Novel AHA Recommendations Aim to Update, Improve CPR Training

Batya Swift Yasgur, MA, LSW

June 25, 2018

The American Heart Association (AHA) is recommending new strategies to address shortcomings in current educational approaches to teaching cardiopulmonary resuscitation (CPR).

Traditional methods of teaching CPR, such as standardized online and in-person courses, are falling short because providers demonstrate a "decay of skills" over time, translating into "suboptimal clinical care and poor survival outcomes from cardiac arrest," write the authors of a new AHA Scientific Statement on CPR education.

The new recommendations include mastery and contextual learning, shorter, more frequent sessions, frequent feedback and debriefing, regular assessment, faculty development, and use of innovative technological platforms to assist with learning retention.

"This focus on education is novel and never before undertaken by the AHA, to look at the literature on education and think about how we can improve and change what we're doing to ultimately impact patient outcomes," Adam Cheng, MD, emergency doctor, Alberta Children's Hospital, and professor, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada, and chair, AHA Resuscitation Education Scientific Statement Development Committee, told | Medscape Cardiology.

"The AHA's goal is to double survival rates by 2020, and this scientific statement and this process were efforts toward achieving that goal," he said.

The statement was published online June 21 in Circulation.

Acquiring Real-Life Skills

"Frontline care providers have been trained for many years through courses delivered in person and via video and simulation, but what we know is that unfortunately, despite our best efforts to train providers, the knowledge and skills acquired during those courses decay over time," Cheng observed.

"So when a real-life situation arises and push comes to shove to do certain procedures, providers still struggle to provide effective CPR according to guidelines, which can influence the patient's survival," he said.

The AHA's steering committee, charged with conducting an extensive literature review and developing recommendations, included individuals with expertise in resuscitation science and education, with each working group comprising people from multiple professions and clinical specialties.

The committee recommended eight key elements to improve CPR training and implementation.

The old adage "practice makes perfect" may be true, but "it is possible for a person to practice something multiple times but have no observable improvement in performance," Cheng said.

The key is "practicing until the learner demonstrates mastery of a given skill, and for that to happen, there must be definition of what 'mastery' actually is."

The mastery learning model prioritizes "those behaviors that have a clear link to patient safety or clinical outcomes," the authors emphasize.

"Deliberate practice" is the training model for behaviors that are difficult to master without feedback and which can benefit from automaticity.

Performance goals for both mastery learning and deliberate practice should consist of observable behavior based on patient outcomes and process measures, they write.

Spaced practice "involves the separation of training into several discrete sessions over a prolonged period with measurable intervals between training sessions (typically weeks to months)," the authors explain.

By contrast, "massed practice" takes place during a single period of training without rest over hours or days.

The authors recommend that the current "massed" approach to resuscitation training be replaced, or at least supplemented, with a spaced practice, with logistical and practical details tailored to context, learning type, objectives, and experience.

"More frequent and, if necessary, shorter training sessions help to combat skill decay," Cheng observed.

Contextual Learning

"We need to create an environment of training similar to the context in which a given group of participants practices — for example, the ICU [intensive care unit], the ED [emergency department], or as a paramedic," Cheng said.

The difference lies in surrounding environment, type of manikin used, and how many team members participate in the exercise, he explained.

Layperson training should focus on "increasing bystander CPR rates, AED [automatic external defibrillator] use, and activation of emergency medical services," the authors recommend.

They also suggest that, given real-life high-stress scenarios, some (although not excessive) stress should be incorporated into training so that engagement is "not too easy."

In situ education "can be considered as a replacement for classroom- or laboratory-based resuscitation training," and the education should be "configured to account for local resource availability."

"This may all seem like common sense, but sometimes when these courses are delivered, logistical challenges prevent modification or adjustments from occurring," Cheng observed.

Feedback highlights "discrepancies between current understanding or performance and the desired goal, with the aim of closing performance gaps," the authors state.

They suggest moving from a traditional model of "giving feedback" provided by educators to a more active role for participants.

Debriefing traditionally occurs after simulation or real clinical events, but the authors recommend several components to a debriefing.

"Prebriefings" should "establish a supportive learning environment," while debriefing should be tailored to context and include quantitative performance data from several sources, such as instructors, CPR devices, and simulators, available either in real time or during debriefings.

The authors emphasize that feedback and debriefing "should be part of a larger curriculum design and should not occur in isolation."

"If we don't assess learners, how are we — and they — supposed to know how they're doing?" Cheng asked.

Moreover, "robust assessments" should be provided throughout the learning experience, not just at the end in the form of a pass-fail, he said.

Assessments use a variety of tools to measure competency throughout the course and might include written and performance models, with data informing the assessment coming from direct observation, retrospective review, or devices.

Innovative Educational Strategies

New digital platforms provide multiple benefits compared to more traditional sources of information, such as textbooks, Cheng pointed out.

Gamified learning, blogs, podcasts, social media, and crowdsourcing all can be used to make promising improvements in learning and assist in retention.

The authors emphasize that content of these platforms should be "developed by content experts and potentially vetted by trusted organizations." Moreover, leading organizations should "support the timely and accurate development of blogs and podcasts."

"We need to provide instructors, not only initially but on an ongoing basis, with the knowledge and skills necessary to ensure that they are successful in training learners," Cheng commented.

"This means encouraging them to reflect on how they are performing, encouraging them to have coaches, and developing community as a practice to encourage them to share information and identify areas where they can improve their instructional skills," he explained.

"How can we apply evidence-based knowledge in a real clinical environment when there is a patient in front of us with cardiac arrest in the most effective and efficient way possible?" Cheng asked.

To answer this question, the authors recommend combining passive knowledge translation techniques with active techniques and using change theory when introducing new guidelines.

Additionally, factors such as ergonomics and physical space should be taken into account in planning implementation, and organizations should participate in a performance measurement program that features benchmarks, feedback, public reporting, and collaboration and data sharing.

Continuous quality improvement is emphasized as an important component, and "de-adoption" strategies should be put into place to rapidly stop use of therapies that are no longer scientifically supported.


Commenting on the statement for Medscape Medical News, Mary Ann McNeil, MA, NRP, program director, Department of Emergency Medicine, University of Minnesota, Minneapolis, who was not involved in authoring the statement, said she is "thrilled."

She called the statement a "total game-changer for medical education in general, not only for resuscitation education."

Mastery of CPR involves more than "getting the initial skill down" because "getting the muscle memory and periodically bringing folks back to train is essential," she emphasized.

Cheng added, "providing benchmarks and feedback to front-line performance, assessing, and making changes for improvement will enable people who performed well in the learning environment to translate their skills into real life, which involves high stress, high stakes, and complex, dynamic situations."

The statement was funded by the AHA. Cheng discloses no conflicts of interest. The other authors' disclosures are listed on the original paper. McNeil reviewed some of the literature that was subsequently used by the committee.

Circulation. Published online June 21, 2018. Abstract

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