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A Comparison of Two
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A COMPARISON OF TWO
CARDIOPULMONARY RESUSCITATION PROGRAMS

BY

Joan Kay-Casemier Nelson

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

ABSTRACT

A COMPARISON OF TWO
CARDIOPULMONARY RESUSCITATION PROGRAMS

By
Joan Kay-Casemier Nelson

Too few lay people have learned CPR with one major
reason cited as class length (4 hours or more). In
addition, method of presentation and type of feedback are
possible reasons for low success rates in those who do
attend classes.

The purpose of the study was to determine the
effectiveness of two video enhanced CPR classes, each
lasting less than two hours, in teaching one-rescuer adult
CPR to the lay public. The sample was 104 self-selected
subjects who were assigned to one of two CPR Programs: AHA
or Citizen. There were no statistically significant
differences between the two groups on passing rates with few
subjects able to pass either course (5.5% for Citizen and
none for AHA). The low passing rate is consistent with the
standard, longer programs reported in the literature.

However, when the component skills (sequencing, timing,
compression, ventilation) were analyzed separately, the
major problems were identified. In addition, a higher
proportion of the Citizen CPR groups was able to complete
all of the component skills successfully.

Implications include allowing longer practice time with
multiple sources of feedback and more focused practice on

ventilations and compressions.

ACKNOWLEDGEMENTS

A special thank you to my thesis committee, Co-Chairs
Rachel Schiffman RN, PhD and Suzanne Budd RN, PhD; and Linda
Spence RN, PhD who provided unending advice and support.

A special thank you also to my husband, M. Elliott
Nelson for his commitment to enroll people into saving
lives, his understanding support of my work and his advice

and aid with this process.

iii

TABLE OF CONTENTS

Introduction .......................................... 1
Statement of the Problem ........................... 3
Research Question .................................. 6

Theoretical Framework Applied to Study ................ 6

Conceptual Definitions ............................... 13
Concept: CPR Program .............................. 13
Concept: Adult One-Rescuer CPR Skills ............. 15

Review of Literature ................................. 16
Instructor Lecture/Demonstration Method ........... 17
Video/Film Presentation of Content With
Instructor Supervised Practice .................... 18
Self-Training Studies ............................. 20

Method ............................................... 21
Design ............................................ 21
Sample ............................................ 21
Operational Definitions ........................... 22

CPR Program ..................................... 22
Presentation of Curriculum ................. 23
Practice Feedback .......................... 23
Practice Format ............................ 24

Adult One-Rescuer CPR Skills .................... 24

Instrumentation ................................... 30
Field Procedures .................................. 32
Data Analysis ..................................... 35
Human Subjects Protection ......................... 36
Assumptions/Limitations ........................... 36

Results/Findings ..................................... 37
Demographic Characteristics of Subjects ........... 37
Analyses to Test the Research Hypothesis .......... 39
Analysis of Component CPR Skills Learned in
Each CPR Program .................................. 40

iv

TABLE OF CONTENTS (continued)

Interpretation of Findings

Related to Model .................................. 42
Interpretation of Findings Related
to Literature ..................................... 43
Interpretation of Results Related
to Methods ........................................ 45
Discussion ........................................... 48
Implications for Practice ......................... 51
Implications for Research ......................... 53
Summary ........................................... 54
List of References ................................... 55
Appendices ........................................... 58
A: Detailed Outline of the AHA CPR Program ........ 58
B: Detailed Outline of the
Citizen CPR Program ............................ 62
C: Laerdal Instruction Manual for Skillmeter ...... 67
D: Print Out of Skillmeter Report ................. 70
E: Skill performance Sheets for Adult
One-Rescuer CPR ................................ 71
F: Training Guide for
Citizen CPR Instructors ........................ 72
G: Training Guide for Testers ..................... 73
H: Participant Questionnaire ...................... 74
I: CPR Skills Training Study Consent Form

2131.“?!

for S. D. Warren ............................... 76
CPR Skills Training Study Consent Form

for the churches ............................... 78
Commonly Asked CPR Questions and Answers ....... 80
Testing Procedure .............................. 85
Testing Form ................................... 86
UCRIHS Consent ................................. 87

Table

Table

Table

Table

Table

Table

Table

LIST OF TABLES

Comparison of AHA and Citizen CPR

Programs by Gagne'—Briggs Outline ...... 12
Curriculum and Format of

AHA CPR and Citizen CPR Programs ....... 25
CPR Pass/Fail Criteria ................. 27
Frequency and Percent of Demographic

and CPR Background Characteristics ..... 38
Frequency and Percentage of Successful

CPR Component Skill Completion
by CPR Program ......................... 41

CPR Study Literature Review Results....44

Recommendations for CPR Programs ....... 50

Vi

LIST OF FIGURES

Figure 1. Model Employed by
Information-Processing Theories
of Learning and Memory ................ 9

Figure 2. Adaptation of Gagné's Model to
CPR Programs ......................... 10

vii

Introduction

Cardiovascular disease continues to be the number one
killer in the United States today. Newman (1993) reports
that cardiovascular disease claimed the lives of 930,000
Americans in 1990. According to the American Heart
Association (AHA) "the cost of cardiovascular disease in
1991 is estimated by the AHA (to be) at $108.9 billion. This
figure includes the cost of physician and nursing services,
hospital and nursing home services, medications and lost
productivity resulting from disability" (American Heart
Association [AHA], 1993, p. 4).

To decrease the number of sudden deaths from
cardiovascular disease the Emergency Cardiac Care (ECC)
Committee of the American Heart Association (AHA), has
recommended the "Chain of Survival" (Cummins, Ornato, Thies,
& Pepe, 1991). ‘The chain of survival is a sequence of
events which, when performed rapidly, will increase the
likelihood of survival from sudden cardiac arrest. The
links in the chain of survival include: early access to
care, early cardiopulmonary resuscitation (CPR), early
(defibrillation, and early advanced care. Weakness in any of
tflie links of this chain decreases the chance of survival for
tile cardiac arrest victim. This study addressed the link of

1

2
CPR, specifically training programs for the lay public. The
AHA has recommended that 20% of the lay public be trained in
CPR (Cummins et al., 1991). Morbidity and mortality from
out-of—hospital cardiac arrest is expected to be
significantly decreased if this goal is achieved (Atkins,
1986; Becker & Pepe, 1993; Cobb & Hallstrom, 1982; Cobb,
Hallstrom, Thompson, Mandel, & Copass, 1980; Copely, Mantle,
Rogers, Russel, & Rackley, 1977; Cummins & Eisenberg, 1985;
Cummins, Eisenberg, Hallstrom, & Litwin, 1985; Cummins et
al., 1991; Guzy, Pearce, & Greenfield, 1983; Kellermann,
1993; Kirk-Gardner, Crossman, & Steven, 1992; Kowalski,
Thompson, Horwitz, Stueven, Aprahamian, & Darin, 1984;
Murphy, Murray, Robinson, & Campion, 1989; Steuven et al.,
1986; Thompson, Hallstrom, & Cobb, 1979; Walz, 1991).

CPR has traditionally been taught by the American Red
Cross (ARC) and the American Heart Association. Michigan
has not met the goal of training 20% of the lay public in
CPR (L. Choate, American Heart Association, personal
communication, January 6, 1994 and L. Proctor, American Red
Cross, personal communication, March 25, 1994). CPR
recertification takes place at least every two years, so
when estimating how many people are currently trained in CPR
a two year time frame is examined. In Michigan between July
1, 1991 and June 30, 1993 there were 252,063 people trained
in CPR by the ARC (L. Proctor, personal communication, March
25, 1994) and 395,096 people trained by the AHA (L. Choate,

personal communication, January 6, 1994). Therefore, the

3
total number of people, of all ages, trained in CPR in the
state of Michigan (population 9,295,297) during those two
years, has been 560,484, or 6% of the population. Six
percent trained is a long way from the recommended 20%
trained. Additionally the population trained included
medical professionals and children (ages 13 years and up),
original CPR program completions and recertifications.

Statement of the Problem

 

According to Eisenberg, Bergner, and Hallstrom (1984),
77% of cardiac arrests occur at home and 15% of the cardiac
arrests occur in a work or public place. Therefore, better
than 85% of the cardiac arrests may be witnessed by someone
who knows the victim. These witnesses, generally lay
people, are the ones who must learn the skill of CPR.

However, the lay public are not learning the life—
saving skill of CPR. Various reasons are cited in the
literature for not learning CPR. Overall, lack of time is
the most frequently cited reason (Ambrose & Stratton, 1993;
Dracup, Moser, Guzy, Taylor, & Marsden, 1994). This barrier
— lack of time — relates, at least in part, to the length of
the CPR class. Traditionally most CPR programs have been
three to four hours or more in length. If class length was
shortened the barrier of lack of time could be eliminated or
at least greatly affected. Currently there are several
video enhanced CPR programs available that teach CPR in one
and one-half to two hours. However, the outcome, adequate

adult one-rescuer CPR, must not be compromised for the sake

4
of a shorter CPR course. There has not been any research
published testing the efficacy of these new video enhanced
CPR programs. This study will examine two currently
available video enhanced CPR programs and assess their
efficacy in teaching adult one-rescuer CPR.

One role of an advanced practice nurse is educator: to
teach the client and family concerning health promotion,
disease prevention and morbidity prevention. Health
promotion education focuses on optimizing the clients'
current health. Disease prevention includes assessment of
the client for risk factors and education in how to avoid
the development of the disease for which they are at risk.
Morbidity prevention focuses on clients with known diseases
such as cardiovascular disease. Education is provided to
modify their current lifestyles to optimize their adjustment
to the disease. Morbidity prevention also includes assuring
the client and family are prepared in the event of an
emergency, if they are at risk for cardiac arrest, they
should know CPR.

The primary health care provider must be aware of the
importance of early access to care and early CPR for the
survival of the clients with cardiovascular disease. It is
imperative that the primary health care provider include CPR
training in the plan of care for families, especially
families at high risk for cardiovascular disease because

tflaey are the ones who may need to perform CPR.

Research has shown families at high risk for

5
cardiovascular disease have not learned CPR because it had
not been recommended by their health care provider (Dracup
et al., 1994). "Discussions about CPR should be initiated
early with competent patients as part of their annual
physical examination" (Miller, Jahnigen, Gorbien, &
Simbartl, 1992, p.582). Discussions about CPR should be
expanded to include the families and significant others of
patients with cardiovascular disease because they are the
ones who may need to perform CPR.

Nurses in advanced practice are also concerned about
the health of their community. Providing CPR education to a
local work place and local churches, such as the sites of
this study, may improve the potential outcome of a cardiac
arrest victim in the work place as well as the community as
a whole.

The purpose of this study was to compare the
performance of adult one-rescuer CPR by lay public trained
in two newly developed CPR programs. The two CPR programs
were the AHA CPR video and Citizen CPR video. Both programs
taught adult one-rescuer CPR in less than two hours,
addressing the barrier of time limitation cited by the lay
public. Each CPR program presented the CPR curriculum and
demonstrated the CPR technique via a videotape with
classroom manikin practice to follow. How the curriculum
was presented in the video, practice, and feedback was

Ciifferent for each program. The quality of the outcome of

tilese educational methods needed to be studied.

6

Research Question

 

Most cardiac arrests are witnessed by lay people who
know the victim; not enough lay people know CPR because it
takes too long to learn. Shortened video—enhanced CPR
programs, lasting less than two hours, are now available.
The research question addressed in this study was: Does the
Citizen CPR video program produce significantly more
students performing correct adult one-rescuer CPR than the
AHA CPR video program? The hypothesis was: A significantly
higher proportion of lay subjects participating in the
Citizen CPR video program would correctly perform adult one-
rescuer CPR than subjects participating in the AHA CPR video
program.

Theoretical Framework Applied To Study

The concepts of CPR video programs and outcomes were
adapted to the Gagné Model of Information-Processing
Theories of Learning and Memory (Gagné, 1977). This study
examined the successful performance of adult one-rescuer CPR
through interaction with two different video curricula,
methods of feedback, and practice.

Gagné (1977) classified human learning into five
categories: verbal information, attitudes, intellectual
skills, motor skills, and cognitive strategies. The
performance of CPR is a motor skill. It was hypothesized,
13y Gagné, that each category of learning required different
lepes of instruction. According to Gagné there are two

lsinds of conditions that must be met for any learning to

occur: internal and external. Internal conditions refer to
acquisition and storage of prior capabilities the learner
has acquired that are either essential to or supportive of
subsequent learning. The internal condition needed for
learning a motor skill is "recall of component motor chains"
(Aronson & Briggs, 1983, p. 83). For this study, an example
of an internal condition may be watching CPR performed on a
television program prior to this class with resultant recall
of what was seen. External conditions refer to various ways
that instructional events outside the learner function to
activate and support the internal processes of learning.

