessing the effect of two educational interventions. Training both groups differently in parallel was unfeasible and this precluded individual randomisation. Instead, two convenience samples of participants were consecutively recruited as they enrolled on the program, and the training modality was arbitrarily assigned to each group. Hence, patients joining the program from February to June 2016 constituted the first group −randomly assigned to CPR-training (G-CPR)-, while those included from October 2016 to February 2017 formed the second group−randomly assigned to standard training (G-Stan)-. A 3-month washout period was left in between to prevent patients with different training modalities from overlapping at the gym. Family members were also invited to participate and provided their written consent. Patients’ performance of a BLS protocol was evaluated at baseline (T0), after brief instruction (T1) and after the 8-week exercise-based program (T2). Only those who attended a minimum 80% of exercise sessions were considered for evaluation at T2. Families and patients’ results at 6 months are currently undergoing evaluation.
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Fig. 2. Basic life support performance of groups over time. Hexagonal concentric lines from 0 to 100 represent the percentage of patients performing the action at each stage, without considering order of execution. Inter-group analysis with Chi-square test: * p < 0.05; ** p < 0.01. Abbreviations: as in Fig. 1. G-Stanstandard-training group; G-CPRCPR-training group; EMSemergency medical services; AEDautomated external defibrillator.
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analysed. McNemar test was carried out to compare the outcomes of dichotomous variables over time. When comparing categorical variables in the inter-group analysis, Chi-square statistic was performed, or Fisher’s Exact Test when the number of cells with expected values ≥5 was over 20%. For continuous variables, the Friedman test was used to assess intra-group differences at the three times, with post-hoc Wilcoxon Signed Rank Test to discern at which exact point significant differences occurred. Inter-group analyses for continuous variables were performed using the Mann-Whitney U Test. Statistical analyses were performed with IBM SPSS Statistics v.21 for Macintosh. A significance level of p < 0.05 was considered for all analyses. Results Participants’ characteristics A total of 114 patients were included in the study (G-Stan: 61, GCPR: 53). Of these, 3 in each group were excluded from T2 analysis because either they abandoned the program or did not fulfil the required minimum of 80% training sessions for any reason including work, illness or injuries (Fig. 1). Baseline characteristics are presented in Table 1. Diagnosis at admission was predominantly acute coronary syndrome (98.2%), with only two patients in G-CPR enrolling on the program after elective revascularization. According to pre-specified criteria, a predominant proportion of low-risk patients was found, followed by intermediate and high-risk patients. Only two patients in G-Stan presented with OHCA at admission. A great majority of participants were male and mean age was 53.7 years. Slightly more than half of patients lived in rural areas and most of them had at least primary and secondary education. Only 4 patients had a healthcare background (nurse, doctor, physiotherapist) and only one quarter reported previous BLS training, most of which had taken place > 2 years ago. A wide majority of participants had never witnessed an OHCA.
Fig. 3. Stringent analysis of the basic life support protocol’s fulfilment. Percentage of participants performing the complete sequence (above), and the complete sequence in the correct standard order (below) at each stage. Inter-group analysis with Chi-square test: * p < 0.05; ** p < 0.01; *** p < 0.001. Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group.
