• Research Studies Conclude that Traditional Instructor Led Classroom Training for CPR and AED is Inadequate.

Traditional Training Fails to Provide Learners with Competence in CPR and AED

Leading emergency training educators from Harvard University concluded that traditional training classes, designed by the AHA and ARC, failed to provide learners with competence in CPR and AED. Braslow A, Brennan RT. Skill mastery in public CPR classes. Am J Emerg Med 1998;16: 653-657

Study Design: 226 trainees were enrolled in 30 CPR classes open to the public. The research evaluators were ARC and AHA instructors who were not involved in teaching the courses in the study. The measurement instruments were a 14- item CPR skills checklist, a 5- point CPR competency rating, and a recording manikin that assessed compressions and ventilations.

Results: Fifty percent of students performed 2% or fewer compressions correctly (most common error was insufficient depth), and 50% performed 10% or fewer of ventilations correctly (most common error was insufficient volume). Sixty-five percent failed to achieve a compression rate of 80-100/minute. Forty-five percent of the subjects failed to open the airway prior to a breathing check, 50% failed to adequately assess breathing, and 53% did not perform an adequate pulse check. Nearly half of all subjects made at least 4 errors in assessment and sequencing of skills.

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• Research Confirms that Multimedia and Blended CPR and AED Training is Superior to Traditional Training.

Trainees who Completed Multimedia Self-Instruction CPR Program Outperformed their Traditional Training Counterparts

Education researchers from Harvard University confirmed that multimedia training was superior to traditional AHA classroom training. Todd KH, Braslow A, Brennan RT, et al: Randomized, controlled trial of video self-instruction versus traditional CPR training. Ann Emerg Med March 1998; 31:364-369

Study Design: 87 Trainees were randomly assigned to either view a 34-minute video or were provided a traditional AHA Heartsaver CPR course. Skill acquisition was measured by blinded observers. The primary measurement instrument was a global competency assessment of the actual performance of CPR skills, rated on a scale of 1-5 (1, not competent to 5, outstanding). Secondary measures of outcome were performance of (14) skill components of CPR, quality of compressions and ventilations (measured by an instrumented manikin), and CPR-related cognitive knowledge (derived from AHA tests) and attitudes about performing CPR.

Results: Students trained by video self-instruction scored a median of 3 (competent) versus a median score of 2 (questionable competence) attained by the traditionally trained group. Forty-three percent of the traditional trainees were judged not competent in performing CPR, compared with only 19% of the video trained students. In 11 of the 14 individual skills, Video trained students performed comparably or better than the traditional trainees. For two of the skills, opening the airway after the first set of compressions and between subsequent sets, video trained students displayed markedly superior performance.

Multimedia CPR and AED Training was Superior to Traditional AHA Classroom Training for Adult Church Congregants

Emergency researchers concluded that video self instruction of a church congregation was superior to traditional classroom training provided by the AHA. Todd KH, Heron SL, Thompson M, et al: Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation in an African American church congregation. Ann Emerg Med Dec 1999;34:6:730-737

Study Design: 177 congregants participated in a randomized, controlled trial of video self-instructional cardiopulmonary resuscitation. Congregants were randomly assigned to receive either video instruction or an AHA Heartsaver course. Two months after training, blinded evaluators assessed skills in a simulated cardiac arrest setting.

Results: Video trained congregants demonstrated similar competency to the traditional trainees in global performance of CPR, as both groups achieved a median rating of 2 however, the mean score was 2.3 for the video group and 1.9 for the traditional trainees. Additionally, 40% of the video trainees were judged competent or better in performing CPR, compared with only 16% of the traditional trainees.

Multimedia Self Instruction Program for CPR is as Effective as a Traditional AHA Instructor Led Training Class in Adults Likely to Witness a Cardiac Arrest

Researchers from the University of Chicago and the University of Washington confirmed that a 30 minute multimedia CPR training program is more effective at training adults between 40 and 70 years of age than the traditional 4-hour instructor led classroom training. Lynch B, Einspruch E, Nichol G, Becker LB, et al. Effectiveness of a 30 min. CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation. October 2005;67 (1):31-43.

Study Design: Researchers conducted a randomized controlled study evaluating the effectiveness of 1) a 30 min. DVD self-instruction program and manikin vs. 2) a traditional 4 hour American Heart Association, instructor-led, CPR training class in adults between the age of 40 and 70, those most likely to witness a cardiac arrest.

