Why CPR Certification?
By Jamie Hale
In 1973, the American Heart Association and the American Red Cross began an aggressive campaign to educate the American public in basic life support CPR procedures (Dworkin 1999). In the beginning the emphasis was on the training of Public Safety and Rescue personnel. Once this training was introduced to that market, it was soon expanded to train the general public.
Do traditional CPR courses teach people how to perform CPR in real life? I wondered about the validity of CPR certification after I earned my first CPR Certification (approximately 14yrs ago). The American Red Cross gave the course. To my knowledge everyone in the class passed the course. The requirement for passing the test was recalling some information we had been given 1-2 hours prior to taking the test and performing some skills on a manikin (even though some people in the class never touched the manikin they somehow passed the course). After earning the certificate I was qualified to use this life saving method in the real world. In reality I had another piece of paper to tuck in my wallet and add to my list of credentials.
Does traditional CPR courses really teach CPR?
Todd et. al. (1998) conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would result in similar or better CPR performance than the current community standard; the American Heart Association Heartsaver course. The researchers found that the VSI trainees displayed superior overall performance compared with traditional trainees.
Effectiveness of CPR performance on a manikin was evaluated immediately after training in public CPR classes by trained independent observers using validated measures and procedures (Brennan & Braslow 1998). An instrumented manikin was used to assess critical skills thought to be key to survival following out-of-hospital cardiac arrest The 226 subjects were enrolled in CPR classes offered to the public by the American Heart Association and the American Red Cross. Fifty percent of subjects performed 2% or less compression correctly, and 50% performed 10% or fewer of ventilations correctly. Other critical skills measured included compression rate (65% failed to achieve a successful compression rate), opening of the airway prior to a breathing check (47% failed), adequate assessment of breathing (50% failed), and adequate pulse check (53% failed). Nearly half of all subjects made at least four errors in assessment and sequencing of skills. Yet, no one fails CPR Cert courses (at least no one in the classes I have attended). If performance is poor immediately following CPR training imagine how poor the performance would be if tested 6-12 months later. CPR re-certification is generally required once every 2 years. I don’t think one class in two years can teach much of anything much less how to save someone’s life with CPR. The earning of a CPR cert indicating you are qualified to save someone’s life is absurd.
In another study Brennan and Braslow (1995) evaluated skill levels of trainees (n = 48) who were taught cardiopulmonary resuscitation (CPR) in "American Red Cross: Adult CPR" classes offered at a work site. The evaluation used a validated skill checklist and a Laerdal Skillmeter mannequin to assess trainee competence. Only 10% of the trainees could correctly perform all 12 CPR skills assessed by the skill checklist. Less than 12% of all compressions met published standards, and less than 25% of the ventilations met the standards as evaluated by the Skillmeter mannequin. Despite poor performance all trainees felt confident that they could use their CPR skills in an actual emergency; 64% felt "very confident." Videotape recordings of the practice sessions showed that instructors overlooked many errors in CPR performance and that trainees provided little corrective feedback to one another. This study indicates the need for better instruction and the need for more teamwork among class participants. In my experience with CPR classes the trainees barely spoke to each other or when they did speak it was not about the task at hand. The instructors seemed to be in rush and were not very attentive when the class was practicing the required skills. Some of the participants didn’t even perform the skills on the manikin. The instructors felt that participants observing others perform the skills was good enough to pass that portion of the test. Another point I would like to mention is the overconfidence that was displayed by the majority of trainees in the study by Brennan and Braslow. I would suggest that the overconfident trainees look at literature relating to CPR in real life situations. Once they see the data and intelligently consider the implications they should realize there is a slim chance that they could actually save someone’s life using CPR. I find the confidence levels displayed by the trainees in this study very different when compared to the confidence levels of people I have spoken with who were CPR certified. The people I spoke with seemed to think there was no way they could save someone’s life with CPR.
Between 1981 and 1985 Curry & Gass (1987) carried out a study in two medium-sized non-teaching community hospitals to determine the rate of deterioration of knowledge and skills in cardiopulmonary resuscitation (CPR) among physicians and nurses, the accuracy of their perceptions of their knowledge and skills, the effects of practice on retention and the effect of CPR training on mortality. The participants' knowledge and skills were measured before training and immediately after, 6 months after and 12 months after training. Information on all attempts at CPR involving hospital staff was collected from medical records and from interviews with the participants. A total of 31 physicians and 54 nurses were followed during the study. Six months after training there was no difference in CPR knowledge or skills between the physicians and the nurses. In both groups CPR skills had deteriorated to near pre-training levels. By 6 months the physicians' knowledge had deteriorated to a level not significantly different from that before training. The nurses maintained a significant improvement in knowledge test scores at 12 months over those before training. The physicians had an accurate perception of their knowledge but not their skills 6 months and 12 months after training, whereas the nurses did not accurately perceive either their knowledge or their skills after training. Experience with CPR did not contribute to post-training knowledge or skills in either group. There was no evidence that death rates were lower when basic life support (BLS) was begun by trained staff. The probability of survival was greater when BLS was begun within 4 minutes of arrest than when it was begun after 4 minutes. It does not seem reasonable to invest the time and money into CPR courses (as they are currently conducted). This study as well as others indicates the lack of real world benefits from such courses.