The external condition needed for acquisition of a motor
skill is "establishment or recall of executive subroutine
(rules) [and] practice of total skill" (Aronson & Briggs,
1983, p.83). For this study the external conditions were
either the instructor feedback in the AHA CPR program or the
Skillmeter and instructor plus fellow student feedback in
the Citizen CPR program.

To learn a motor skill, according to Gagné (1977), it
was advised to teach the part skills that make up the total
skill. This is performed similarly in both CPR programs by
first learning how to check a carotid pulse and proper hand
placement for CPR, for example, before attempting to put all
the skills together to perform CPR. "When each of the part
skills has been mastered, the person can practice them
together in order to learn the timing and rhythm necessary

for the smooth execution of the total skill" (Aronson &

Briggs, 1983, p. 89).

Figure 1 is Gagné's Model of Information-Processing
Theories of Learning and Memory (Gagné, 1977, p. 53).
According to Gagné (1977) the learner receives stimulation
from the environment which activates the receptors and
transforms the information into neural information. The
neural information passes briefly through the sensory
register and on to the short-term memory where it can
persist for twenty seconds. A process called encoding,
which occurs in the transfer of the information between the
short and long-term memory, is the most critical
transformation of the information. During encoding the
information is transformed into conceptual or meaningful
pictures and then stored in the long-term memory. In order
to verify learning the information must be retrieved from
the long-term memory, returned to the short-term or working
memory, and transformed to stimulate the response generator.
The response generator determines (1) the form of the
response such as speech, use of large or small muscles, or
whatever and (2) the pattern of the performance such as the
sequence and timing of the movement. The ultimate
information processing occurs in the effectors which results
in patterns of activity that can be externally observed.
Learning is a process that requires the closing of a loop
which begins with stimulation from the external environment
and ends with feedback. Executive control processes

influence attention and selective perception and ultimately

 

 

 

 

 

 

 

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Figure 1. Model Employed by Information-Processing Theories
of Learning and Memory. (Gagné, 1977, p. 53)
influence what is stored in the long term memory.
Expectancies represent the specific motivation of the
learners to reach the goal of learning which has been set by
or for them. What learners intend to accomplish can
influence what they pay attention to, how they encode their
information, and organize their responses.

Figure 2 is an adaptation of the CPR programs to
Gagné's model. The students watched the CPR video
and received the information through their eyes and ears
(receptors), the skills to be performed were transferred
through the sensory register to the short term and then to
the long term memory along with any prior knowledge of how
to perform CPR. The students practiced CPR skills and

received feedback, an external condition, from the

10

Motivation to Learn: 7
PersonalIJoh Re uirement
iAdult One-Rescuer, Determination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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P CPR Performance of Appropriate
R ' Action Feedback:
‘—""—‘ Instructor VS.
P :censrio Instructor +
R V3538 [Practice/r CPR Skills TI é Fellow Students +
0 ‘— Lecture Skillmeter
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A . ort Term
. Receptors. Memory Memory
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Internal Condition.
Previous Viewing
of CPR Performance

 

 

 

Figure 2. Adaptation of Gagné's Model to CPR Programs

(Gagné, 1977, p. 53)

instructor or Skillmeter plus instructor and fellow students
which helped the student determine the appropriate reactions
(response generator) leading to the performance of adult
one—rescuer CPR (activation of effectors). In this
adaptation of Gagnés model executive control and
expectancies are both included in one box describing
motivation to learn. Internal condition and feedback, an
external condition, are added to Gagné's model to show their
impact on the process. Personal motivation is an example of
an executive control process and performance of CPR may be
influenced by the students personal motivation for learning
the skill: the possibility of using the skill on a loved one

or the need to learn the skill as a job requirement.

11

Gagné (1977) also described instructional events: that
is, classes of events that occur in a learning situation.
Each event functions to provide the external conditions of
learning described previously. The instructional events
usually occur in the following order: gaining attention,
informing the learner of the objective, stimulating recall
of prerequisite learning, presenting the stimulus material,
providing learning guidance, eliciting performance,
providing feedback about performance correctness, assessing
the performance, enhancing retention and transfer.

Table 1 shows the instructional events, their
definitions and how the two CPR programs compared. Both CPR
programs were consistent with Gagné's theory, however, there
were differences between the programs which are outlined in
Table 1. One important difference is the AHA CPR program
provided one source and type of feedback: subjective delayed
feedback on performance. The Citizen CPR program provided
multiple sources and types of feedback: immediate objective
feedback from the Skillmeter plus delayed subjective
feedback from the instructor and fellow students. "The
usefulness of frequent feedback during the acquisition of
newly learned capabilities should not be overlooked" (Gagné,
1977, p. 298). The multiple sources and kinds of feedback
were hypothesized to produce better learning than providing
only the delayed subjective instructor feedback. "When
entire tOpics are being learned, feedback for the correct

accomplishment of each subtopic can be of considerable value

Table 1. Comparison of the AHA and Citizen CPR Programs

 

by Gagné-Briggs Outline (Aronson & Briggs, 1983)

 

 

 

 

Instructional Definition AHA CPR AEitIien OER
Events Program Program
Gaining Gain the On-screen Scenario
Attention learner‘s instructor based
attention guided instruction
so other video, few with rapidly
instructional rapidly changing
events can changing stimuli
function properly stimuli
Informing How will I Covered Covered
learner of know when I during during
objective have learned? introduction introduction
Stimulate Recall of Learned in Learned
recall of subroutine and parts after during video
prerequisite part skills the video when stopped
is completed to practice
Presenting Varies from AHA Videos Citizen CPR
the stimulus demonstration and Video
material of skills to HeartSaver
written Book
information
Providing Designed to Instructor Skillmeter,
learning help learner feedback on instructor
guidance acquire performance and fellow
capabilities student
of the objective feedback
on
performance
Eliciting the Perform an Find a Same
performance overt action carotid
pulse or
proper hand
placement
Providing An informative, Delayed Immediate
feedback about crucial subjective Skillmeter
performance instructional instructor feedback +
correctness event feedback instructor
and fellow
student
feedback
Assessing Objective Assessed Assessed
performance attained and subjectively objectively
consistently by by
performed instructor Skillmeter
and
subjectively
by
instructor
and
fellow

Table 1. Continues

students

13

Table 1 Continued.

 

 

 

instructional Definition AHA CPR I—Eitizon CPR
lvonta Program Program
Enhancing Transfer Practice Same plus
retention and information from continues visual
transfer one situation to until scenarios
another student is aid in
comfortable application

to different
real-life
situations

 

in increasing the efficiency of learning" (Gagné, 1977, p.

298). The Skillmeter provided immediate feedback on each

component CPR skill learned, the amount of instructor

feedback varied by instructor. The differences between the

programs were believed to strengthen the Citizen CPR

programs' ability to teach the students the skills of CPR.
Conceptual Definitions

Concept: CPR Program

 

For the purpose of this study a CPR program will be
defined as: a video presentation of CPR skills and life-
saving information with practice of CPR skills on a manikin
with feedback on performance. The skills learned in these
programs included the psychomotor skills of adult one—
rescuer CPR and adult foreign body airway obstruction (FBAO)
management. Additional vital information regarding heart
attack symptom recognition, how and when to access the
emergency medical system, and identification and
modification of personal cardiac risk factors were provided

in both of the programs. This study focused only on adult

14
one—rescuer CPR skill acquisition.

Motor skills, attitude and knowledge are essential
concepts of CPR programs. The motor skills learned
included: assessment of unresponsiveness, activation of the
EMS system, positioning the victim, rescuer position,
opening the airway, determining breathlessness, rescue
breathing, determining pulselessness, and performing
external chest compressions.

The importance of appropriate response in the event of
an emergency such as a cardiac arrest, the ability to stay
calm and take definitive action are attitudes discussed in
the CPR programs. These attitudes are included as part of
the content because the appropriate quick response in an
emergency is a learned response and a quick response is
often critical to the survival of the victim.

The curriculum taught in a lay person CPR program has
been determined by the AHA Emergency Cardiac Care Committee
and includes heart and lung structure and function; a
discussion of coronary heart disease including pathology,
risk factors, prudent heart living, and clinical
presentation of coronary heart disease; events requiring
resuscitation; introduction to the performance of CPR;
techniques of CPR including airway, breathing, circulation;
the sequence of one-rescuer CPR; and manikin practice.
Because the AHA was the body that established the current
recommended standards for CPR, their programs have been the

traditional standard for CPR training. The Citizen CPR

15
Program teaches according to the AHA standards of CPR using
a scenario based video tape and a unique practice format
with multiple types and sources of feedback.

Concept: Adult One-Rescuer CPR Skills

 

The outcome variable, for this study, was performance
of the motor skill of adult one—rescuer CPR according to AHA
standards for health care providers. A motor skill is a
kind of human performance. Motor skills involve different
portions of the body musculature and a variety of internal
processes. To learn motor skills it is advised to first
teach the parts of the skill that make up the total skill.
"If the component motor acts of a total skill have been
previously well learned, a minimal amount of time may have
to be spent in 'putting them together' in a procedural
sequence" (Gagné, 1977, p. 217).

Motor skills improve with practice: "Without practice
during and after training, CPR skills retention is doomed to
be inadequate" (Moser & Coleman, 1992, p. 378). Practice is
important to learn a motor skill because:

some very important stimuli (cues) are internal to the

learner and arise as feedback from the muscles... By

repeating the essential movements in successive trials
of practice, the learner is discovering the kinesthetic
cues which signal the difference between error and
error—free performance. In addition to the external
cues, these internal cues come to control and regulate
the performance, and thus lead to increasing degrees of
precision and timing accuracy. Practice is necessary,
then, because only by repeating the essential movements
can the learner be provided with the cues that regulate

the motor performance. (Gagné, 1977, p. 219)

Practice is the repetition of the procedure "(1) with the

l6
intent on the part of the learner to achieve an improved
performance, and (2) with feedback, which provides
information to the learner" (Gagné, 1977, p. 217). Feedback
for CPR performance has been provided by: instructors
observing performance and giving subjective feedback;
manikins producing a rhythm strip after performance which
can be used to provide objective delayed feedback; and a
newer manikin with a Skillmeter which provides continuous
immediate objective feedback while performing CPR. Gagné
(1977) described "augmented feedback" which provided
additional external cues while the motor skill was being
performed, like the Skillmeter. The subjects receiving
augmented feedback performed superiorly to the subjects
receiving feedback following performance.
Review of Literature

Many different methods of teaching the content of the
CPR program to adult lay public have been reported in the
literature. There have been no published studies, however,
about the efficacy of the AHA videos. The AHA video program
is comparable to the traditional AHA HeartSaver program as
the same skills are taught in each program. Other types of
CPR programs including additional content and skills, such
as pediatric basic life support, were not reviewed. The
literature review was classified according to the criteria
of teaching method: (1) instructor lecture, demonstration by
instructor and supervised manikin practice with instructor

feedback; (2) video presentation of curriculum with

17
demonstration of CPR performance in the video or by the
instructor with supervised manikin practice; and (3) self-
training systems.

Instructor Lecture/Demonstration Method

 

CPR programs with instructor lecture, instructor
demonstration of skills and instructor supervised practice
have been reviewed (Mandel & Cobb, 1982; Ramirez, Weaver,
Raizner, Dorfman, Herrick & Gotto, 1977; Weaver, Ramirez,
Dorfman, & Raizner, 1979). These studies have shown that no
students to 11% of the students were able to perform adult
one-rescuer CPR following training. Ramirez et a1. (1977)
reported 84.3% of the trainees were capable of correctly
performing the sequencing of CPR, 2.8% were able to
correctly perform the ventilations and compressions, and
only 1% correctly put all the skills together to perform
CPR. Weaver et a1. (1979) found 10% to 100% of their
students were able to complete various skills of CPR and
only 2% were able to put all the skills together to
successfully perform CPR. Mandel and Cobb (1982) reported
11.7% to 97.1% of their students were able to perform
individual CPR skills with no students able to successfully
perform CPR. Weaver et a1. (1979), Ramirez et a1. (1977),
and Mandel & Cobb (1982) utilized tape recording manikins
for objective evaluation of CPR performance. The Weaver et
a1. (1979) lay public sample, from Houston Texas, was small
(N = 61) and randomly selected from a larger self-selected

sample (N = 280). Ramirez et a1. (1977) had a larger

l8
convenience sample (N = 772) of lay public from business,
civic, religious organizations and the general community in
Houston, Texas. Mandel & Cobb (1982) reviewed a random
small sample (N = 105) of lay citizens from Seattle,
Washington.

