Why Trained Workplace Responders Need Regular Practice

Many EMS professionals complete skill refreshers every 90 days to keep their skills current. A hands-on skill session every 90 days is ideal for workplace lay responders.

• By John Jerin
• Nov 01, 2012

Do your AED and CPR-trained employees regularly practice their resuscitation skills? If not, they may not be prepared for an actual emergency. Federal guidelines recommend workplace AED responders engage in periodic "scenario" practice sessions to maintain their skills and rehearse protocols.¹ In addition, researchers have found practicing just once every two years during recertification is not enough to keep skills up to date.

CPR Skills Deteriorate Quickly
Cardiopulmonary resuscitation (CPR) together with using an automated external defibrillator is a complex procedure. It involves more than two dozen steps and at least a dozen different skills (see below), including recognition of clinical signs. Although using an AED by itself is fairly easy, it becomes much more complicated when combined with CPR.

A body of scientific research shows AED/CPR skills deteriorate quickly after initial training -- in as little as three months in some cases.^2-9 Studies that use a high standard for skill competence show skills degrade within weeks after initial training. Therefore, CPR/AED skills are a use it or lose it proposition. This is particularly true for trained lay responders who respond infrequently to workplace emergencies.

AED/CPR Skills

• Determine unconsciousness
• Recognize breathlessness
• Recognize agonal respirations
• Perform chest compressions
• Open an airway (head tilt-chin lift)
• Apply and use a protective facemask
• Deliver a rescue breath
• Recognize an effective rescue breath
• Deliver proper breath volume
• Determine the CPR compression site
• Apply electrode pads
• Troubleshoot electrode placement

The American Heart Association (AHA), the organization that sets national CPR and AED standards, recently reaffirmed that frequent retraining is "a critical factor in improving the effectiveness of resuscitation."

CPR is Important in Survival of Cardiac Arrest
For the past several decades the emphasis for treatment of sudden cardiac arrest has been on defibrillation and the use of an AED. Attention now is returning to CPR and chest compressions, in particular. It is known that defibrillation and CPR are important therapies in reviving a victim of cardiac arrest, but new evidence points to the importance of the quality of CPR.

Researchers in the field of resuscitation recently found "high-quality" CPR improves defibrillatory shock success and boosts survival rates.¹⁰ In order to perform high-quality CPR, rescuers must: compress the chest at a rate of at least 100 times per minute, allow full chest recoil when doing compressions, minimize interruptions of chest compressions, and avoid excessing force in rescue breaths.

Chest compressions provide temporary blood flow to the brain and heart. Even minor delays or interruptions to chest compressions are correlated with poor outcomes for victims of sudden cardiac arrest. If you stop chest compressions for only a short time, the coronary perfusion pressure (CPP) goes down considerably. It then takes another minute of chest compressions to build up enough CPP to start circulating blood effectively again. Thanks to this new understanding, we know the combination of high-quality CPR and defibrillation provides the best chances for survival.

How Often Should You Practice?
For a long time it has been known that regular practice of a skill will improve performance, but how often should you practice AED/CPR skills? Most people wait for two years to practice, when they renew their CPR cards. The American Heart Association now believes retraining once every two years is not enough and that "skill performance should be assessed during the two-year certification with reinforcement provided as needed."

Many EMS professionals complete skill refreshers every 90 days to keep their skills current. A hands-on skill session every 90 days is ideal for workplace lay responders. However, some employers would be hard-pressed to provide instructor-led, hands-on practice every 90 days. In these situations, you might consider alternatives like an online AED/CPR skill refresher or simulator.

The maximum time between practice sessions should be no more than six months.⁵ However, you should take into account past experience and background of the individual when selecting a refresher interval.

Does Online Practice Work?
Online AED/CPR simulators are inexpensive and can be accessed conveniently through the Internet. Several studies suggest they are equivalent to hands-on practice after initial training once AED/CPR skills have been acquired.^11-12 Any online skill refresher should be highly interactive and require users to rehearse AED/CPR procedures in a variety of scenarios.

Conclusion
Because AED/CPR skills are complex, they are a use-it-or-lose-it proposition. Retention studies show skills decline rapidly over a few months. Make sure your responders are confident and competent by giving them the opportunity to practice their AED/CPR skills every three months, either in an instructor-led practice session or with an online AED/CPR simulator.

References
1. U.S. Department of Health and Human Services - Federal Occupational Health. Public Access Defibrillation Guidelines. Federal Register: May 23, 2001 (Volume 66, Number 100). Page 28495-28511. Retrieved July 1, 2012 from http://www.foh.dhhs.gov/Whatwedo/AED/HHSAED.ASP
2. Morgan CL, Donnelly PD, Lester CA, Assar DH. Effectiveness of the BBC's 999 training roadshows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. BMJ. 1996 Oct 12;313(7062):912-6.
3. Donnelly P, Assar D, Lester C. A comparison of manikin CPR performance by lay persons trained in three variations of basic life support guidelines. Resuscitation. 2000 Aug 1;45(3):195-9.
4. Dracup K, Doering LV, Moser DK, Evangelista L. Retention and use of cardiopulmonary resuscitation skills in parents of infants at risk for cardiopulmonary arrest. Pediatric Nurs. 1998;24:219-25.
5. Weaver FJ, Ramirez AG, Dorfman SB, Raizner AE. Trainees' retention of cardiopulmonary resuscitation: how quickly they forget. JAMA 1979;241:901-3.
6. Mahony PH, Griffiths RF, Larsen P, Powell D. Retention of knowledge and skills in first aid and resuscitation by airline cabin crew. Resuscitation. 2008 Mar;76(3):413-8.
7. Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: a randomised controlled trial. Resuscitation. 2006 Nov;71(2):237-47.
8. Chamberlain D, Smith A, Woollard M, Colquhoun M, Handley AJ, Leaves S, Kern KB. Trials of teaching methods in basic life support (3): comparison of simulated CPR performance after first training and at 6 months, with a note on the value of re-training. Resuscitation. 2002 May;53(2):179-87.
9. Berden HJ, Bierens JJ, Willems FF, Hendrick JM, Pijls NH, Knape JT. Resuscitation skills of lay public after recent training. Ann Emerg Med. 1994 May;23(5):1003-8.
10. Vaillancourt C, Everson-Stewart S, Christenson J, Andrusiek D, Powell J, Nichol G, Cheskes S, Aufderheide TP, Berg R, Stiell IG. The Impact of Increased Chest Compression Fraction on Return of Spontaneous Circulation for Out-of-Hospital Cardiac Arrest Patients not in Ventricular Fibrillation. Resuscitation. 2011 Dec;82(12):1501-1507.
11. Jerin JM, Ansell BA, Larsen MP, Cummins RO. Automated external defibrillators: skill maintenance using computer-assisted learning. Academic Emergency Medicine. 1998 Jul;5(7):709-17.
12. Bonnetain E, Boucheix JM, Hamet M, Freysz M. Benefits of computer screen-based simulation in learning cardiac arrest procedures. Med Educ. 2010 Jul;44(7):716-22.

This article originally appeared in the November 2012 issue of Occupational Health & Safety.