Fossel et. al. (1983) evaluated performance and knowledge of cardiopulmonary resuscitation (CPR) in a group of pre-clinical medical students who had received CPR certification either two or three weeks (group 0), one year (group 1), or two years (group 2) prior to the study. Assessment, ventilation, compression, and complications caused by incorrect technique were evaluated. A written examination was also given. There was a significantly higher rate of failure to perform adequate CPR by students in groups 1 and 2 when compared with group 0. There was no significant difference between the failure rates of groups 1 and 2. Written test scores were also lower in group 1 and 2 than group O. Written examination scores were not reliable indicators of CPR skill in individual cases. If we are going to continue to provide CPR Cert courses there needs to be refresher classes on a regular basis. A refresher course once every year or two is not sufficient. How about we require refresher courses once every 4-6 weeks. Of course the refresher classes are not that valuable if the real objective is to simply earn another paper trophy (this leads to lack of attention from participants). If the objective is to learn CPR refresher classes on a regular basis should be a priority. Another topic I would like to mention is online CPR certification. How can an online course measure CPR skills?
Berden et. al. (1994) investigated the ability of laypeople to apply basic CPR techniques after recent training. The researchers looked at 151 laypeople that were trained twice in the preceding 20 to 24 months. Practical skills were tested using six primary recorded variables that describe the quality of CPR techniques in a training situation. A total score on the skills of each participant was computed on the basis of a predefined scoring system. Thirty-three percent of the participants were able to perform adequate CPR. The findings of this study indicate that practical skills in basic CPR after a 12-month training interval are insufficient in most laypeople. The authors of the study suggested a need for a better-tailored instruction program, with an emphasis on regular, frequent refresher courses. I agree with the authors. I think there would be better instruction if the requirements to become a CPR instructor were stricter. In my opinion as I mentioned earlier refresher courses every 4-6 weeks would be a good idea.
Studies were conducted by Kaye et. al. (1991) to investigate what actually occurs during a CPR course. Despite precisely defined curricula, they found that instructors did not teach in a standardized way. Practice time was limited and errors in performance were not corrected. Instructors consistently rated the students' overall performance as acceptable. At the same time, using the same checklist, the researchers consistently rated performance as unacceptable. Even though the researchers documented poor performance students and instructors were satisfied with the courses and believed that the level of performance was high. These studies show that the problem of poor retention of CPR skills may be due to poor instruction.
I would like to address another question concerning CPR. Is CPR a reliable method for saving lives? CPR has not been shown to be very successful in resuscitation efforts. Death is the most common outcome of out of hospital CPR. Estimations of survival rates are low. The goal of saving a life with CPR is rarely attained. Yet, CPR is perpetuated by mass media, as some sort of medical magic (Timmermans 1999).
Recently I conducted a brief interview with veteran Paramedic Brent Shelton. Shelton has been involved with EMS for over 18 years. Throughout his career he has assisted CPR instructors in certifying people for CPR. During the course of his career he has worked as a field medic and currently works in the business sector of EMS.
J Hale: Approximately how many people have you certified in CPR? How many of those people would you say could perform CPR in a real life situation?
B Shelton: I could not pin down the exact number of people that I have helped certify, but it has been more than enough to know when watching one become certified who might be good in a real life situation and who might not be. I have witnessed many people perform CPR for their first time, and often have been surprised at who is capable of performing good CPR in a real life situation. First let’s look at a basic scenario for what could happen in real life. You have been recently certified in CPR, and you have never been exposed to someone actively about to go into cardiac arrest. You are having a conversation with someone you have never met while in the line at the movie ticket counter. Suddenly, this person simply falls to the ground. You notice this person is in big trouble, they are not breathing and you don’t believe you feel a pulse. They have an appearance to their flesh that you have never seen in your life. Their eyes have become empty of life and now you just realized the time has come for you to perform your new skills. Can you do it? I have had this conversation with hundreds of people over the years that are certified but gratefully, have never been in a moment where they have had to perform CPR. I responded to a 911 call one evening with the information that a patient would be unresponsive when we arrived. I had two EMT students accompanying myself and the attending EMT that night. They had two completely different personalities and demeanors about them. They were both smart; one was very athletic, bold, and mentally confident. The other student was ridiculously shy, not athletic, and simply meek. They both were recently certified in CPR. Once we arrived on scene, sure enough the man was in complete cardiac arrest. Throughout the duration of this incident from beginning at the home until our arrival at the emergency room I was amazed at the difference on how the two performed. Shy girl outperformed the bold, athletic, and mentally confident girl by a landslide. The patient did not make it, but the ability of the shy girl to perform good CPR at the level she did for her first time was amazing. She was calm, collect, and did not panic; looked like a pro from beginning until end. The other girl was in shambles and was very upset by the entire event. It was difficult for her to even help us during the transport. My point, you never really know until you are in that spot. For me, the first time I ever witnessed someone in cardiac arrest also was my very first call in EMS. I felt confident and was not remotely upset during the events. I knew from that day forward that this career was for me, but it’s not that way for everyone.