Video/Film Presentation of Content With
Instructor Supervised Practice

 

 

The only study reported in the literature that
consisted of curriculum delivered by video, video or
instructor demonstration of skills, and supervised manikin
practice was by Ambrose and Stratton (1993). Ambrose &
Stratton compared a video—enhanced CPR program with the
traditional four hour instructor taught AHA Heartsaver CPR
program. Ambrose & Stratton reported, "overall the students
compliance with AHA standards was 85% for the video-enhanced
course, while the students attending the AHA Heartsaver
course met 41% of the AHA standards" (p.66). However, upon
closer examination of the results, the lowest reported
percentage for any one section of the final evaluation:
sequence, timing, ventilations and compressions, was 6% for
the control group and 60% for the experimental group.
Therefore, the total number possibly completing all four
sections of the AHA standards correctly was 6% for the
control (AHA HeartSaver) and 60% for the experimental group
(video-enhanced CPR).

Some negative aspects of the Ambrose & Stratton (1993)

study included the research variables were not clearly

19
defined, inter-instructor reliability was not controlled,
the sample was not randomized, the sample selection was not
defined, there was incomplete statistical analysis, and
there was a small sample (N = 100). The most critical fault
of the Ambrose & Stratton study was allowing the
experimental group to observe and self—correct their
performance during the testing process (R. Ambrose, Citizen
CPR, personal communication, February, 1994). By watching
the Skillmeter the experimental group was able to correct
any errors in performance immediately and thereby improve
their score overall. This investigator believes the Ambrose
& Stratton study did not indicate that the students in the
experimental group integrated the concept of how far they
need to compress the chest or how much air they need to
breathe into the victim to perform effective CPR, only that
they successfully learned how to read the Skillmeter and
self-correct their performance. Positive aspects of the
Ambrose & Stratton study included the use of the Skillmeter
Resusci® Annie and the equal, although not random,
distribution of the sample between control and experimental
groups.

In summary, the Ambrose and Stratton (1993) study
appears on the surface to show dramatic differences between
the abilities of the students to perform CPR in the control
and experimental groups. However, in reality, this author
believes the Ambrose and Stratton study shows how well

students can perform to the Skillmeter, not how well they

20
can perform CPR.

Self Training Studies

 

Two studies (Edwards & Hannah, 1985; Kaye, Montgomery,
Hon, Linus, Stewart, & Richards, 1983) compared an
interactive videodisc, self training CPR program with the
traditional instructor led CPR program. Kaye et al. (1983)
reported the computer led session and the instructor led
session had 60% and 44% passing rates, respectively. Kaye
et a1. summarized that the results obtained indicated the
computer led session was more effective in teaching the
skill of CPR than the instructor led session. When
comparing the computer videodisc CPR and instructor led CPR
courses Edwards and Hannah (1985) reported "no statistical
differences between the two groups" (p. 250). Edwards and
Hannah concluded these results signify the computer is at
least as effective as the currently accepted instructor led
sessions. However, they did not cite specific numerical
results.

Not enough information is included in the articles to
consider the positive and negative aspects of general
considerations, experimental design, validity, or
reliability of measurements. Edwards and Hannah (1985) and
Kaye et a1. (1983) both had small, adult, lay public samples
of 65 and 46 subjects respectively.

One self-training study that used only a videotape to
teach CPR, no instructor, and no manikin practice is

reported in the literature (Schluger, Hayes, Turino,

21

Fishman, & Fox, 1987). The study does not report on
pass/fail of CPR, only on individual CPR skills achieved.
The CPR skills were performed accurately by 23% to 85% of
the subjects (N = 262). Schluger et al. (1987) concluded
that the use of a video may be a valuable, inexpensive
vehicle for training the lay public in the key skills of
cardiopulmonary resuscitation using television broadcast or
other mass viewing situations.

Method

Design

This study was a quasi-experimental design in which

subjects were randomly assigned to one of two video enhanced
CPR programs. The independent variable was type of video
enhanced CPR program. The dependent variable was the
performance of the skill of adult one-rescuer CPR according
to the AHA standards for health care providers.

Sample

There were 148 subjects trained and 44 were eliminated

from the study because of previous CPR training within the
past ten years. The 104 remaining subjects included in the
study were: 32 (31%) male and 72 (69%) female. Subjects
were recruited from S. D. Warren Company in Muskegon,
Michigan and churches in the Grand Haven, Michigan area.
The sample size was based on an estimated power of .8, with
an effect size of 0.3 (a medium effect size), and an a of
.05. The sample consisted of 10 S. D. Warren employees and

94 parishioners of local churches. S. D. Warren is a medium

22

sized industry which employs approximately 2,000 associates
in Muskegon, Michigan. Three church sites were used in the
Grand Haven, Michigan area: First Christian Reformed Church,
Gospel Chapel, and Christ Community Church.

Exclusion criteria for this study included: (1) formal
CPR training in the past ten (10) years; (2) any disease or
physical impairment that would confound the results - such
as emphysema, blindness, arthritis, or a heart condition;
and (3) anyone under the age of 18 years. The determination
of prior CPR training and age was on self-report from the
participants. Determination of physical impairments was
made by the primary investigator by questioning the subjects
regarding health problems.

Operational Definitions

 

CPR Program

 

The independent variable in this study was type of CPR
program. The AHA CPR program was considered the traditional
method of teaching CPR because the AHA has always been the
organization to establish the standards for CPR. The
Citizen CPR program was the comparison program for this
study, it was developed privately by Robert Ambrose and
consultants, but teaches according to the AHA standards (R.
Ambrose, Citizen CPR, personal communication, February,
1994).

The basic outline for both programs consisted of:

(1) introduction, (2) video presentation of curriculum, and

(3) practice of skills until student and instructor were

23
comfortable with the student's ability to perform. The two
programs differed in: (1) how the curriculum was presented
in the video, (2) practice format, and (3) practice
feedback. The similarities and differences of these three
aspects follows.

Presentation of Curriculum.

 

Both of the CPR programs presented the curriculum and
demonstrated the technique of CPR via a videotape. The
Citizen CPR video was scenario based, meaning it depicted
what may actually happen during a cardiac arrest. The
Citizen CPR video also showed a lay person realistically
demonstrating the signs and symptoms of a heart attack and
then going into cardiac arrest, another lay person
performing CPR and an additional lay person calling the
emergency number for help.

The AHA CPR video had an instructor describing the
signs and symptoms of a heart attack, why CPR training is
needed and then leading a demonstration of CPR skills. The
information was presented without scenarios. Table 2
compares the AHA and Citizen CPR video contents. Detailed
outlines of each program's content can be seen in Appendices
A and B.

Practice Feedback.

 

Method of feedback on performance of CPR varied in the
two programs. The AHA CPR program provided delayed
subjective feedback. Delayed subjective feedback is defined

as an instructor responding to performance with advice for

24

Table 2. Curriculum and Format of AHA CPR and Citizen CPR

 

Programs

 

ABA Videos

Citizen CPR Video

 

*Introduction Video

*Sudden Death Statistics
Actions for Survival

*Anatomy and Physiology
Recovery Position

*Special Conditions

Coronary Heart Disease

Warning Signs of Heart Attack
Actions to Take

Risk Factors for Heart Disease
Prudent Heart Living

*Adnlt CPR Video

 

Techniques of CPR (ABC's)
Manikin/Demo Practice

*Poreigginod17Video

Foreign Body Airway Obstruction
(FBAO) Recognition

Techniques of Management
Conscious FBAO
Conscious->Unconscious FBAO
*Unconscious PBAOINInagement

Review
Practice FBAO

Instructor led CPR practice

Subjective delayed instructor
feedback

*All included in one video

Actions for Survival
Brief Anatomy and Physiology
Recovery Position

Coronary Heart Disease

Warning Signs of Heart Attack
Actions to Take

Risk Factors for Heart Disease
Prudent Heart Living

Techniques of CPR (ABC's)
Manikin Demo/Practice including
* Skillmeter Demo

FBAO Recognition

Techniques of Management

Conscious FBAO
Conscious—>Unconscious FBAO

Brief unconscious FBAO including

* Pregnant or Obese IRAQ management
Review

Practice FBAO

* Chain of Survival Information
*Shield-Barrier Device Use

Instructor and * Student led CPR
practice

* Immediate objective Skillmeter,
with instructor and * fellow student
feedback

 

Note. Differences between programs printed in bold print

with an asterisk *

25
changes during and after performance. The instructor
utilized no objective instrument to evaluate performance,
they would watch, analyze performance based on their
experience, and comment on ways to improve performance. In
the comparison program, Citizen CPR, objective and
subjective feedback on performance was provided. The
Skillmeter provided immediate objective feedback by showing
how well the student performed on a screen the student could
watch, and delayed subjective feedback from the instructor
and fellow students.

Practice Format.

 

Only the instructor coached all students through
practice in the AHA CPR program. In the Citizen CPR program
fellow students coached each other through practice, with
help from the instructor, once the first student was coached
by the instructor.

Adult One—Rescuer CPR Skills

 

The outcome measure, or dependent variable, was
performance of adult one-rescuer CPR according to the AHA
standards for health care providers. CPR performance was
measured for both groups using the Laerdal Skillmeter
Resusci® Anne (see Appendix C). The Skillmeter provided an
analysis of performance which could be printed or copied
onto a recording sheet (see Appendix D). This analysis was
used to evaluate performance of CPR.

Historically, the lay public skills of CPR performance

were tested according to the health care provider criteria.

26
In 1992, however, the Emergency Cardiac Care Committee of
the American Heart Association changed their recommendation
in an attempt to make learning CPR less frightening for the
lay public (see Appendix E). A written and skill
performance test was no longer required of the lay person.
At the same time the development of the AHA videos began.
In this study the participants were measured according to
this criteria because it was the benchmark or gold standard
for correct performance of CPR (AHA, 1987).

There are four specific components of the AHA criteria
for adult one-rescuer CPR: sequencing, timing, ventilations,
and compressions. .All criteria must be successfully
completed according to the established guidelines in all
four components in order for the performance to be
considered passing. Table 3 shows the pass/fail criteria
for CPR.

CPR manikin practice varied in the two programs. The
AHA CPR group received only instructor feedback whereas
Citizen CPR group received multiple sources of feedback.
Feedback on performance allowed the student to correct
errors and perform correctly while practicing a skill and
therefore improved outcomes. The feedback on performance
was received only from the instructor in the AHA CPR program
and feedback came from the resuscitation manikin, instructor
and fellow students in the Citizen CPR program. Recent
literature reports "quantitative, simultaneous feedback is

most effective (in learning CPR), the use of a recording

27

Table 3. CPR Pass/Fail Criteria

 

 

 

Sequencing Timing ventilations Compressions
Determine 15-35 seconds During the one- During the
responsiveness Step A to Step rescuer sequence one-rescuer

Activate EMS
System

Position Victim

Open Airway

Determine
responsiveness

Ventilate Twice
Determine
Pulselessness

> 5 seconds

Recheck

Pulselessness

H (determine
unresponsiveness
through 4 cycles
of CPR.

50-76 seconds
for 4 cycles
of comp/vent
(allowed 10%
47-79

seconds).

error:

5-10 seconds for
initial pulse

check

10-12
ventilations

are given.

2 ventilation
errors are
acceptable.

Ventilation
errors include:
-incorrect
number of
ventilations

- incorrect
volume

<.8 or >1.2
Liters

-not allowing
total exhalation
between breaths
-breaths given
in <l.5 seconds
or >2 seconds

sequence 60
compressions

are given.

6 compression
errors are
acceptable.

Compression
errors include:
—incorrect hand
placement
-compression
depth too
shallow or deep
-pressure
maintained on
chest during
relaxation
(upstroke)
—incorrect number
of compressions
per cycle
-unequal
compression/
relaxations
ratio (50%)

 

For scoring
purposes
omission of
steps was a
failure.

For scoring
purposes any
timing outside
these parameters
was a failure.

For scoring
purposes <84%
performance
(>2 errors)
a failure.

For scoring
purposes <90%
performance
(>6 errors)
a failure.

 

28
resuscitation mannequin is recommended for lay...CPR
training" (Moser & Coleman, 1992, p. 378). The AHA group of
students were not exposed to the Skillmeter during practice.
The Citizen CPR group of students used the Skillmeter
initially during practice. After CPR skills were improved
the Skillmeter was placed out of their eyesight and they
continued to receive feedback from the instructor and fellow
students who could see the Skillmeter. This allowed the
student to develop the "kinesthetic cues" (Gagné, 1977, p.
219) or get the feel of the appropriate compressions and
ventilations without relying on the feedback directly from
the Skillmeter. The resuscitation manikin used in the study
was the Laerdal Skillmeter Resusci® Anne. "The Skillmeter
Resusci® Anne is a sensorized manikin connected to the
Skillmeter, which is a computing and displaying device for
storing and handling up to ten minutes of CPR data received
from the manikin" (Laerdal, 1986, p. 12). The Skillmeter
provides immediate and continuous objective feedback on the
performance of the skills required to perform CPR.

Operationalization of the students performance by the
Skillmeter manikin was as follows:

Step A: The Skillmeter was capable of displaying an "r"
when the student taped or shook the victim to establish
unresponsiveness.

Step B: "Activate EMS system." This step was not
recorded on the screen or printout. (The tester recorded on

the testing form if this was done.)

