Simulation and education“Rolling Refreshers”: A novel approach to maintain CPR psychomotor skill competence☆
Introduction
Cardiopulmonary resuscitation (CPR) guidelines1 recommend target values for selected CPR parameters related to rate, depth and release of chest compressions and ventilations, and avoidance of CPR-free intervals. Recent studies on adult patients however show that rescuers adherence to these guidelines is often inconsistent. Out of hospital, chest compressions are not delivered more than half of the time and compressions are too shallow.2 Additionally, the quality of in-hospital delivered CPR for adult patients is inconsistent and often does not meet guidelines even when performed by well-trained staff.3 Numerous studies have demonstrated that when high quality CPR is provided to adults, specifically adequate chest compression rate and depth, controlled ventilation, and limited CPR-free intervals, resuscitation outcome is improved.4, 5, 6, 7, 8, 9, 10, 11
Healthcare providers are required to maintain BLS certifications in an effort to preserve good CPR skills. Yet CPR classes are traditionally taught in an instructor-led classroom-based manner with emphasis on the cognitive aspects of CPR rather than the actual psychomotor skills of delivering a chest compression or rescue breath.12, 13, 14 No study has demonstrated that didactic instruction regarding CPR theory will improve CPR quality.15 Proficiency performing CPR psychomotor skills is variable after traditional BLS education, but overall poor. Retention of CPR skills is problematic with poor performance 3–6 months posttraining.16, 17, 18 Inadequate time to practice skills on a manikin has been implicated as a specific cause of poor skill acquisition.18
Recent modifications of defibrillator technology using a force sensor and accelerometer (Philips MRx/Q-CPR) can provide real-time audiovisual feedback on the rate, depth, and quality of chest compressions (CC) during CPR. To implement these new monitor–defibrillators and in an attempt to “train to excellence”, we instituted a novel program of frequent bedside refresher psychomotor training (“Rolling Refreshers”). We hypothesized that frequent “just-in-time” and “just-in-place” training (defined as a training session conducted directly prior to a potential intervention and at/near the site of the potential intervention) would be effective and well-accepted to maintain high quality CPR skills among bedside Pediatric ICU healthcare first responders.
Section snippets
Study design
This prospective, observational study was approved by the Institutional Review Board at the Children's Hospital of Philadelphia in the 45 bed tertiary care Pediatric ICU (PICU). Data collection procedures were completed in compliance with the guidelines of the Health Insurance and Portability and Accountability Act to ensure subject confidentiality. Written informed consent was waived since all data collected were de-identified.
Equipment and training
A commercial monitor/defibrillator system (Heartstart MRx/Q-CPR,
Results
Over the course of 15 weeks, 420 “Refresher” sessions were conducted in the PICU. Refreshers were completed by nurses 340 times, physicians 34 times, and respiratory therapists 46 times. All were previously trained and certified in basic life support according to the AHA standards according to hospital policy. Individual participation frequency ranged from 0 to 15 refresher sessions.
A consecutive sample of 20 PICU staff was assessed over the course of one day before subsequent refresher
Discussion
Our study demonstrates that a ‘just-in-time’ and ‘just-in-place’ educational program aimed at optimizing psychomotor skill performance during CPR is feasible and was well-accepted by participants. Our data also suggest that healthcare providers who underwent these sessions more frequently displayed better skill performance during subsequent assessments, as measured by our set of prospective criteria for manikin skill success.
Our novel sessions were brief (<5 min), focused entirely on the
Limitations
There are several limitations to this study. A small, consecutive sample was used to confirm the effectiveness of frequent refresher training in the provider's competence in CPR. We attempted to analyze the actual clinical performance of the trained staff; however, the resuscitation events were infrequent to achieve this purpose. This was originally designed as a quality improvement check, and should be confirmed in a larger, randomized study sample across multiple units. Also, the psychomotor
Conclusions
A novel “Rolling Refresher” bedside CPR skill training approach using “just-in-time” and “just-in-place” education is effective and well received by PICU staff despite bedside responsibilities and time constraints. Participation in ≥2 refreshers/month resulted in significantly shorter duration to achieve proficient CPR skills on manikins. Bedside providers delivering CPR during actual cardiac arrests rated the Rolling Refresher method as highly effective. CPR performance during actual cardiac
Conflicts of interest
The authors acknowledge the following potential conflicts of interest. Dana Niles, Vinay Nadkarni and Robert Sutton receive grant support from the Laerdal Foundation for Acute Care Medicine. Vinay Nadkarni receives unrestricted grant funding from NIH and Medical Education Technologies, Inc.
Acknowledgments
Funding provided by Laerdal Foundation for Acute Care Medicine and the Endowed Chair of Critical Care Medicine at the Children's Hospital of Philadelphia. We wish to thank Stephanie Tuttle MBA, Jamie Sklar RN, BSN, MS, Larissa Hutchins RN, MSN, CCRN, Kellyann Papianou RN, BSN, Robert A. Berg MD, Benjamin S. Abella, MD and the multidisciplinary team of the Pediatric Intensive Care Unit and Emergency Department at Children's Hospital of Philadelphia for their support and contributions to this
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.04.021.