J Hale: How many people have you seen saved by CPR?
B Shelton: Unfortunately, the number of people that I have seen successfully resuscitated and fully recovered is few. Meaning, people that were in cardiac arrest when I arrived on scene and made it back to a normal life. When you go into cardiac arrest, the next several minutes of your remaining life could be determined on whether someone performs adequate CPR on you or not. In most cases, the time that elapses from you going unresponsive, until an ambulance arrives can be simply to long. Brain damage occurs quickly; then, even if you get a person’s other organs performing again the patient’s long-term outcome can be arguably worse than death itself. I have witnessed patients be revived with CPR only to be in a nursing home as a shell of themselves for the remainder of their lives.
I do believe everyone should be certified in CPR. The reason is that if I go into sudden cardiac arrest, I have a better chance of making it if someone around me has an idea of what to do rather than them having no clue where to even begin. Then maybe, just maybe, they will keep me going long enough for the cavalry to show up with more advanced equipment to get me back to a full recovery. I went to high school with a young lady who years down the road would have a beautiful little girl. I picked that child up one day, dead in her home. We did everything we could, but it was too late because CPR was not performed quickly enough. Two years later I was in a restaurant casually eating lunch when this former classmate walked up to my table and said to me, with tears and emptiness, “If I had taken a CPR class my little girl might, just might, still be with me today.”
I would like to thank Mr. Shelton for the interview. I would also like to comment on a statement that was during the interview. Shelton said, “I do believe everyone should be certified in CPR. The reason, if I go into sudden cardiac arrest I have a better chance of making it if someone around me has an idea of what to do rather than them having no clue where to even begin”. I don’t think being certified or having an idea of how to perform CPR would influence the outcome. I think having a sufficient CPR skill set would definitely increase the chances of saving someone’s life. There is a huge difference between having an idea of what to do and really knowing what and how to do it. As I pointed out earlier even when you really know how to perform CPR the odds of resuscitation are very low. Therefore having an idea of what to do would have an even lower chance of success.
CPR Certification courses have not been shown to be very good at teaching CPR. If we are going to continue to stress the importance of CPR and CPR Certification Courses the courses need to be re-structured and the criteria for becoming an instructor needs to be stricter. Here’s an idea. How about videotaping training courses and on occasion randomly submitting a videotape to a board for evaluation.
References
Berden HJ, Bierens JJ, Willems FF, Hendrick JM, Pijls NH, Knape JT (1994). Resuscitation skills of lay public after recent training Ann Emerg Med. May;23(5):1003-8.
Brennan RT, Braslow A (1998) Skill mastery in public CPR classes. AM J Emerg Med Nov;16(7):653-7.
Brennan RT, Braslow A (1995) Skill mastery in cardiopulmonary resuscitation training. Am J Emerg Med. 1995 Sep;13(5):505-8.
Curry L, Gass D (1987) Effects of training in cardiopulmonary resuscitation on competence and patient outcome. CMAJ. Sep 15;137(6):491-6
Dworkin GM (1999) Evolution of Resuscitation. http://www.lifesaving.com/issues/articles/10evolution.html
Fossel M, Kiskaddon RT, Sternbach GL (1983) Retention of cardiopulmonary resuscitation skills by medical students. J Med Educ. Jul;58(7):568-75.
Kaye W, Rallis SF, Mancini ME, Linhares KC, Angell ML, Donovan DS, Zajano NC, Finger JA. (1991) The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum. Resuscitation. Feb;21(1):67-87.
Timmermans S (1999) Sudden Death and the Myth of CPR. Temple University Press.
Todd KH, Braslow A, Brennan RT, Lowery DW, Cox RJ, Lipscomb LE, Kellermann AL(1998).Randomized, controlled trial of video self-instruction versus traditional CPR training. .Ann Emerg Med. 1998 Mar;31(3):364-9.
Copyright 2008 Jamie Hale
Below are a few comments from readers.
Comment: I would agree that CPR courses are not very good at teaching CPR. I am in nursing school and I have a CPR Certification, but there is no way I could perform CPR. I think the guidelines definitely need changed.
Reply: Your experience seems to be the norm.
Comment: I thought your article was good but also contained a serious error. I am a CPR instructor and I take great pride in my teaching skills. All CPR instructors are not bad. I did not appreciate the way CPR instructors were portrayed in the article.
Reply: I am sorry you were offended, but I never made the comment that all CPR instructors are bad. It would be nice if all instructors took pride in their work the way you do.
Comment: I agree that refresher courses would be a good idea. I think once every couple of months would work well. If courses are only required once every two years I don’t think instructor competence will make much difference.
Reply: I would like to see the refresher courses offered once every 4-6 weeks. I would also agree with your comment about the instructors (to a degree). Although it wouldn't hurt to have quality instructors. As I mentioned in the article if these courses are going to continue to be offered why not design them to really teach people how to do CPR and be able to use in real life. We can’t expect people to learn this skill in one session.
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