Results: The researchers determined that the CPR performance data showed a clear pattern of evidence in favor of utilizing the 30 minute DVD. The authors concluded that the shorter, self-paced multi-media CPR training program offers potential learners logistical convenience, a comfortable learning environment, and time efficiency without compromising acquisition of CPR skills.

An Interactive Multimedia CPR and AED Computer Based Training Program was Sufficient to Teach CPR and AED Knowledge and AED Actions to High School Students

Researchers from the University of Washington concluded that High School students who completed an interactive multimedia CPR and AED computer based program were competent to perform CPR and operate an AED. Reder S., Cummings P. Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students. Resuscitation. Jun 2006;69(3):443-53.

Study Design: Researchers in Seattle provided CPR and AED training to high school students using 3 instructional interventions and a control group. The 3 instructional groups were 1. Computer-based training alone (45 min.) 2. Computer-based training (45 min.) with instructor-led hands on practice (45 min.) and 3. DVD-based training (45 min.) with instructor-led hands on practice (45 min.) No option exceeded 90 minutes total instruction time.

Results: All trainees who received training performed significantly better than those who did not receive any training. The authors observed that all 3 instructional options resulted in approximately equal performance when evaluated immediately after training, with some advantage to those options that included hands-on training in addition. The initially observed advantage conferred by hands on practice was significantly reduced when trainees were evaluated 2 months after the initial training. The authors concluded that interactive computer-based self-instruction alone was sufficient to teach CPR and AED knowledge and AED actions to high school students.

Computer Based Multimedia Programs Maintained a Competent AED Skill Level in Experienced EMTs

Researcher from King County Seattle concluded that multimedia computer based training was a satisfactory solution to maintain AED skill competence in EMT Firefighters. Jerin JM, Ansell BA, Larsen MP, Cummins RO. Automated external defibrillators: skill maintenance using computer-assisted learning. King county EMS Division, Acad EMerg Med. 1998 Jul;5(7):709-17.

Study Design: EMT-Ds in King County, Seattle were studied to determine whether computer assisted training could effectively be utilized to learn and maintain AED skills. The trainees were experienced EMT-Ds already trained in automated defibrillation and employed as full-time professional EMT-D firefighters. Pre-and post study skill levels were measured using a skills performance test.

Results: There were no differences between training groups in performance test scores. The authors established that computer assisted multi-media training satisfactorily maintained the AED skill level for experienced EMT-Ds with significant cost and convenience advantages over instructor-based skill maintenance and was therefore an acceptable alternative.

The European Resuscitation Council Advocates Multimedia CPR Training

Researchers from the European Union concluded that multimedia trained CPR trainees outperformed their instructor led counterparts and were equally willing to initiate CPR. Baskett PJ, Nolan JP, Handley A, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 9. Principles of training in resuscitation. Resuscitation. 2005;(Suppl 1):181-89. Ann Britt Thoren, Asa B. Axelsson, Johan Herlitz. DVD-based or instructor-led CPR education-A comparison. Institute of Medicine Goteborg, Sweden. Resuscitation. 2007 Feb;72(2):333-4.

Study Design: The European Resuscitation Council (ERC) advocates home-based learning with the use of video or interactive CD as a method for enhancing CPR training. In a pilot study, researchers investigated the quality of CPR as a function of the number of approved chest compressions administered during a two minute cycle of CPR. The groups evaluated performance following an instructor-led class vs. following a DVD-based course.

Results: Trainees who attended the DVD-based course administered a number of compressions (median 119) more closely approximating the optimal number (120) of compressions required within 2 minutes than did the instructor-led group (median 138). It was postulated that DVD trained responders may be less willing to initiate CPR in event of an emergency. However, participant responses to 3 mock cardiac arrest scenarios indicated that both groups of trainees were equally willing to initiate CPR. The authors conclude that DVD-based CPR courses offer a good alternative to instructor-led courses or are perhaps even better.

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• Frequent Refresher Training is Required to Competently Perform CPR and Operate an AED.

