A Novel, 5-Minute, Multisensory Training Session to Teach High-Quality Cardiopulmonary Resuscitation to the Public
Alive in Five
Nearly 350 000 people in the United States have out-of-hospital cardiac arrest (OHCA) each year.1 Initiation of bystander cardiopulmonary resuscitation (CPR) improves survival after OHCA; however, there is significant geographic variation in the rates of both bystander CPR and OHCA survival in the United States, as much as 5-fold.2 The disparate geographic survival from OHCA was deemed unacceptable by the Institute of Medicine, prompting a call for strategic efforts to educate and train the public in CPR.2 In response, the American Heart Association set the goal to increase the rate of bystander CPR nationally from 31% to 62% of cardiac arrests by 2020.3
Rates of CPR training in the United States are low (median 2.4% of population) and vary by community, with low-income, rural, and minority communities having disproportionately low rates of CPR training.4 The Institute of Medicine identified this low rate of training as a critical barrier to performance of bystander CPR, recognizing that “initiatives designed to increase bystander CPR must overcome existing barriers… and teach the technical skills necessary to perform CPR with confidence.”2 Traditional 4-hour CPR training is costly in terms of time and money, limiting the number of bystanders who are able to be trained by this method. Despite development of alternative CPR training methods, nationwide rates of both CPR training and bystander-initiated CPR remain low. No true gold standard exists for training the public in CPR that is efficient, effective, and leads to retention of CPR skills.
Goals and Visions of the Program
The goal of this innovation was to increase the effectiveness and efficiency of public CPR training by creating and implementing a novel, brief, multisensory CPR training method, which we call Alive in Five.
Local Challenges in Implementation
In Jefferson County, Kentucky, the rate of bystander CPR in 2015 was 15.4%, below the national average of 31%; additionally, there was striking disparity in bystander CPR rate according to zip code, ranging from 0% to 100%, (Lokits, AAS, unpublished data, 2015; Figure [D]). The challenges faced locally reflect those faced nationally.
Several barriers exist to increasing the number of lay-persons trained in CPR, including cost, length of training, and limited training classes. We developed a CPR training method that uses minimal resources and is, therefore, free of charge to the public. Most importantly, this training is short in duration (5 minutes) and engages participants via multiple sensory modalities, including hands-on practice.
Design and Implementation of the Initiative
Our CPR training program, called Alive in Five, is a novel, 5-minute, multisensory CPR training suitable for implementation in a public venue. It has been demonstrated that learning and retention are improved via multisensory input.5 Therefore, the program Alive in Five engages subjects via multiple sensory modalities (Figure [A]):
Visual input (2-minute video)
Auditory input (Stayin’ Alive song)
Active live coaching
Tactile input (psychomotor practice)
Consolidation of learning.
In this method, passers-by are recruited to learn CPR in 5 minutes. Participants watch a 2-minute Anytime CPR video created by the American Heart Association, which emphasizes a 2-step response to witnessing a person collapse: (1) call 9-1-1, and (2) push hard and fast in the center of the chest to the beat of the song Stayin’ Alive. After viewing the video, participants practice CPR on noninflatable Little Anne (Laerdal Corporation) mannequins while receiving active verbal coaching to achieve appropriate rate (>100 per min) and depth (>2 inches). After coaching, each participant then performs a timed, 1-minute round of CPR while listening to the song Stayin’ Alive.
While other CPR training techniques combine 1 or 2 sensory modalities of teaching, we think the strength of Alive in Five lies in incorporating multiple sensory modalities into a streamlined training.
State fair attendees were considered an important target audience for CPR training because (1) they represent a diverse population with regards to age, sex, and level of education; (2) attendance at the state fair is high, with daily foot traffic at our station averaging between 5000 and 8000; and (3) attendees travel from throughout the region, creating a geographically diverse population, including those from rural areas.
Alive in Five was first implemented at the Kentucky State Fair on August 20, 2015. Participants were recruited by study personnel in a health exhibit. In groups of 5, participants completed the brief, multisensory CPR training course as detailed earlier. The timed, 1-minute round of CPR was performed on a Little Anne mannequin equipped with CPR quality monitoring technology (TrueCPR, PhysioControl Inc.). This device silently recorded chest compression (CC) rate and percentage at appropriate depth.
Success of the Initiative
We trained 152 adults (≥18 years.) and 66 minors (<18 years.) over 7.5 hours. Our training efficiency index was 4.6 participants per personnel-hour [(218 participants)/(47 personnel-hours)]. Adult participants ranged in age from 18 to 76 years. (median 51). The majority of participants were women (77%); did not work in a healthcare-related field (87%); and had never previously received CPR training (57%).
To measure success of Alive in Five, we measured quality of CPR performed, participation numbers, and geographic reach for participation. CPR quality during 1 minute of CPR, as well as on repeat testing, was measured by CC rate and percentage of CC at appropriate depth.