Performance of a BLS protocol Fig. 2 shows the evolution of the BLS sequence performance by both groups over time. Variables were considered dichotomous (performed/ not performed, regardless of performance quality) for the elaboration of the graphics. When items were considered as “performed/not performed”, the intra-group analysis showed poor performance at baseline (T0), which significantly improved after brief instruction (T1, p < 0.001 for all analyses, except for G-CPR when alerting the EMS, p = 0.004). After the program results markedly differed. Although both groups did better with respect to baseline, skill deterioration from T1 to T2 was striking in G-Stan, whose proficiency significantly sank for the items safety (T1: 91.8% vs. T2: 77.6%; p = 0.036) and response (T1: 85.2% vs. T2: 53.4% p = 0.001). Conversely, G-CPR maintained similar results from T1 to T2 for response, breathing and initiating CPR. A slight although non-significant improvement regarding safety, alerting the EMS and sending for an AED was even shown in the latter group. The inter-group analysis revealed an overall poor performance at baseline, only better in G-CPR when checking response (T0: G-CPR: 41.5% vs. G-Stan: 23.0%; χ2(1) = 4.521, p = 0.033). After brief instruction both groups improved similarly, but participants in G-Stan remembered better to evaluate response this time (T1: G-Stan: 85.2% vs. G-CPR: 67.9%; χ2(1) = 4.833, p = 0.028). Finally, G-CPR showed better skill retention than G-Stan after the program. Except for comparable results when alerting the EMS (T2: G-Stan: 94.8%; G-CPR: 96.0%) and initiating CPR (T2: both groups 100.0%), participants in G-CPR remembered better to perform all other items. This superiority was statistically significant when checking safety (T2: G-Stan: 77.6%; G-CPR:
Fig. 4. Self-rated preparation and confidence. Values are reported in each group over time and expressed as median with interquartile range Inter-group analysis with Mann-Whitney U Test: *** p < 0.001 Abbreviations: G-Stan, standard-training group; G-CPR, CPR-training group.
Additionally, patients rated their confidence and preparation to encounter a hypothetical situation of OHCA at the three time points (T0, T1, T2), by means of a 10 cm visual analogue scale.
Statistical analysis Continuous variables are expressed as mean with standard deviation or median with interquartile range (IQR) as appropriate. Categorical variables are described using proportions. The effect of both an intra-group (evaluation of each group over time: T0 vs. T1 vs. T2) and an inter-group (G-Stan vs. G-CPR) factor was 18
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98.0%; χ2(1) = 9.918, p = 0.002) and sending for an AED (T2: G-Stan: 79.3%; G-CPR: 94.0%; χ2(1) = 4.845, p = 0.028). The items response, breathing and alerting the EMS were further examined considering a three-grade score (correctly performed/with errors/not performed), with two differentiated trends. On the one hand, barely one quarter of participants and < 10% in each group respectively checked response and breathing correctly at baseline, with substantial improvement to somewhat over 80% after instruction. After the program, proficient performance declined in G-Stan (< 50%) and was reasonably maintained in G-CPR, whose ability to adequately check breathing was significantly superior to that of G-Stan (G-Stan: 43.1%; GCPR: 74.0%; χ2(2) = 10.856, p = 0.004). Recurrent errors were respectively omitting one of the two steps to check response (verbally and shaking) and inadequately opening the airway to check breathing. Accordingly, the latter error was significantly minimized in G-CPR after training (G-Stan: 48.3%; G-CPR: 74.0%; χ2(1) = 7.415, p = 0.006). On the other hand, nearly 60% of participants succeeded alerting the EMS at baseline; 90% did after the course and up to 95% after the program. Contacting the police was the most frequent mistake among those who did the call. A stringent analysis to determine how many patients in each group executed the complete sequence and how many additionally followed the correct order was performed (Fig. 3). A significantly higher percentage of patients in G-CPR performed all items after the program (T2: G-Stan: 36.2%; G-CPR: 58.0%; χ2(1) = 5.129, p = 0.024), even if G-Stan had performed slightly better at the previous test (T1: G-Stan: 73.8%; GCPR: 52.8%; χ2(1) = 5.400, p = 0.020). Besides, more patients in G-CPR remembered the correct order of the sequence (T2: G-Stan: 20.7%; GCPR: 54.0%; χ2(1) = 12.914, p < 0.001). AED use and CPR resumption after defibrillation were additionally assessed. Hardly half of participants were able to deliver an effective shock at baseline despite the device’s acoustic direction (T0: G-Stan: 44.3%; G-CPR: 50.9%; χ2(1) = 1.275, p = 0.529), whereas a wide majority accomplished it following brief instruction (T1: G-Stan: 91.8%; GCPR: 100.0% Fisher’s Exact Test, p = 0.060). A fall in quality was observed in both groups after the program, although less pronounced in GCPR (T2: G-Stan: 79.3%; G-CPR: 90.0%; χ2(1) = 2.313, p = 0.128). Likewise, < 50% of patients resumed chest compressions after the shock at T0, with substantial improvement at T1 (G-Stan: 95.1%; GCPR: 84.9%) and opposite trends at T2 (G-Stan: 82.8%; G-CPR: 94.0%).