Annual Refresher Training for CPR is Inadequate to Preserve Skill Competence

Emergency physicians concluded that CPR refresher training is required to preserve skill competence. Wilson E, Brooks B, Tweed WA. CPR skills retention of lay basic rescuers. Ann Emerg Med Aug 1983;12:8:482-484

Study Design: 950 telephone company personnel were trained in an 8 hour CPR class and tested on instrumented manikins. A random group of 40 was retested at approximately 1 year after the initial training.

Results: All subjects were able to perform adequate CPR immediately after the initial training. Only 40% were able to perform these skills adequately when retested approximately 1 year after initial training.

Refresher Training for CPR is Required More Often than every 6 Months to Maintain Competence

Researchers from Great Britain demonstrate the necessity of frequent refresher training. C.L. Morgan, P.D. Donnelly, C.A. Lester, D. H. Assar. Effectiveness of the BBC's 999 training road shows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. British Medical Journal 1996 313: : 912-6.

Study Design: 280 unforewarned participants in the BBC CPR Training Road Show, were contacted at home six months after traditional CPR training. The research design required investigators to cold call a sample of trainees in their homes six months after training. The subjects were instructed to read a hypothetical scenario and perform CPR on an instrumented manikin, and the European Resuscitation Council's guidelines provided test criteria.

Results: 6 months after initial training, 87% performed CPR ineffectively. 45% of the errors were classified as potentially injurious.

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• Abbreviated CPR and AED Training is Effective.

8th Grade Students Become Proficient at CPR and Use of an AED Utilizing a 1-Hour Curriculum

Mayo Clinic researchers demonstrated that middle school students can learn and retain CPR and AED knowledge and skills utilizing a 1-hour curriculum. Kelly J, Richman PB, Ewy GA, et al. Eighth grade students become proficient at CPR and use of an AED following a condensed training programme. Mayo Clinic Arizona, Department of Emergency Medicine Resuscitation. 2006 Nov;71 (2):229-36.

Study Design: In Phoenix, Arizona, 33 8th grade public school students completed a 1-hour condensed training program to learn continuous chest compression CPR and AED skills.

Results: 88% of students demonstrate proficiency in a mock adult cardiac arrest scenario. At 4 weeks, 85% of students demonstrated skill retention and similar scenario testing. 8th grade students demonstrated adequate proficiency in performing AED and CPR in a mock cardiac arrest scenario after completing a 1 hour condensed training program.

A 24 Minute Multimedia CPR Training Program is as Effective as a 6 Hour BLS Program for Initial Training

Researchers from the European Union compared a 24 minute multimedia training program to a traditional to a 6 hour BLS course and concluded that the multimedia training program was equally effective and much shorter, hence more efficient. Isbye D, Rasmussen LS, Lippert FK, et. al. Laypersons may learn basic life support in 24 min. using a personal resuscitation manikin. Resuscitation. 2006;69(3)435-442.

Study Design: In a study conducted on 238 adult trainees (age 21 to 55)in Copenhagen Denmark, researchers compared a 24 minute self- instructional DVD combined with a take-home resuscitation manikin to a conventional 6 hour course for teaching BLS to laypersons. The skills of the participants were evaluated 3 months after training.

Results: Trainees were assessed on a recording manikin and a total score was calculated. There was no significant difference between groups in BLS performance The authors concluded that DVD-based self instruction was equally effective to a 6 hour instructor-led BLS course and is therefore more efficient.

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• Education Research Confirms the Superiority of Multi-Sensorial Blended Training.

Social science research supports the shift from the traditional classroom environment to a learning environment that includes visual presentation of information, via pictures or videos. Studies show that learning and retention are significantly better if information is communicated visually, in addition to verbally. ^{1 2} In fact, some studies confirm that if information is presented through multiple "channels" - auditory, written, and visual - understanding and memory are substantially improved.³ It has been suggested by educational research data that the learning process itself is realized through the interaction between visual, actional, and linguistic communication (i.e. learning is multimodal) and involves the transformation of information across different communicative systems (modes), e.g. from speech to image.¹ Studies also show that a learning environment that affords the learner choice of modalities and control over the sequence and tempo at which they are processed, is an optimal learning environment. ³ This environment takes into account different learning preferences and styles, and varying needs to accomplish memorization of facts and sequences of information. The neurophysiology of memory supports the multimodal approach to learning, and the common practice of repetition to enhance memory.⁴ An independent multimodal learning environment such as online training affords the learner all of the above.