29

Step C: "Position the victim." This step was evident
by any documentation on the manikin. The manikin would not
record properly if the positioning was incorrect.

Step D: "Open the airway" and Stop E: "Determine
breathlessness". When both steps were performed correctly a
"b" was displayed on the Skillmeter.

Step F: "Ventilate twice." This was demonstrated by a
horizontal bar created at the top of the sequence tracings
as the student performed ventilations. Each ventilation was
accompanied by an ascending bar graph which correlated to
ventilation volume.

Step 6: "Determine pulselessness." A "c" appeared when
the student palpated for a carotid pulse for a minimum of
five seconds. A signal bar was displayed at the bottom of
the Skillmeter as soon as the student correctly located the
carotid pulse area.

Step 8: "Perform 4 cycles of compressions/ventilations
(ratio 15:2)." A horizontal bar was created at the bottom
of the sequence tracing line as student performed chest
compressions, additionally each compression was accompanied
by a descending bar graph which correlated to compression
depth (1 l/2"-2"). Each of the four cycles of compressions
and ventilations was indicated on the Skillmeter by the
sequence tracing lines for compressions (the lower line) and
ventilations (the upper line). Any erroneous ventilations
or compressions were recorded when performed for analysis at

completion of performance.

30

Step I: "Recheck the pulse." This was recorded by a
"c" on the screen following a minimum of a 5 second pulse
check in the carotid pulse area.

Upon completion of the testing, the Skillmeter screen
was placed on "freeze" and "analyze" to give the exact
number of correct/incorrect breaths and compressions, the
compression rate, ratio, percentages of correct ventilations
and compressions. This information was then compared to the
established AHA criteria. Mistake markers, errors in
compressions or ventilations, lit during performance were
permanently lit when the analysis button was pressed. The
number, type, and classification of each mistake was given.
All of this information was recorded from the Skillmeter at
completion of the test. A copy of the Skillmeter printout
can be seen in Appendix D.

Instrumentation

 

The Laerdal Skillmeter Resusci®.Anne, a CPR training
manikin, was utilized to measure the outcome of the CPR
programs. Sensors in the head, neck, and chest of the
manikin detected the student's physical interaction with the
manikin, see Appendix C. The ventilations and compressions
were electronically recorded on the manikins' Skillmeter
screen and a record of the performance was produced.

The manikins did not need any calibration prior to use
according to the manufacturers, Laerdal Medical Corporation,
(A. Davis, personal communication, January 5, 1994). There

were two "potentiometers" inside the manikin, one for

31
responsiveness (which marked "r" on the printout) and one
for opening the airway (which marked "b" on the printout).
The potentiometers could be set according to the amount of
effort required to obtain the "r" or the amount of
hyperextension required in the neck to get a "b". The
potentiometers were set by the investigator at the lowest
setting prior to any training programs. There was no
written documentation on the reliability or validity of the
potentiometers. Accuracy of the Skillmeter manikins was
tested by the principal investigator prior to each class.
During the study eight manikins were used and three were
taken out-of—service because the chest plates were recording
compressions and/or ventilations incorrectly. When the
chest plates malfunctioned the errors were very obvious.
Appendix C shows an overview of the Skillmeter keyboard and
button functions, recording of displayed results and the
criteria for Skillmeter calculations.

The reliability of the Skillmeter Resusci® Annie was
questioned during this study. When a tester observed a
subject checking a pulse in the correct location for the
appropriate amount of time but no "c" appeared, was the
manikin erroneous or the tester observing the student?
Without documentation of the reliability and validity of the
Skillmeter it is unknown if the error was with the manikin
or the instructor. Additional errors in recording the
students assessment of breathlessness and pulselessness were

noted. These errors occurred frequently and necessitated a

32
subjective evaluation of assessment of responsiveness,
breathlessness and pulselessness to accurately reflect the

students performance.

Field Procedures

 

1. Seven experienced AHA CPR instructors were recruited
from the Muskegon/Grand Haven area. Training of instructors
for the Citizen CPR program was done by the principal
investigator (see Appendix F). The instructors taught both
the AHA and Citizen CPR programs.

2. Seven testers, also experienced CPR instructors, were
recruited to do final testing of all subjects. See Appendix
G for outline of tester orientation.

3. Subjects were recruited from S. D. Warren with pamphlets
placed at the time clock and posters placed throughout the
plant. Classes were scheduled before and after work hours
for all four shifts. The classes took place in the training
center at S. D. Warren. The times and dates of the classes
were on the posters and pamphlets with instructions to
register at the medical office of S. D. Warren. There were
six CPR programs held at S. D. Warren with 1 to 6 students
in each class.

4. Subjects were also recruited from local churches with the
use of notices in the church bulletins, posters placed
throughout the churches, and word of mouth promotion by the
pastors. The times and dates of the classes were determined
by the pastors of the churches. Registration for the

rxrograms occurred at the church offices. There were 12 CPR

33
programs held at the various church sites with 2 to 49
students in each class. There was an instructor assigned to
every 6 to 7 students in the classes. For the largest class
of 49 students the principal investigator also participated
as an instructor.
5. When subjects arrived for the class, consent was obtained
and questionnaires were completed (see Appendices H, I, and
J).
6. Randomization of program type was achieved by the closed
envelope technique. There were an equal number of envelopes
for AHA CPR and Citizen CPR assignment. The principal
investigator randomly predetermined which program would be
taught at each class prior to the classes being scheduled.
7. AHA CPR and Citizen CPR programs followed the previously
described outlines in Appendices A and B. When the program
was completed the student was instructed to remove their
name badge, leave on their student number badge and proceed
for testing with one of the testers. Simultaneous AHA CPR
and Citizen CPR programs were not held, so the testers were
not blinded to which program the subjects had attended.
8. The primary investigator audited each of the CPR classes
to assure consistency of content and method in each group.
9. Frequently questions are raised by the participants
during a CPR program. In an effort to standardize all
responses to these questions some frequently asked questions
with appropriate answers were provided to the instructors

Uprendix K). Instructors were directed to answer questions

34

based on Appendix K.

10. Each participant was tested, see Appendix L, following

the completion of the CPR program as follows:
A. Students were tested individually.
B. Upon entering the room the tester asked the
student to perform one minute of CPR as he/she was
just taught in their respective CPR programs.
C. In the initial classes it was noted that the
Skillmeter did not always accurately record if
responsiveness was checked, airway opened, or pulses
checked. The student would check responsiveness but if
the manikin was not shaken hard enough or the correct
way (side to side) the "r" would not appear; or if the
pulse was not checked in exactly the correct spot on
the manikins' neck the "c" would not appear, many times
the pulse bar would flicker indicating the student was
in the correct spot but unless the pulse bar stayed lit
long enough the "c" would not be recorded. So to
remedy this problem, the tester documented if the
student assessed responsiveness of the victim, opened
the airway, and checked the initial and second pulses
according to AHA criteria. Additionally, the request
for EMS at Step B was recorded on the form shown in
Appendix M.
D. At the completion of the one minute of CPR the
student was excused after the student number badge was

obtained.

35
E. The tester froze the Skillmeter and recorded the
results with the attached printer or Skillmeter score
sheets. The students number badge was attached with
the printout to the testers form shown in Appendix M.
The same Skillmeter Resusci® Anne manikins were used
for testing both AHA CPR and Citizen CPR groups. Eight
manikins were supplied by Muskegon and NorthWest Ottawa
County Project HeartStart Fire Departments.

Data Analysis

 

The descriptive demographic data obtained from the
sample included: sex, age, marital status, prior medical or
CPR training, occupation, family member at high risk for
cardiovascular disease, educational level, and an optional
ethnic group question. Chi-square analysis and Analysis of
Variance, as appropriate, were used to compare the number of
AHA CPR and Citizen CPR students who successfully completed
all four components of CPR: sequence, timing, ventilations
and compressions - the definition of successful completion
of CPR. Both methods of evaluation, (1) the objective
Skillmeter reports and (2) the subjective instructor reports
with the objective Skillmeter reports, were analyzed. Chi-
square analysis or Analysis of Variance, as appropriate, was
also done comparing AHA CPR and Citizen CPR students for

each of the CPR component skills.

36

Human Subjects Protection

 

Prior to initiation of the study, approval was obtained
from the Michigan State University Committee on Research
Involving Human Subjects (Appendix N). Subjects were
informed that data obtained from the CPR programs would be
used for research purposes and the purpose of the study was
to compare two programs for teaching CPR. Participants in
the study were identified during testing only by their
student number on an adhesive name badge. The student
number badge was affixed to the testing form following
completion of the testing sequence. Only the principal
investigator has a list, at her residence, of names and
student numbers of the participants. Data were reported in
aggregate form only.

Assumptions and Limitations

 

Certain assumptions were made for this study as
follows:

1. Adult one-rescuer CPR skills can be learned by the

lay public.

2. The students would truthfully report if they had CPR

training before - there would be minimal contamination

of the environment.

3. Students would not share information about the

teaching sessions with other students waiting for the

training.

4. The Laerdal Skillmeter Resusci®Amne Training

Manikin was a valid and reliable instrument.

37

Limitations of this study were:
1. The Hawthorne effect — knowledge by the students
that they would be tested following the CPR program may
have made them try harder than if this class was
offered to the lay public without additional testing.
2. External validity concerns: generalizability of
results to other settings or samples. This sample was
a convenience sample.
3. Interaction of history and treatment effect — a
family member of a high-risk patient may be more
motivated to learn the skill at a higher performance
level and could alter the overall results.
4. Measurement effect - the results obtained may not be
applicable to anyone except another group exposed to
the same data collection situation.

Results and Findings

Demographic Characteristics of Subjects

 

The subjects were white, predominantly female, married,
and had at least a high school education. The mean age of
the sample was 44 years (S2 = 11.5), with a range of 18 to
74 years. Sixty—eight percent (68%) of the subjects had
family members at risk for cardiovascular disease and
eighty-three percent (83%) participated because of a
potential need to perform CPR on a family member, friend, or
co-worker. Table 4 provides more demographic and CPR
background data.

The sample was divided into two groups, AHA CPR, and

38

Table 4. Frequency and Percent of Demographic and CPR
Background Characteristics

 

 

 

 

Demographic Variable REA CPR Citizen CPR Total
No. (%) No. (’3) No. (%)
Sex
Male 18 (37) 14 (26) 32 (31)
Female 31 (63) 41 (74) 72 (69)
Age
18-40 20 (41) 21 (38) 41 (40)
41-60 24 (49) 29 (53) 53 (51)
61+ 5 (10) 5 (9) 10 (9)
Ethnicity
White 49 (100) 55 (100) 104 (100)
Marital Status
Single 4 (8) 8 (15) 12 (11)
Married 41 (84) 44 (80) 85 (82)
Widowed 2 (4) 0 (0) 2 (2)
Divorced 2 (4) 2 (5) 5 (5)
Education
< High School 3 (6) 3 (6) 6 (6)
High School 17 (37) 15 (28) 32 (32)
Some College 11 (24) 15 (28) 26 (26)
Associates Degree 4 (9) 7 (13) 11 (11)
Bachelors Degree 8 (17) 12 (21) 20 (20)
Graduate Degree 3 (7) 2 (4) 5 (5)
Occupation
Sales/Customer
Service 10 (20) 9 (13) 17 (16)
Factory Worker 9 (18) 4 (7) 13 (12)
Homemaker 7 (14) 5 (9) 12 (11)
Teacher 3 (6) 7 (13) 10 (10)
Manger 6 (12) 3 (5) 9 (9)
Retired 2 (4) 5 (9) 7 (7)
Nurses/Medical 2 (4) 4 (7) 6 (6)
Accountant 0 (0) 6 (11) 6 (6)
Secretary 2 (4) 3 (5) 5 (5)
Other 8 (8) 9 (11) 19 (19)
CPR.Background
Past CPR Experience
None 38 (78) 41 (75) 79 (76)
> 10 years ago 11 (22) 14 (25) 25 (24)

Members in family at risk
for cardiovascular
disease 33 (69) 36 (66) 69 (68)

Reason for Participation in
CPR program

Personal - may need

to perform on

family/friend/

co-worker 37 (83) 44 (81) 81 (81)
Job Requirement
Other

\IH

(15) 1 (2) 3 (8)

 

39
Citizen CPR. There were no statistically significant
differences between the groups in the categories of sex, age
stratification, marital status, presence of a family member
at high risk for heart disease, number of subjects who had
taken a CPR class over 10 years ago or had never taken a CPR
class, occupation, education level, or ethnic origin (see
Table 4). There was a statistically significant difference
between the groups in reason for participation in the CPR
program. The Citizen CPR group had more subjects (p = 9)
participating because of a job requirement then the AHA CPR
group (p = 1). In summary, the AHA CPR and Citizen CPR
groups were alike for all demographic variables except one,
reason for participation in the CPR program.