For analyzing before and after differences, we used McNemar’s test for evaluating marginal frequencies of categorical outcome variables. For Likert scale–based questions, we used Wilcoxon signed-rank sum tests. This method accounted for within-subject covariance. Data were analyzed using SAS software (SAS Institute, Inc., version 9.4). A P value <0.05 was considered statistically significant.
The median rate of CC during 1 minute of CPR was 105 per min (interquartile range [IQR], 101–111), meeting the American Heart Association recommendation of 100 CC/minute. The median percentage of CC performed at appropriate depth was 73% (IQR, 51%–100%; Figure [C]). Approximately 11% (n=17) of participants returned for repeat CPR testing. Their median CC rate was adequate at 105 per minute (IQR, 95–112), with median percentage of CC performed at appropriate depth of 73% (IQR, 41%–95%).
CPR training resulted in improvement in self-reported knowledge of how to perform CPR (from 34% before training to 96% after; P<0.0001) and willingness to perform bystander CPR (from 65% before to 95% after; P<0.0001). CPR training improved self-reported confidence on a scale of 1 to 10 (with 10 being most confident) in performing CPR from a median of 5 (IQR, 2–7) to 9 (IQR, 8–10; P<0.0001).
Of responding participants from zip codes within Jefferson County, 77% were from zip codes with bystander CPR rates less than the national average of 31%.1
Alive in Five has since been implemented in other settings, including hospital lobbies during a month-long CPR training initiative, the Kentucky state legislature, and University of Louisville basketball games (>22 000 spectators). The method was adapted at the basketball games to include not only training before start of game, but also a half-time show demonstrating the steps of hands-only CPR. Through these efforts, over 1000 people received hands-on CPR training and over 29 000 spectators received in-person education. At a repeat event at the Kentucky state fair in 2016, 442 adults and children were trained on a single day. Alive in Five has become part of our institutional culture because of the success of this initiative; we now perform yearly training at the state fair and basketball games. It remains to be seen whether these events will have an impact on rates of bystander CPR in Jefferson County, Kentucky.
Translation to Other Settings
This method is uniquely suited to public venues where passers-by can be recruited for a brief 5-minute training session. We have used the same technique in hospital lobbies, sporting events, fairs, and college campus student centers. Other venues such as community festivals, outdoor markets, high school classes, or college campus fairs would also be suitable.
The core components of Alive in Five for successful implementation are described in the Data Supplement. Briefly, requirements include tables; publicity/signs; CPR mannequins; screen and speakers to play video and Stayin’ Alive song; and CPR coaches. We have found success of the program to directly correspond to success of recruitment efforts; enthusiastic CPR coaches and participation gifts tend to greatly increase the number of participants. This program could be easily adapted to include automated external defibrillation training, although this would add several minutes to the training.
Summary of the Experience, Future Directions, and Challenges
Alive in Five, a novel, 5-minute, multisensory CPR training course offered at a public event, was feasible, efficient, and effective in teaching the skills necessary to perform bystander CPR with confidence. Specifically, participants performed CPR with adequate depth and rate after the multisensory training. Participants reported significantly increased knowledge of skills, confidence, and willingness to perform bystander CPR after versus before the training. This technique (multisensory training), in this brief time frame (≈5 minutes), at this location (public venue) is effective in teaching high-quality CPR.
This method of strategically bringing the training to a central gathering of untrained people, rather than requiring untrained people to find and participate in a training, is a practical method of providing large-scale CPR training. Future research should investigate whether targeted public CPR training impacts regional rates of bystander CPR initiation, quality of bystander CPR, and survival after OHCA.
There were several challenges to implementation of this program. Participant recruitment was a challenge, as many people expressed disinterest. However, as participants were self-selected, they might be more likely to perform bystander CPR by virtue of their willingness to participate. This same selection bias is a limitation of the data. Additionally, these data are limited by lack of a comparison group for CPR performance. However, the quality of CPR performed by participants in this study is comparable to that reported in other studies.
We think that the implications of these results are far-reaching. The Alive in Five CPR training technique requires low time commitment and no cost to participants, yet is effective in teaching technical CPR skills and the confidence to use them. Furthermore, public venues represent a strategic opportunity to target people from communities with low rates of bystander CPR training and implementation and a potentially more effective means of increasing bystander CPR in those areas.
Training mannequins were supplied by the University of Louisville School of Medicine Paris Simulation center. PhysioControl Inc. loaned TrueCPR devices. KentuckyOne Health provided the booth at the Kentucky State Fair and also provided water bottle gifts. The Kentucky Chapter of the American Heart Association (AHA) donated “I got trained in CPR” stickers. Robin Thompson, a graphic designer, produced the Jefferson County maps. Neither PhysioControl Inc. nor KentuckyOne Health had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of article.
The Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.116.003404/-/DC1.
- © 2017 American Heart Association, Inc.
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