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• Online and Blended Training: Widely Utilized In Health Care Professional Training.

Numerous studies document the effective utilization of online and blended training to educate all levels of health care professionals such as EMTs, ^{5 6} paramedics,⁷ nurses,^{8 9 10} medical and dental students.^{11 12 13} Online and blended training have been utilized in initial training to deliver course content as well as in continuing education to review and maintain essential skills.

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• Online and Blended training: Successfully Utilized For CPR and AED Training.

Specifically, online and blended training have been utilized to provide CPR and AED training to healthcare professionals, as well as non healthcare professionals, with ages ranging from middle school and high school students through Medicare eligible adults. Most studies evaluating online and blended training have concluded that online and blended training result in trainee performance equal to or better than traditional 4-6 hour instructor-led classes.

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• Effectiveness of a Thirty Minute Self Instruction Program.

Researchers from the University of Washington conducted a randomized controlled study evaluating the effectiveness of 1) a 30 min. DVD self-instruction program and manikin vs. 2) a traditional 4 hour American Heart Association, instructor-led, CPR training class.¹⁴ The researchers determined that the CPR performance data showed a clear pattern of evidence in favor of utilizing the 30 minute DVD. The authors concluded that the shorter, self-paced multi-media CPR training program offers potential learners logistical convenience, a comfortable learning environment, and time efficiency without compromising acquisition of CPR skills.¹³

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• Comparison of Three Instructional Methods for Teaching CPR and AED to High School Students.

Researchers in Seattle provided CPR and AED training to high school students using 3 instructional interventions and a control group. The 3 instructional groups were

1. Computer-based training alone (45 min.)
2. Computer-based training (45 min.) with instructor-led hands on practice (45 min.)
3. DVD-based training (45 min.) with instructor-led hands on practice (45 min.) No option exceeded 90 minutes total instruction time.
All trainees who received training performed significantly better than those who did not receive any training. The authors observed that all 3 instructional options resulted in approximately equal performance when evaluated immediately after training, with some advantage to those options that included hands-on training in addition. The initially observed advantage conferred by hands on practice was significantly reduced when trainees were evaluated 2 months after the initial training. The authors concluded that interactive computer-based self-instruction alone was sufficient to teach CPR and AED knowledge and AED actions to high school students.¹⁶
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• AED Skill Maintenance Via Computer Assisted Learning.

EMT-Ds in King County, Seattle were studied to determine whether computer assisted training could effectively be utilized to learn and maintain AED skills. The trainees were experienced EMT-Ds already trained in automated defibrillation and employed as full-time professional EMT-D firefighters. Pre-and post study skill levels were measured using a skills performance test. There were no differences between training groups in performance test scores. The authors established that computer assisted multi-media training satisfactorily maintained the AED skill level for experienced EMT-Ds with significant cost and convenience advantages over instructor-based skill maintenance and was therefore an acceptable alternative.¹⁷

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• A Comparison of Instructor Led CPR Versus Multimedia Training.

The European Resuscitation Council (ERC) advocates home-based learning with the use of video or interactive CD as a method for enhancing CPR training.¹³ In a pilot study, researchers investigated the quality of CPR as a function of the number of approved chest compressions administered during a two minute cycle of CPR. The groups evaluated performance following an instructor-led class vs. following a DVD-based course. Trainees who attended the DVD-based course administered a number of compressions (median 119) more closely approximating the optimal number (120) of compressions required within 2 minutes than did the instructor-led group (median 138). It was postulated that DVD trained responders may be less willing to initiate CPR in event of an emergency. However, participant responses to 3 mock cardiac arrest scenarios indicated that both groups of trainees were equally willing to initiate CPR. The authors conclude that DVD-based CPR courses offer a good alternative to instructor-led courses or are perhaps even better.¹⁹

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• Blended CPR and AED Training Courses Yield Comparable Results.

Several studies have evaluated whether reducing the time associated with CPR and AED training can be accomplished without loss of skill acquisition and retention.

In Phoenix, Arizona, 8th grade students demonstrated equal proficiency in performing AED and CPR in a mock cardiac arrest scenario after completing a 1 hour condensed training program.²⁰

In a study conducted on adult trainees, researchers compared a 24 minute self- instructional DVD combined with a take-home resuscitation manikin to a conventional 6 hour course for teaching BLS to laypersons. The skills of the participants were evaluated 3 months after training. The authors found no significant difference in performance between the two groups and concluded that DVD-based self instruction was equally effective to a 6 hour instructor-led BLS course and is therefore more efficient.²¹

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• Emergency University's "Integrated Training" Combines the Best of Both Worlds to Maximize the Learning Potential of All Adult Learners.