of a BLS protocol and confidence, compared to conventional training. The profile of those more likely to witness an OHCA −middle-aged woman in a family setting- is far from that of usual participants in BLS courses [20,21], thus selective training of high-risk populations −such as families of cardiac patients- has been advocated [22,23]. Although they are unlikely to seek out training on their own [24], there are reasonable grounds to believe they may present a positive attitude towards training [25]. Extending CPR training to cardiac patients has been encouraged; far from causing psychological distress, it has shown to reduce anxiety and increase their relatives’ participation and engagement [26]. Accordingly, patients in our study showed high motivation to participate, with no reported cases of serious concerns or rejection. Given its multidisciplinary character and educational vocation, cardiac rehabilitation may represent an optimal frame to implement such training [24]. Previous works have applied single interventions consisting of 2.5–4 h courses [25,26], but a growing trend to find innovative learning tools has been observed over the last decade, including self-instruction [27], gamification [28], simulation [16] and CPR rolling refreshers [15,17]. The latter have proven to be effective at improving paediatric CPR skills among healthcare staff.15 Similarly, different formulas providing low-dose, high-frequency CPR training have shown to enhance their skill retention [17]. Regarding cardiac patients, Cartledge et al. recently assessed the feasibility of introducing self-instructed CPR learning in a cardiac rehabilitation program, with encouraging results [14]. However, fewer studies have analysed the BLS sequence in detail [29–31] and none to our knowledge have assessed the usefulness of CPR rolling refreshers to retain it. Consistently with previous studies [24–26], baseline skills in our sample were overall poor. Participants especially failed to check safety −which may be a limitation of the simulation setting- and did not consider sending for an AED, reflecting low awareness of bystander defibrillation despite mass social campaigns. As expected, substantial improvement was achieved in both groups at T1, particularly remarkable for localizing an AED, suggesting that simple instruction may be enough to remind it. After the program, checking response was frequently forgotten, but checking breathing achieved acceptable accomplishment, which could make it possible to recognize cardiac arrest if performed correctly. However, opening the airway was frequently missed or incorrectly performed, as previously described [31], suggesting this aspect should be stressed in BLS courses. The superior results achieved by G-CPR at T2 make the difference between strategies. The sole incorporation of CPR rolling refreshers, without specific reminders of the BLS sequence, improved patients’ performance and confidence two months after. Our finding that “providing a single piece helps complete the whole puzzle” may be interesting for further studies in this field. Exercise-based cardiac rehabilitation programs are more successful than those simply providing risk factor counseling [13,32], and it is expected that the trend will be moving towards the former model, which may allow implementing BLS training formulas such as the proposed. Being at higher risk of adverse events does not preclude cardiac patients to help in an emergency situation. Furthermore, this chance to “give back” may help them to move from a vulnerable position following myocardial infarction to a state of regained control. In the same way they are motivated to promote healthy lifestyles in their environment, they may share their knowledge with others [14], becoming a lever for social awareness. Our study has some limitations. First, although no important baseline differences were found between groups, we cannot guarantee that other factors did not influence their skills. For instance, two patients in G-Stan presented with OHCA at admission, which might have influenced their attitude towards learning. Likewise, patients’ access to information about BLS from other sources was not controlled throughout the study, but investigators avoided favouring different access to such information between groups. Secondly, the CPR-training strategy