Analyses to Test the Research Hypothesis

 

Pass/fail criteria was obtained by two methods: (1)
objectively by the Skillmeter criteria alone and (2)
subjectively by the tester in combination with the data
obtained from the Skillmeter. There were no statistically
significant differences in the outcomes of the AHA CPR
program and the Citizen CPR programs when either pass/fail
criteria was evaluated.

Using objective Skillmeter criteria alone, no subjects
passed the AHA CPR program and 5.5% (p = 3) passed the
Citizen CPR program, X2(1, N = 104) = 2.75, p >.05. When
the subjective evaluation by the instructor in combination
with the objective Skillmeter evaluation was analyzed 4.1%

(p = 2) passed the AHA CPR program and 14.5% (p = 8) passed

40
the Citizen CPR program, X2(1, N = 104) = 3.26, p >.05.
These results indicate that neither program successfully
taught a large number of subjects adult one-rescuer CPR to
the standards required of health care providers.

Analysis of Component CPR Skills Learned in Each CPR Program

 

Table 5 compares the number and percentage of students
who successfully performed the individual CPR component
skills in each program. Sixteen skills were objectively
measured by the Skillmeter and six skills were subjectively
measured by the testers.

More subjects in both groups performed sequencing and
timing skills accurately than ventilation and compression
skills. Sequencing showed a statistically significant
difference between groups X2 (1, N = 104) = 7.41, p <.01.
Fifty—five percent (55%) and eighty percent (80%) of the
subjects, AHA and Citizen CPR respectively, were able to
accurately perform the correct sequence of events. The
other three component skills of timing (47% and 66%),
ventilations (33% and 46%) and compressions (10% and 20%),
AHA and Citizen CPR groups respectively, were done
accurately by more Citizen CPR subjects than AHA subjects
but not at statistically significant levels. Ventilations
and compressions were poorly performed by both groups with
compressions being the worst performed CPR skill.

Every component CPR skill was performed accurately by
more Citizen CPR subjects than AHA CPR subjects. A

statistically significant number of Citizen CPR subjects

41

Table 5. Frequency and Percentage of Successful CPR
Component Skill Completion by CPR Program.

 

 

 

 

CPR Component Skill m CPR Program Citizen CPR Program
No. (%) Nb. (t)
Sequencing
Comp:Vent Ratio 41 (83) 46 (84)
Second Pulse Check 21 (43) 51 (93)***‘
"r" present 34 (69) 46 (84)
Responsiveness Checked 44 (90) 55 (100)*‘
EMS Activated 40 (82) 52 (95)*'
15:2 Ratio 41 (84) 46 (84)
Sequencing done
correctly 27 (55) 44 (80)**‘
Timing
One minute of CPR 23 (47) 36 (65)*
Initial pulse check 35 (71) 49 (89)**'
Four cycles of CPR 26 (53) 40 (73)*
"c" present 10 (20) 28 (51)**
Second "c" present 3 (6) 22 (50)***
Initial assessment to
first compression 36 (73) 44 (80)
Timing done correctly 23 (47) 36 (66)”
ventilations
>84% correct 16 (33) 21 (38)
Correct number of
ventilations given 28 (57) 39 (71)*
"b" present 46 (93) 51 (93)
ventilations done
correctly 16 (33) 25 (46)
Compressions
>908 correct 3 (6) 11 (20)*
Correct number of
compressions 24 (49) 31 (56)
Compression rate 24 (49) 35 (64)
Compressions done
correctly 5 (10) 11 (20)

 

Note. 5 = Subjective Measurement, all others objectively
measured by the Skillmeter.
*g<.05. **g<.01. ***g<.001.

42
performed better on ten of the component CPR skills, five
objectively measured and five subjectively measured. Of
those ten skills, eight (8) were sequence or timing skills.
The only skill performed by 100% of the students in either
group was assessment of responsiveness done by the Citizen
CPR students. Obtaining more than 90% correct compressions
was the most difficult skill for the Citizen CPR (20%) and
AHA CPR (6%) students to perform. Over 80% of the subjects
in each group activated the emergency medical system (EMS)
as required in the CPR sequence. Activation of the EMS is
an essential component to a good outcome from a cardiac
arrest.

Interpretation of Findings Related to Model

 

The Gagné Model of Instruction (Gagné, 1977) in its
entirety was applicable to teaching the motor skill of CPR.
Gagné (1977) emphasized gaining the students attention and
the Citizen CPR video appeared to gain and hold the
students' attention for a longer period of time than the AHA
CPR video. (This notation is by primary investigator
observation only, no objective data was collected to
validate this observation.) Perhaps the faster paced
scenario Citizen CPR video was more appealing than the
lecture based AHA CPR video. Both CPR programs informed the
learner of the objective, stimulated recall of prerequisite
information, presented the stimulus material, and enhanced
retention and transfer in comparable manners.

The practice format and feedback correlated strongly

43
with Gagné's instructional events of emphasis on providing
learning guidance, providing feedback about performance
correctness, and assessing performance. Both CPR programs
allowed for practice of CPR skills as long as desired by the
student or instructor. However, most student were ready to
leave after only practicing 1—2 CPR sequences whether they
performed well or poorly.

Gagné (1977) recommended practice to improve motor
skills. The practice or repetition of the procedure is more
successful if it is done with "(1) intent on the part of the
learner to achieve an improved performance, and (2) with
'feedback' which provides information to the learner"
(Gagné, 1977. p.217). The Citizen CPR course provided
multiple sources of feedback; the Skillmeter, instructor,
and fellow students, and produced better results than the
AHA CPR course which had only one source of feedback, the
instructor. The multiple sources of feedback provided
additional information to the student and might be thought
to have improved the outcome.

Interpretation of Findings Related to Literature

 

Students in this study were able to perform the
individual CPR component skills but unable to put them all
together to perform CPR according to AHA standards, which is
consistent with most findings in the literature (Mandel &
Cobb, 1982; Ramirez et al., 1977; and Weaver et al., 1979
[see Table 6]). Mandel & Cobb (1982) reported no students

were able to perform one minute of CPR according to the AHA

44

Table 6. CPR Study Literature Review Results

 

 

 

Parcent Percent
CPR Studyy Passing CPR PassinggCPR Skills
Casemier Nelson (1995) O-5.5% 6-100%
Ramirez et a1. (1977) 1% 8—84%
Weaver et al. (1979) 2% 10—85%
Mandel & Cobb (1982) 0% 12-76%
Ambrose & Stratton
(1993) 85% 6—60%
Kaye et a1. (1983) 60% Not reported

 

standards and the CPR component skills providing the most
difficulty were: timing (12% done correctly), compressions
(32% correct), ventilations (50% correct), and sequencing
(76% correct). Ramirez et a1. (1977) reported 1% able to
perform CPR with 8% doing compressions correctly, 16%
performing ventilations correctly, and 84% performing
sequencing correctly. Timing was not reported. Weaver et
al. (1979) results were similar with 2% able to perform CPR,
10% performing correct compressions, 17% performing correct
ventilations, 85% performing correct sequencing, and timing
not reported. The component skills of compressions,
ventilations and timing are consistently the most poorly
performed skills reported in the literature.

When compared to the Ambrose and Stratton (1993) study
many field procedures were similar: the same type of
manikins were used, similarly trained CPR instructors were
used, the same practice format and practice feedback was

used. The results, however, are extremely different;

45
Ambrose and Stratton reported an 85% passing rate. The
major reason for the extremely different results was the
variation in the testing procedure. Ambrose and Stratton
allowed the students to watch the Skillmeter and correct
performance while testing (R. Ambrose, Citizen CPR, personal
communication, February, 1994), whereas this study did not
allow the student to see the Skillmeter during testing.

Ambrose and Stratton do not report on the manikins'
accurateness in recording assessment of responsiveness,
breathing or pulselessness. If the Ambrose and Stratton
data was collected strictly from the Skillmeter the same
problem encountered in this authors' study could have
occurred, the student performed the skill however the
Skillmeter did not record the action. This could explain
the lower scores noted for Ambrose and Stratton control
group.

Unfortunately the only information available regarding
the Kaye et a1. (1983) study is an abstract with limited
information. The overall performance of CPR is recorded but
the performance on the component skills of CPR and the
criteria utilized to evaluate the CPR performance was not
revealed. Therefore the reason for the significantly
improved results is not known.

Interpretation of Findings Related to Methods

 

The reason or motivating factor for participating in
the CPR program may have influenced the component CPR skills

or the overall CPR performance results. Several Citizen CPR

46
students (p = 9) were participating because of a job
requirement which may have motivated them to strive for
better CPR performance. Because of the small sample size,
removing these nine subjects could cause a significant
change in the overall results.

Another motivating factor for participation in the CPR
classes was a potential need to perform this skill on a
loved one (85%), which would be an interaction of history
and treatment effect. The anticipation of performing CPR on
a loved one may have increased the students' anxiety and
therefore altered the results with better or poorer
performance. A certain amount of stress is needed to effect
good learning however too much stress can hinder learning.

One methodological constraint was the reliability of
the Laerdal Resusci® Anne manikin in measuring some of the
component CPR skills. The use of the Skillmeter to record
all of the CPR skills except calling for help was supposed
to remove the potential bias or inadvertent error of the
subjective testers. However, during this study the
Skillmeter did not accurately record pulse checks,
determination of responsiveness and determination of
breathlessness. Additionally three of the eight manikins
had chest plate failure during this study teaching 148
subjects over two months. The unanticipated problems with
the reliability of the manikin necessitated a subjective
evaluation of those component CPR skills by the testers.

The increased failure rate of the chest plates during the

47
short duration of this study was disappointing but did not
interfere with the results of the study.

Sample characteristics such as gender and age may have
affected the results of the component skill of compression
which would then affect the overall results. The majority
of the AHA and Citizen CPR groups were female, 63% and 74%
respectively. The AHA and Citizen CPR groups also had
several students over the age of 60, 10% and 9%
respectively. The upper body strength necessary to perform
correct chest compressions may not be as developed in women
and the elderly. Therefore, with a sample composed of a
large percentage of women and elderly, the number performing
correct chest compressions could be lower.

The criteria used to measure satisfactory CPR
performance definitely affected the results obtained in this
study. The AHA health care provider criteria was very
strict criteria. Other studies reported in the literature
have used subjective instructor criteria and older model
recording manikins which provided delayed objective
feedback. Some studies measured CPR performance at times
other than at the completion of one minute of CPR. So many
different CPR measurements complicated comparisons between
studies. Additionally, it is unknown how well CPR needs to
be performed by the lay person to have a positive eventual
outcome (Schluger, 1987). The use of less strict criteria
in research studies, as is being done in real classes, would

perhaps be more applicable. Perhaps reducing the lay public

48
criteria from eighty-four percent (84%) to seventy—five
(75%) or even fifty percent (50%) correct ventilations and
ninety percent (90%) to eighty (80%) or even sixty (60%)
percent correct compressions would be a better evaluation of
successful completion of CPR for a lay person.

Additional methodological constraints were interrater
reliability, number of instructors and testers, and
inability to blind the testers. Subjective measurements by
testers are more prone to inadvertent errors in recording
than objective measurements. Use of numerous testers
increased the chance of inconsistency between measurements.
Ideally a select few instructors and testers would be used
to conduct a research study however seven (7) instructors
plus the principal investigator were utilized for this small
study. The testers were not blinded to which program the
subject had attended, so the level of anonymity hoped for
was not attained.

Discussion

The video enhanced CPR program of less than 2 hours
produced comparable results to the traditional four hour CPR
courses reported in the literature. Few subjects were able
to perform adult one-rescuer CPR according to the AHA
standards for health care providers but many were able to
effectively perform the individual CPR component skills.
Results noted in this study were: (1) every component CPR
skill was performed accurately by more Citizen CPR subjects

than AHA CPR subjects, and (2) component skills were

49
performed better than the performance of one-rescuer adult
CPR.

The acquisition of the component CPR skills was
positively influenced by the use of Gagné Model of
Instruction, with the best results coming from the program
which used a scenario based video tape presentation of the
curriculum and multiple types and sources of feedback on
performance. It is hypothesized that the component CPR
skill acquisition could be further improved with practice
focused on the most difficult skills, compressions and
ventilations. Improvement of the performance of the
component skills would then improve the performance of one-
rescuer adult CPR.

The recommendations from this study include expanding
the practice time and format to emphasize ventilations and
compressions as separate skills. Recommendations for future
CPR courses/research studies, summarized in Table 7,
include:

1. Use of a scenario based video to present the content

of the CPR course to capture and hold the students'

attention. The use of a video provides concise,
consistent, and correct curriculum presentation.

2. Utilization of the Citizen CPR model of multiple

sources of feedback such as the Skillmeter, instructor

and fellow students.

3. CPR practice to be organized and performed in

distinct practice sections as follows:

50

Table 7. Recommendations for CPR Programs

 

 

A.

B.

Use of a scenario based videotape to present the
curriculum.

Multiple sources of feedback while practicing CPR, using
objective and subjective feedback.

Focused CPR practice:

\lmU'lIb-UJNH

Location/palpation of carotid pulse.

Compression practice.

. Ventilation practice.

Initial sequencing practice.

Practice cycle of ventilations and compressions.

Practice one minute cycle of CPR viewing Skillmeter.

Practice one minute cycle of CPR with subjective
feedback only.

 

a. Location and palpation of carotid pulses on
each other.

b. Location of proper hand placement for chest
compressions on each other.

c. Correct hand placement on the manikin with
correct compressions and rate.

d. Correct ventilation depth and speed of delivery
on the manikin.

e. Initial sequencing segment from assessing
responsiveness through assessment of
pulselessness.

f. Cycles of ventilations and compressions until
timing is appropriate.

g. Entire sequence of one minute of CPR with
Skillmeter until performance is acceptable.

h. Practice entire sequence without the student
viewing the Skillmeter. The instructor will

provide objective corrections in performance but

51
the student must get a feel for how far to
compress the chest and how deeply to ventilate.

Implications for Practice

 

Victims in cardiac arrest have no hope of surviving
without CPR. Eight-five percent of the cardiac arrests
occur at home or work and could be witnessed by someone who
knows the victim. Schluger (1987) reports the quality of
bystander CPR is not as much of an issue as the time of its
initiation. The lay public needs to learn the life-saving
skill of CPR which includes how and when to notify the
emergency medical system.

Implications for the nurse in advanced practice are
numerous. The shortened video CPR programs offer an
opportunity for the advanced practice nurses (APN) to
provide CPR education in their practice to high risk
families or to the practice clientele in general. The APN
can easily identify the clients and families at risk for
cardiovascular disease: the diabetic, the family/client with
a family or personal history of cardiovascular disease,
those with hyperlipidemia, tobacco abuse, obesity, sedentary
lifestyle, and hypertension. After identification, annual
participation in CPR classes would be an essential part of
the management plan. The client at risk, their family
members, their co—workers and friends should also learn CPR.
The client can be encouraged to schedule or request annual
CPR classes in the workplace, neighborhoods, churches, and

social groups both to benefit themselves and others.

52

The information obtained in this study should be used
by the APN when referrals to CPR programs are made. Having
knowledge of what has been shown to be effective in teaching
CPR in this study allows the APN to refer clients only to
programs utilizing similar principles.

Fellow CPR instructors, the AHA, and ARC should be
informed by lecture, letter, or publication of the results
of this study to allow them to integrate these findings into
their classes or prompt them to do more CPR research.
American Heart Association or American Red Cross committee
membership to participate in the decision making regarding
lay person CPR training would be appropriate for the
advanced practice nurse.

The APN must also be aware of the community and how
best to reach the 20% who need to know CPR. Approaching
individual churches and schools in the community resulted in
a large number of lay people learning CPR as a result of
this study. These same tactics, an APN teaching the lay
public through churches and schools, may work in other
communities. If for some reason this method does not work
an assessment of the community may be needed to best
determine how to reach the target population.

The advanced practice nurse could also influence health
policy to place CPR training in the schools, by becoming
actively involved in school boards/committees. There are so
many causes attempting to gain the attention of the public:

fund raising activities, family activities, community

53
involvement, employment issues, church/religious
involvement, etc. that unless a concentrated effort is made
to push CPR education for the lay public the goal of 20%
trained will not be achieved.

Implications for Research

 

The advanced practice nurse should be involved in
further research on effective CPR teaching methods for the
lay public. This study could be duplicated and expanded to
include a larger sample from more geographic locations and
ethnic groups to expand the generalizability of the results.

A secondary analysis of this data comparing the results
of those subjects with family members at risk for heart
disease and those without family members at risk would be of
interest. Secondary analysis could also be done on the
results of this study in regards to the motivating factor
for participation, job requirement versus potential need to
perform CPR on a loved one. Further research into how well
lay people need to perform CPR after training and/or how
important is it for lay people to perform perfect CPR on
victims would add insight into this issue. The frequency
with which lay people should take CPR classes to
maintain/improve their skills is unknown. Perhaps
increasing the frequency of their class participation to
every 6-9 months would improve results.

Further testing of the reliability of the Skillmeter to
accurately document assessment of responsiveness,

breathlessness and pulselessness is needed. The reliability

54
increasing the frequency of their class participation to
every 6-9 months would improve results.

Further testing of the reliability of the Skillmeter to
accurately document assessment of responsiveness,
breathlessness and pulselessness is needed. The reliability
of the instructor is questionable because their
subjectivity, a reliable objective CPR instrument would
greatly add to the reliability of the results of a study.

Summary

The video enhanced CPR program of less than 2 hours
produced comparable results to the traditional four hour CPR
course. Few lay subjects were able to perform adult one—
rescuer CPR according to the AHA standards for health care
providers but many were able to effectively perform the
individual CPR component skills. More than 80% of the
students in both programs quickly contacted the emergency
medical system which is an essential component for a
positive outcome with a cardiac arrest. Both programs
should be further studied with larger, more heterogeneous,
samples with more focused practice on ventilations and
compression and multiple sources and types of feedback on

performance.

LIST OF REFERENCES

LIST OF REFERENCES

Ambrose, R. S., & Stratton, S. J. (1993). One—hour CPR
training. Emergency Medical Services, 22(7), 63-68.

 

American Heart Association. (1993). 1992
cardiovascular statistics (Research Rep. No. 51-1033 (COM),
11—91-325M, 77 03 12). Dallas, TX: Author.

 

Aronson, D. T., & Briggs, L. J. (1983). Contributions
of Gagné and Briggs to a prescriptive model of instruction.
In C. M. Reigeluth (Ed.), Instructional design theories and
models: An overview of their current status (pp. 75-100).
New Jersey: Lawrence Erlbaum Associates.

 

 

Atkins, J. M. (1986). Education and evaluation in
emergency cardiac care programs (CPR and advanced life
support): State of the art. Circulation 74, 18-22.

 

Becker, L. B., & Pepe, P. E. (1993). Ensuring the
effectiveness of community-wide emergency cardiac care.
Annals of Emergency Medicine, 22(2), 354-365.

 

Cobb, L. A., & Hallstrom, A. P. (1982). Community-based
cardiopulmonary resuscitation: What have we learned? Annals
New York Academy of Sciences, 382, 330-342.

 

Cobb, L. A., Hallstrom, A. P., Thompson, R. G., Mandel
L. P., & Copass, M. K. (1980). Community cardiopulmonary
resuscitation. Annual Reviews of Medicine, 31, 453—462.

 

Copley, D. P., Mantle, J. A., Rogers W. J., Russell,
R. 0., & Rackley, C. E. (1977). Improved outcome for
prehospital cardiopulmonary collapse with resuscitation by
bystanders. Circulation, 56(6), 901—905.

 

Cummins R. 0., & Eisenberg, M. S. (1985). Prehospital
cardiopulmonary resuscitation is it effective? Journal of
American Medical Association, 253(16), 2408-2412.

 

 

Cummins, R. O., Eisenberg, M. S., Hallstrom, A. P., &
Litwin, P. E. (1985). Survival of out-of—hospital cardiac
arrest with early initiation of cardiopulmonary
resuscitation. American Journal of EmergencyfiMedicine, 3(2),
114-119.

 

55

56

Cummins, R. O, Ornato, J. P., Thies, W. H., & Pepe, P.
E. (1991). Improving survival from sudden cardiac arrest:
The 'chain of survival' concept. Circulation, 83, 1832-1847.

 

Dracup, K., Moser, D. K., Guzy, P. M., Taylor, S. E., &
Marsden, C. (1994). Is cardiopulmonary resuscitation
training deleterious for family members of cardiac patients?
American Journal of Public Health, 84(1), 116-118.

 

Edwards, M. J. A., & Hannah, K. J. (1985). An
examination of the use of interactive videodisc
cardiopulmonary resuscitation instruction for the lay
community. Computers in Nursing, 3(6), 250.

 

Eisenberg, M. S., Bergner, L. & Hallstrom A. (1984).
Sudden cardiac death in the communipy. Washington: Praerger.

 

Gagné, R. M. (1977) The conditions of learning (3rd
ed.). New York: Holt, Rinehart & Winston.

 

Guzy, P. M., Pearce, M. L., & Greenfield S. (1983). The
survival benefit of bystander cardiopulmonary resuscitation
in a paramedic served metropolitan area. American Journal Of
Public Health, 73(7), 766—768.

 

 

Kaye, W., Montgomery, W., Hon, D., Linus, A., Stewart,
R., & Richards, G. (1983). Interactive computer-videodisc
CPR training and testing. Circulation Abstracts, 68, 14.

 

Kellerman, A. L. (1993). Impact of first-responder
defibrillation in an urban emergency medical services
system. Journal of American Medical Association, 270(14).

 

Kirk-Gardner, R., Crossman, J., & Steven D. (1992). A
community survey of cardiac emergency skills: Symptom
recognition and CPR. Canadian Journal Of Cardiovascular
Nursing, 2(40), 3-8.

 

 

Kowalski, R., Thompson, B. M., Horwitz, L, Stueven H.,
Aprahamian, C., & Darin J. C. (1984). Bystander CPR in
prehospital coarse ventricular fibrillation. Annals Of
Emergency Medicine, 13(11), 1016-1020.

 

 

Laerdal Medical Corporation. (1986). Laerdal Resusci®
Anne, Direction for use. (No. 15 29 00/6020). Stavanger,
Norway: Author.

 

 

Mandel, L. P., & Cobb, L. A. (1982). CPR training in
the community. Annals Of Emergency Medicine, 14(7), 669-671.

 

Miller, D. L., Jahnigen, D. W., Gorbien, M J., &
Simbartl, L. (1992). Cardiopulmonary resuscitation: How
useful? Archives of Internal Medicine, 152, 578—582.

 

57

Moser, D. K., & Coleman, S. (1992) Recommendations for
improving cardiopulmonary resuscitation skills retention.
Heart & Lung, 21(4), 372-380.

 

Murphy, D. J., Murray, A. M., Robinson, B. E., &
Campion, E. W. (1989). Outcomes of CPR in the elderly.
Annals of Internal Medicine, 2, 25-27.

 

Newman, M. M. (1993, Spring). New "heart and stroke
facts" booklet released. Currents in Emergency Cardiac Care,
p. 12.

 

Ramirez, A. G., Weaver, F. J., Raizner, A. R., Dorfman,
S. B., Herrick K. L., & Gotto Jr., A. M. (1977). The
efficacy of lay CPR instruction: An evaluation. American
Journal of Public Health, 67(11), 1093-1095.

 

Schluger, J., Hayes, J. G., Turino, G. M., Fishman, S.,
& Fox, A. C. (1987). The effectiveness of film and videotape
in teaching cardiopulmonary resuscitation to the lay public.
New York State Journal of Medicine, July, 382-385.

 

Stueven, H., Troiano, P., Thompson, B., Matee , J. R.,
Kastenson, E. J., Tonsfeldt D., Hargarten K., Kowalski, R.,
Aprahamian, C., & Darin J. (1986). Bystander/first responder
CPR: Ten years experience in a paramedic system. Annals of
Emergency Medicine, 5(6), 707-710.

 

 

Thompson, R. G., Hallstrom, A. P., & Cobb, L. A.
(1979). Bystander—initiated cardiopulmonary resuscitation in
the management of ventricular fibrillation. Annals of
Internal Medicine, 90(5), 737—740.

 

 

Walz, B. (1991, June). Bystander intervention: Help or
hindrance? Journal of Emergency Medical Services, 60-62.

 

Weaver, F. J., Ramirez, Ac G., Dorfman, S. B., &
Raizner, A. E. (1979). Trainees' retention of
cardiopulmonary resuscitation. Journal of American Medical
Association, 241(9), 901—903.

 

 

APPENDICES

APPENDIX A

58

Appendix A

Detailed Outline of the AHA CPR Program

1. Welcome, instructor introduction

2. Ask to sign consent form and agree to not discuss the
educational session with students waiting for the

training. Reassure about confidentiality.

3. Ask to complete the demographic questionnaire.

4. Thank participants for agreeing to participate in this
study comparing two CPR programs. Following this class you
are asked to leave on your student number badge and go the
testing site. There you will be asked to give your student
number badge to the tester and perform one minute of adult
one—rescuer CPR as you have learned it here today.