Self-perceived preparation Confidence and self-rated preparation to confront a situation of OHCA showed significant differences in both groups over time (Friedman test: p < 0.001) (Fig. 4). Initial values ranged from a very low basis (15%) in both groups. Further analyses carried out with Wilcoxon Signed Rank Test detected significant improvement to over 80% in self-perceived preparation after instruction (p < 0.001 in both cases). However, even if there was a significant confidence decline from T1 to T2 (p < 0.001 in both groups), this was substantially lessened in G-CPR, whose reported selfrated preparation was 20% higher than G-Stan after the program (p < 0.001). Discussion In this sample of patients with coronary disease undertaking a cardiac rehabilitation program skills to perform a BLS sequence were poor at baseline, improved substantially after brief instruction and showed opposite trends after the program, with marked deterioration in the standard-training group and reasonably maintenance in the CPRtraining group. In addition, confidence and self-perceived preparation to act in a hypothetical situation of OHCA were also enhanced in the latter group. Our results suggest that implementing this new CPRtraining model is feasible and significantly improves patients’ retention 19
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proposed in this study would not apply to cardiac rehabilitation programs excluding the exercise component. Thirdly, the encouraging results achieved by means of simulation may not apply to an actual scenario of OHCA; however, interventions removing psychological and knowledge barriers have shown to make people more likely to act in a real setting [33]. Finally, as a shared limitation with this type of studies, no conclusions about the impact of training on survival from OHCA can be drawn, given its low incidence that would require an enormous sample size to detect differences.
sudden cardiac death. Circ Res 2015;116:1887–906. [10] Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation 2016;133:e38–360. [11] Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC) Endorsed by: association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–867. [12] Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG, et al. European resuscitation council guidelines for resuscitation 2015. Section 10. Education and implementation of resuscitation. Resuscitation 2015;95:288–301. 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Conclusions Exercise-based cardiac rehabilitation programs provide an optimal frame to implement BLS learning among cardiac patients and their families, taking advantage of the existing resources. The integration of CPR hands-on rolling refreshers into exercise training enhanced patients’ retention of a BLS protocol, as well as their confidence and selfperceived preparation to act. This formula could be exportable to other programs on an affordable inversion, resulting in increased numbers of trained citizens and bystander initiated BLS. Further studies are needed to assess long-time retention of skills and the impact of such strategies on the patient’s familiar setting. Conflicts of interest None. Acknowledgements The authors thank all those who voluntarily contributed to the realization of this project, especially C. Gómez-González for her excellent collaboration during the data collection, M. Sestayo-Fernández for her language editing and F. Gude-Sampedro and G. Prada-Ramallal for their statistical assessment. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.resuscitation.2018.03.018. References [1] Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander efforts and 1-Year outcomes in out-of-hospital cardiac arrest. N Engl J Med 2017;376:1737–47. [2] Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-ofhospital cardiac arrest in North Carolina, 2010–2013. JAMA 2015;314:255–64. [3] Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307–15. [4] Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81. [5] Gräsner J-T, Lefering R, Koster RW, Masterson S, Böttiger BW, Herlitz J, et al. EuReCa ONE—27 Nations, ONE Europe, ONE Registry. Resuscitation 2016;105:188–95. [6] Perkins GD, Handley AJ, Koster RW, Castrén M, Smyth MA, Olasveengen T, et al. European resuscitation council guidelines for resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99. [7] Herlitz J, Eek M, Holmberg M, Engdahl J, Holmberg S. Characteristics and outcome among patients having out of hospital cardiac arrest at home compared with elsewhere. Heart Br Card Soc 2002;88:579–82. [8] Fujie K, Nakata Y, Yasuda S, Mizutani T, Hashimoto K. Do dispatcher instructions facilitate bystander-initiated cardiopulmonary resuscitation and improve outcomes in patients with out-of-hospital cardiac arrest? A comparison of family and nonfamily bystanders. Resuscitation 2014;85:315–9. [9] Hayashi M, Shimizu W, Albert CM. The spectrum of epidemiology underlying
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