5. Apply adhesive student number tag.

6. Conduct AHA CPR program with AHA Introduction, AHA Adult

CPR and AHA Foreign Body Airway Obstruction Videos:

 

 

Time Tppig

0000 Begin AHA Introduction Video
02:10 Definition of Basic Life Support
02:50 Chain of Survival/Sudden Death
03:20 Definition of CPR

03:50 Cardiovascular Anatomy/Physiology
04:30 Respiratory Anatomy/Physiology
06:20 Respiratory Arrest Definition

07:20 Chain of Survival - Statistical Survival

O7:

08:
09:
10:

12:
Begin One
15:
16:

17

17:
18:
19:
19:
20:

21

21:

22

22:
23:
23:
23:

40

10

10
20

30

00
20

:10

3O
3O
10
4O
50

:20

3O

:20

30
10
30
4O

59
AHA BLS Program - Prevention/Guidelines for
CPR
Warning Signs of Heart Attack
Actions to take

Prudent Heart Living

low fat, low cholesterol diet

- exercise

stop smoking

control high blood pressure

- maintain ideal weight

End of video

Rescuer Adult Video

Definition of CPR

Assess — when to do CPR

Check Responsiveness with demonstration
Call 911, what to tell them

Victim Positioning

ABC's of CPR

Opening Airway Demonstration

Assess Breathing

Recovery Position

Rescue Breathing

Reposition & attempt to ventilate

Pulse Check

Rescue breathing for Respiratory Arrest only
Chest Compressions

Hand Positioning for Compressions

25:
26:
26:
27:
28:
29:

4O
10
4O
30
40
00

60
Ratio of Compression to Ventilations
When to stop CPR after beginning
How to hand victim over to EMS personnel
Review of Sequence
End of Video

Manikin Practice — students will be allowed to

practice two cycles of one minute of adult one-rescuer CPR

each.

(teaching method will be generalized supervision with

individual aid as needed, no specific sequence for practice)

(approximately 15 minutes)

Begin Foreign Body Airway Obstruction Video

 

45:
46:
47:
47:
48:
48:

49:
49:
50:
51:
52:
52:
53:
53:
>54:

10
20
00
40
00
50

10
50
4O
00
10
50
OO
40
00

Definition of FBAO/causes/differentiation
Partial Airway Obstruction

Total Airway Obstruction

Assessment

Demonstration of Abdominal Thrusts
Treatment of conscious victim becoming
unconscious

Finger Sweep

Opening Airway

Rescue Breathing

Reposition Airway if breath unsuccessful
Abdominal Thrusts for Unconscious
Ventilations

Pulse Check

Recovery Position

Review of Sequence

61
54:50 Production Credits
56:00 End of Credits/Video
Group practice of FBAO Management
7. When student and instructor are satisfied with the
students performance, escort students to the testing site,
and remain with students until testing is completed.
Provide student with card of program completion. (A CPR
program held in the community would be completed when the
student and instructor were satisfied that the student had

reached their optimal performance level.)

APPENDIX B

62

Appendix B

Detailed Outline of Citizen CPR Program

1. Welcome, instructor introduces self

2. Have participants sign consent form, discuss not

telling future students about the educational

sessions to prevent any contamination of the study.

Reassure about confidentiality.

3. Ask participants to complete the demographic
questionnaire.

4. Thank participants for agreeing to participate in this
study comparing two CPR programs. Inform participants that
following this class they will be asked to remove their name
badge and go to the testing site. There they will be asked
to perform one minute of adult one—rescuer CPR as learned.
5. Apply adhesive student number tag that was assigned at
registration.

6. Explain outline of program: Video and practice until
comfortable, then they will be released to go for testing.
7. Begin video (differences from control teaching method are

written in italics)

 

Time Topic
0000 Introduction
00:35 Adult CPR Scenario

Heart Attack
Drowning

Electrocution

63

01:50 Chain of Survival
02:25 Instructor Identification
03:00 Coronary Heart Disease Review

Signs and Symptoms

Take charge of situation
Lay victim down

Offer reassurance

Call emergency number

Begin CPR
06:35 Review of signs and symptoms
07:50 Purpose of CPR- Anatomy and
Physiology
08:50 CPR demonstration one rescuer real time
12:25 Detailed steps of CPR performance:

Determine unresponsiveness

Call Emergency number

Position the victim

Open airway

Determine breathlessness

Ventilate twice

Determine pulselessness
13:50 Practice pulse check
14:15 Stop video - practice pulse checks on each other
for approximately three minutes, until all students are
comfortable with the skill.
17:20 Hand placement for chest compressions

18:00 Student practice of hand placement

64

18:10 Stop video- practice checking proper hand
placement on self for approximately three minutes.
21:15 Chest compressions

rate, body position

Ventilate twice

Perform four cycles

Reassess pulse and continue
22:50 Review sequence of CPR
23:40 CPR demonstration

Individual face application

Review of CPR steps with

partial explanation of Skillmeter

28:35 Freeze and analyze function of
Skillmeter
29:35 Use of face shield-barrier device
30:10 Description of student practice
30:55 Practice CPR in the following manner: The CPR

instructor will coach the first student in how to perform
correct one—rescuer adult CPR through one minute of CPR.

The first student will then coach the second student through
one minute of CPR. This process will continue with each
student coaching the next student until all 6 students have
completed one minute of CPR. Then the last student will
again coach the first student through one minute of CPR and
the cycle begins again, however, this time the student is
not allowed to see the Skillmeter and is provided feedback

from the Skillmeter via the instructor and fellow students.

65
At completion of the second one minute performance of CPR

the students will return to their seats. (approximately 15

minutes)
47:00 Signs and symptoms of foreign body
airway obstruction
Anatomy and physiology of
Heimlich maneuver
48:30 Hand placement for Heimlich
48:50 Conscious victim - FBAO sequence
49:55 Conscious victim becomes unconscious
51:35 Review of steps for FBAO management
52:20 Treatment for FBAO management if alone
53:05 Pregnant or obese FBAO management
54:20 Rescue breathing
55:30 Recovery position
55:50 Review of conscious and unconscious

FBAO management

57:30 Practice FBAO management on each other with

instructor assistance. When last student has successfully

performed FBAO management all students will return to their

seats. (approximately 10 minutes)

67:35 Risk factor for coronary heart disease and
prudent heart living

72:20 Review of risk factors

Risk factors will play a total of two times. After the

first time through allow any students who wish to practice

any portion of the program again to do so now.

66
Practice adult one-rescuer CPR or FBAO management if
desired.
8. Inform the students that the difference between teaching
and testing is that you will not be allowed to watch the
Skillmeter results as you test.
9. When student and instructor are satisfied with
performance escort student to testing center for testing.
Provide student with a card of program completion. (A CPR
class held in the community would be completed when the
student and instructor were satisfied that the student had
reached their optimal performance level.) Remain with the

students until testing is completed.

APPENDIX C

Laerdal Instruction Manual for Skillmeter

67
Appendix C

TO OPERATE
The following overview shows the Skillmeter keyboard
and button functions.

 

 

 

6 3
- M «owns III. “Mm .7“' Ct“- “V
D.- 4 ”one
Ml no" m
0'! W I“. in. m not and on
Yum pot-on Pravda l Freon "our Drum“ mm Slam flock to Tum pm on
0'! new Mn. on 150 toe. of shoe cream. H
s. mogul“ Mm MO roam-91 of "mom I ' Img'm‘;
”soon! for tour 03mm new I I r retool». rm ‘
"'0” 0 "V w o MOI-{div often

mien-amt. or Immm 0”

 

 

 

 

 

 

 

 

2"" "n a... 1 £2319. $13.1. '° '""‘
Mne~d *1 "PI N‘HII‘R ‘;"::"=‘
'0'“ -" 73’2"...“ "0 M": ‘ W max.
’- sellv .td'l “N" e-ve'ci
‘0 ”mm pm
To start:
Batteries must be installed and the “'."'”"" mm-

Skillmeter must be connected to the
manikin. To prepare for registration 3
of CPR performed on the manikin, o t D
push On. .
Accumulation of CPR data can now
be started in two different ways:
1. Automatic activation
When a CPR measure (i.e. check unu— armre-
rcsponsiveness. breathing, 7_ ’7 '7'
circulation. compression or ven- I
tilation) activates one of the O 0
sensors in the manikin. the
Skillmeter clock sums and a 0
graphic symbol denoting the first """"""""""
performed CPR measure appmrs on the lower left
part of the display.
Example: Responsiveness checking starts
registration (r).
2. Manual activation
To test the student for reaction 2"?“ ... -.—- .._
time from encountering an , ,4
unconcious patient until initiation )
of CPR. push On. then press the O _ it 0
Start clock button when you wish ;
to start measuring the student's ‘30. 9.1;. _ _ _ _.
reaction time.

eeeeeeeeeeeeeeeee

Immediate feedback during training an“.
1. Compression bargraph is '- ‘. ‘
synchronized with compression
direction (downwards) and com-
pression depth. Sufficient depth is
obtained when the black bargraph
converts the "target" to a black dor. ------- - --------

mm
“—: \
l
0

Mistakes signalled by compression bargraph:

If the bargraph does not convert the 3'“? __ _ mm...
target. compression is too shallow ..... "
(less than 1 1'; ". about 4 cm). @ .

If bargraph surpasses the target. 0 O
compression is too deep ~—
(more than 2". or 5 cm). 7’ " "" "

eeeeeeeeeeeeeeeee

-,—..a.<.--.,.._

:‘2'... .. '1'"
If pressure is not fidly released I Q .__, "~— .
between compressions, a portion l A
ofthebarznphisretainedontop I U _- ‘1’0
during the pause between com- r i. n
pmions. ~

on.
2. Incorrect hand placement markers "— '-
lf compression force is applied to I I
an incorrect area on the chest. at 1
black dot marker will appear to I
denote that the hands were placed l.
too high. or too low or too far left.
or too far right. Markers appear within the chest
outline on the display screen. to clearly indicate
hand misplacement. No marker will appear for
compression: with correct hand placement.

3. Ventilation bargraph is m m
synchronized with directions of the ””””” .-
ehest wall movement during ‘
inflation (up-wards) and exhalation
(downwards). Sufficient volume is
obtained when the black bargraph
converts the "target" to a black dot.

Mistakes signalled by ventilation
bargraph: If the bargraph does not
convert the target. ventilation
volume is insufi'icient (less titan
0.8 liter). If the bargraph surpases

the target. volume Is excessive “ .."."--: '. t r
(more than 1.2 liters). If inflation speed and/or
inflated volume' Is so high that It could cause
stomach distention in a real resuscitation case, the
word ”Stomach" is shown to the right of the bargraph.

4. Sequence tracing
sequence rmcmo. em: One m cm for too see. Adult victim.

.‘W‘I'i7'
-.-‘.‘.‘.

68

 

 

Determine pulselessness Como res: Redeterrnine VenIIlete RecommenCe
(feel erect porn for at lees! See I /‘ 15 times pulselesm mice compression
Vent |a\re twice \
- - - - -\ —
j 0 I O I O O 0 O
I) —\\< 30 40 50 60 70 00 90 '00
Determine Determme

breathlessness
, he! held trite! backwards)

Performed CPR steps are traced by symbols across
the lower portion of the display screen. The symbols
are gauged against a 150 see. time scale.

unr vetoes
(town. of welders!

The sequence tracing represents the succession of
performed CPR steps. the duration of each step. the
duration of a series of steps. and the progression of
the entire sequence.

 

To read a sequence traced over a period of time longer
than the 150 sec. display line. press the “Step Sequence"
button to display up to three more lines of tracings. each
of 150 we.

5. Quantification ”u“ _ m
Compressions and ventilations are -"= ff
counted. Total numbers of com- I‘
pressions and ventilations are D ' ' 0
given on the top line. along with 9....,
numbers of correct compressions - —'—'—'— '-
and ventilations. ' ' ' '
The comp-vent. ratio is shown for m_
each cycle of compressions and u 5: -;~ -:
ventilations. In addition the
compression rate is given. This 0

will appear for each compression-
ventilation cycle as soon as a
following cycle is started.

Note: Pressing the "On” or ”Of!“ button removes any
registered data.

Final assessment

1. Freeze
Press the Evaluation button once to
freeze the displayed numbers and a“
sequence tracing. for further study
and discussion. Rate and ratio are
then automatically recalculated to
show average values.

“Ill”.

................

2. Analyze
Press the "Evaluation” button
again to analyze the performance.
A detailed overview of mistakes.
and a calculation of ”correct" - ._
numbers to percentages will
appear on the display.
Mistake markers lit occasionally
during performance will be
permanently lit during the analyze
period. Numbers for each type of
mistakes are given along with the
classification of mistakes.
However. one number is given for
all four types of hand misplace-
ment.

3. Assessment of sequence
Responsiveness check:
The letter "r" comes up immedi-
ately when the manikin's shoulders
are shaken, confirming that an 2'5"!" .. .. ..
attempt to check responsiveness ,, , .
was made. ,\

 

eeeeeeeeeeeeeeee

()pcmlmn and lunttmn

69

 

 

:2. mur-
. “WI
Breathing check: 3 D ‘f D
The letter "b' comes up when the t ’ a?" .
manikin'sheadhasbeen held {:0 . ‘ . .-
continuouslyintheopenairway ""'°"'"“"‘“"
position for 3 sec.
23'2”..- .. 21'“!
l \ ‘ v 1”
Circulation check: ‘ Q ~_ tr 0
An easily seen black line is lit in 75:.“
the lower midportion of the display [1s Q .. -.
as soon as fingers are in the correct """ \‘J """

location and feeling the neck pulse. —; r; --— _,-_ 77.... .-._.
This marker must be lit contin- _. _ i"
uottsly for at least 5 sec. before the (

letter "c" comes up to indicate that D _ __- . U
the pulse has been checked :5:
appropriately. " 0

Initial checks should be followed by comp-vent. cycles
plus a repeated pulse check. Succession and timing
.lzould comply \Vllll x'IIlIIl guulelmes. See example of
complete tracing on page 13.

RECORDING OF DISPLAYED RESULTS
Results shown on the Skillmeter can be saved for
review in one of two ways:

1. Manual copying

To use Skillmeter "Score Sheets”:

- Hold Skillmeter in one hand and press the
"Evaluate" button twice for performance analysis.

- Apply score sheet over Skillmeter - --
display so that numbers and
tracings can be read through the
clear score sheet windows.

- Copy numbers and tracings onto
windows using a permanent ink

 

 

felt tip pen. Discard' paper
interleaving.
tum "Qt“ Y!“ can”
2. Printed rem" oo-I-two- astute.
eon-or. out car—nu flm err-Ia 1m.
a o It a at r a... .-
t-Ion
3.32.... '3:

lac-mt:
tre- - I-
r r. t - _ ---_. t . . t
r I o n to I
0..- ha—

 

 

 

The optional battery operated Laerdal Printer. or
certain standard computer printers, (See "Standard
computer printer”. page 15) can be connected to the
Skillmeter and will produce a printed report which
graphically is similar to the display on the
Skillmeter. incorporating a tabulation of results.

  
  

 

- —--—o M -m‘I—g... “'Ch

APPENDIX D

. r

70

Appendix D

Print out of Skillmeter Report

 

LRERDQL SKILLMETER REPORT
C0fiPRESSlOE VfiiilLSTEOR
CORRECT TOTAL COFP.EATE RATEO CCiifCfi' TOTRL
average avatar?
£0 (liLX) (0 it !5:2 It (lift) 10
QNB
ll’fifi'lété release =3 gttmacn distentitn J
loo tittle J [00 nucn J
lto nucn ‘ Q Too little 9
Uron't hind position it
SEOIEICL’
(50119 in sec.)
- - - - -
rb I: _ _ _ _ t:
I I I I. I I ' I. I I I _ I I I _ I I —
[i ci‘ bl] 9U l't'U iE-‘U
Student 2 El Passed

Dd” 3 instructor :

-

APPENDIX E

Skill Performance Sheets for Adult One—Rescuer CPR

71

Appendix E

Skill Performance Sheet éAmeticon Heart
Adult One-Rescuer CPR Assocrotton

Student Name Date

 

 

Performance Guidelines Performed

 

1. Establish unresponsiveness.
Activate the EMS system.

 

2. Open airway (head tilt—chin lift or
jaw thrust).
Check breathing (look. listen, teel).'

 

3. Give 2 slow breaths (1 ‘/2 to 2 seconds
per breath), watch chest rise, allow tor
exhalation between breaths.

 

4. Check carotid pulse.
If breathing is absent but pulse is present,
provide rescue breathing
(1 breath every 5 seconds, about 12
breaths per minute).

 

5. If no pulse. give cycles at 15 chest
compressions (rate, 80 to 100
compressions per minute) followed by
2 slow breaths.

 

6. Alter 4 cycles of 15:2 (about 1 minute),
check pulse.‘ If no pulse, continue 15:2
cycle beginning with chest compressions.

 

 

'Il victim is breathing or resumes ettective breathing, place in recovery position.
Comments

 

 

 

Instructor

 

Circle one: Complete Needs more practice

50

APPENDIX F

72

Appendix F

Training Guide for Citizen CPR Instructors

Seven AHA CPR instructors will be trained to teach the
Citizen CPR program for this study. Following is the
outline of the training procedure:
Intro
Review of the Video and Detailed Outline of Citizen CPR
Program in Appendix B.

Practice with Skillmeter until proficient.

APPENDIX G

73

Appendix G

Training Guide for Testers

1. Review of testing procedure in Appendix L.

2. Demonstration and return demonstration for how to freeze,
analyze and print or record subject's CPR results.

3. Student identification by student number badges.

4. Where to place reports when completed.

APPENDIX H

74

Appendix H

Participant Questionnaire

PLEASE ANSWER THE FOLLOWING QUESTIONS:

 

ID # _ _ _ _Group # _ _ Day/Date Instructor #_ _
(circle)
1. Male 1
Female 2

2. What was your age on your last birthday?

 

3. What is your marital status?

Single, never married _ Widowed
__ Married __ Divorced
__ Separated
4. Do any of the members of your family (spouse, parents, in-Iaws, etc) have heart disease,
high blood pressure or diabetes? (Circle correct answer) Yes No
5. Have you ever had any medical training? Yes No
Did it include teaming CPR? Yes No

6. Have you ever had a formal CPR class before? Yes No
7. What is your occupation?
8. Why are you participating in this CPR program?
_May need to perform CPR on family/neighbor/co-worker
___Job requirement

Other -Please explain

 

CONTINUED ON BACK OF FORM

75

9. What is the highest level of education you completed?
__ Some elementary school (grades 1-7)
__ Completed elementary school (8th grade)
__ Some high school (9—11 years)

__ Graduated from high school
__ Some college/technical training (1 -3 yrs)
_ Graduated from technical program
__ Graduated from college (associate's degree)
Some college beyond an associate's degree
__ Graduated with a bachelor's degree
__ Some graduate school beyond bachelor's degree

Graduate degree (Please specify

 

_ Other (Please specify
10.0PTIONAL Ethnic origin: African American White
QUESTION Hispanic Asian
Oriental Other

American Indian

APPENDIX J

78

Appendix J

Consent for church classes

CPR SKILLS TRAINING STUDY CONSENT FORM
I, , voluntarily consent to participate in the

study comparing two alternate methods of teaching adult one-rescuer
cardiopulmonary resuscitation (CPR). This study is being conducted by Joan
Nelson RN, graduate student from Michigan State University. I understand I
will attend a lecture session and then be supervised in practicing the skills of
adult one-rescuer CPR. At the completion of my class time, and when I am
comfortable will my CPR skills, I will perform one minute of adult one-rescuer
CPR which will be analyzed for the study. I understand that at the completion
of my class session I will receive a card of completion signifying I have
completed the CPR program.

I will attend one training session which will be approximately 1 1I2 to 2
hours in length. I understand testing will take approximately five minutes per
student at the completion of the CPR program.

Risks or discomforts possible from participation in this study may be
physical soreness of my lips, wrists or back. I may also be uncomfortable with
the knowledge that I may need to perform CPR on a loved one sometime in the
future. I understand that if I am injured during this study I should seek medical
care from my personal health care provider or the health care provider of my
choice. I further understand that I will be responsible for any medical expenses

incurred as a result of this injury.

CONTINUED ON BACK

77

I understand the purpose and outline of the study, including any inherent
risks and/or discomforts.

I understand that I am freely choosing to participate in this study. I
know I may choose to not participate at all, or may discontinue my participation
at any time prior to the completion of the study without penalty or loss of
benefits to which I may otherwise be entitled.

I understand that all results obtained with this study will be treated with
strict confidence, my identity will not be revealed in any report of the research
findings. A copy of the findings will be available to me upon written request to
the author of the study.

If I have any questions or concerns regarding participation in this study I
may contact Joan Nelson RN at 844-1266.

Signature:

 

Witness:
Date:

 

 

APPENDIX K

80

Appendix K

Commonly Asked CPR Questions and Answers

The following has been copied from the Basic Life
Support, Heartsaver Guide, a Student Handbook for
Cardiopulmonary Resuscitation and First Aid for
Choking. 1993 American Heart Association ISBNO—87493-

614-4. Pages 60—67.

'\

81

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APPENDIX L

85

Appendix L

Testing Procedure

A.

B.

Students will be tested individually.

When beginning to test the tester will ask the
student for their student number badge and to
perform one minute of one-person adult CPR as
he/she was just taught in their respective
programs.

The tester will document if the student properly
requests notification of EMS at Step B of the CPR
procedure, checks responsiveness initially, opens
airway, checks pulse initially and after one

minute of CPR.

. At the completion of the one minute of CPR the

student will be excused.

The tester will freeze the Skillmeter and record
the results with the attached printer or onto a
Laerdal Skillmeter Report sheet. The Skillmeter
report will be stapled to the testing form along

with the student number.

APPENDIX M

86

Appendix M

Testing Form

Student Number Badge: Staple Here
Student requests notification of

EMS at step B Yes No

Responsiveness checked Yes No

Initial Pulse Check Yes No

Second Pulse Check Yes No

Skillmeter printout: Staple here

APPENDIX N

UCRIHS Letters

87

Appendix N

. MLCHICAN smug

U id I V’ E ll S l 1‘ Y

 

November 14, 1994"

TO: Joan K. Nelson

1700 Robins Road I132
Grand Haven, MI 49417
RE: iRDI: 94-526
TITLE: A COMPARISON OF TWO CPR (CARDIOPULHOHARY

RESUSCITAITION rnocnnns;
navxsxou nsoussrso: N/h
carscuny: I—n.s
nrrnovnt oars: 11/14/94

The University Committee on Research involving Human Subzects'(UcanS)
review of this project is complete. 1 am pleased to adv an that the
rights and welfare of the human subjects appear to be adequately
)rotected and methods to obtain informed cansent are approprizte.
’heretore, the UCRIHS approved this project including any revision
listed ahove.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. investigators planning to
continue a project be and One year must use the green renewal
form (enclosed with the original agproval letter or when a
pro ect is renewed) to seek ugdate certification. There is a
max mum of four such expedite renewals ossible. Investigators
wishin to continue a roject beyond tha time need to submit it
again or complete rev ew.

REVISIONS: UCRIHS must review an changes in rrocedures involving human
subjects, rior to in tiation of tie change. if this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any 0 her time during the year
send your wr tten request to the CanS Chair, requesting revised
approval and referencin the project‘s Inc I and title. include
in your request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS]

CHANGES: Should either of the following arise during the course of the
work, investl ators must noti i UCRIHS promptly: ‘1) problems
(unexpected a de effects comp aints, e c.) involv ng uuman
subjects or [2) changes in the research environment or new

 

an"? 7

onmvm' information ndicating greater risk to the human suhiecta than
existed when the protocol was previously reviewed an: approved.
RESEARCH
AND If we can be of any finunre helo, please do not hesitate to contact us
GRADUAIE at (517)355—2180 or FAX (511)130-1171.
SIUDIES

Sincerel

    

Unlvmlly Commlllee on
naumh Involving
Human Submit
nmnmsp

  

i0/

‘0
F vid E. Wright,
lel i "5 Chair

  

Mirhiqm 5|ch linivcusily
225 Mmiuklmllon Building
[MI | aiming, erhiq m
mMJHHG cc: Rachel F. Schiffman

SHIJSS NU"
MK SUN]? ll"

DEw:p)m

 

CFECEC
RESEARCH
AND
GRADUAIE
STUDIES

9
f

Unwemly Commune: on
Research Involvung
Human Sumezts
(UCRMS)

Eir"}"¢ an 0"-..
4.: --".’ o . .

.....

'35:; ,) m J3 I'.'7‘.i'..:‘4 I. .' ."‘

'2'..JI-1‘C:C’.'Lfi'l I'll (”57,173.

g

 

88

MICHIGAN STATE

UNIVERSITY

 

February 2, 1995

To: Joan K. Nelson
1700 Robins Road IliZ

Grand Haven, MI 494 7
RE: IRBI: 94-526
TITLE: A COMPARISON OF TWO CPR (CARDIOPULHONARY

RESUSCITATION) PROGRAMS
REVISION REQUESTED: 01 16/95
CATEGORY: - ,8
APPROVAL DATE: 11/14/94

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately
retested and methods to obtain informed consent are appropriate.
herefore, the UCRIHS approved this project including any revision
listed above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project bevond one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u date certification. There is a
maximum of four such expedite renewals possible. Investigators
wishing to continue a project beyond that time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t 0 change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year,
send your written request to the CRIBS Chair, requesting revised
approval and referencing the project's IRS I and title. Include
in our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PRosLsHS/

CBANGES: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: (1) problems
(unexpected side effects, comp aints, etc.) involving uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub‘ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, please do not hesitate to contact us
at (517)355-2180 or FAX (517)3 6- 171.

Sincerely,

D Jid E. Wright, P .D '
CRIHS Chair

DEW:pjm

cc: Rachel F. Schiffman

 

HICHIGQN STRTE UNIV, LIBRARIES
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