  Emergency rescue theory and skills can be effectively taught through an innovative "integrated training" approach that combines on-line training modules that teach the cognitive portion of the training with instructor led hands-on skills classes to build confidence.

  Integrating on-line multi-media training with instructor led skills classes brings together the best of both worlds. Not only is this approach more cost effective, in most cases significantly decreasing necessary classroom time, but it is also educationally sound. Multiple studies confirm that the optimal learning environment affords the learner a choice of modalities and control over the sequence and pace of learning.

  On-line training creates an interactive multi-media learning environment that affords a consistent quality of instruction. It allows the student to learn at his or her own speed in a non-intimidating environment. The unlimited availability of training permits employees and employers greater access and flexibility in their training schedules. It permits repetition and thus greater retention.

  Training in emergency skills differs from training in non-emergency subjects. Individuals responding to an emergency are under significant stress, and unless their skills are performed frequently, they are likely to remember only a few principles. On-line training permits the use of animation, which creates a visual image that reminds a student as to why he or she is performing the required skill. If the student can visualize and understand why he or she is performing that skill, that student is more likely to remember the required skill.

  Instructors are essential to the emergency care training process, bringing experience, expertise and the human element to the student. Students benefit from the personal interaction with their instructors, having the opportunity to ask questions, and the ability to receive constructive feedback on their skill performance. When students are properly prepared, instructor classroom time can be devoted to addressing specific skills and answering student questions.

  One of the most challenging aspects of any corporate training program is administration. Companies are required to demonstrate compliance with company regulations, as well as OSHA, state and federal regulations. Emergency University's on-line training programs are supported by a state-of-the-art learning management system that simultaneously tracks students' training and testing results, generates reports demonstrating compliance, and sends automatic e-mails when refresher or re-certification training is due.

  EU's "Integrated training" delivers the critical components corporations and individuals require in these challenging economic times; satisfying regulatory compliance and reducing training costs while maintaining high-quality training that results in improved clinical outcomes.
  

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• Research shows 20-minute CPR class works

  Too busy to take a four-hour CPR course? New research shows the lifesaving procedure can be effectively taught in a little more than 20 minutes.
  The finding, presented Sunday at an American Heart Association meeting in Dallas, could broadly expand the number of Americans who can perform CPR.

  "It's brilliant," said Dr. Lance Becker, director of the Emergency Resuscitation Center at the University of Chicago. "I think it's going to make our ability to train people much, much easier."

  The study, led by Dr. Ahamed Idris, professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas, found that just five minutes of training on defibrillator use and 20 minutes of instruction in CPR was as effective as the standard four-hour course.

  Idris said it makes sense that the shorter course was just as memorable: "The more you have to remember, the more likely you are to forget," he said.

  The study used American Airlines employees and compared standard training to a short course taught by DVD. Participants were tested by performing cardiopulmonary resuscitation on a computerized mannequin that took data on chest compression and ventilation. Their performance was also reviewed and graded by instructors.

  The 150 people who took the short course did as well or better than the 118 who received standard training. More importantly, retention rates of knowledge remained similar six months later.

  People suffering cardiac arrest can die in minutes unless they get effective CPR and sometimes a shock to the heart from a defibrillator, which restores a normal heart rhythm.

  Defibrillators are becoming more common in schools, airports and other public places, but the key is having people nearby who are trained to use them.

  Having a short course should help meet the heart association's goal to double in the next five years the number of Americans trained annually in cardiopulmonary resuscitation — currently about 8 million. The time commitment for a four-hour course seemed to be a stumbling block in getting people trained, officials said.

  "It's very difficult for a company to release their employees for four hours to take a CPR course," Idris said.

  The study was funded by Laerdal Medical, maker of the training DVD, the heart association, and device maker Philips Medical.

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• Research Supports Need for On-Line Training in CPR

  Social science research supports the shift from purely aural and written to an environment that includes visual presentation of information, via pictures or videos. Studies show that learning and retention are significantly better if information is communicated visually, in addition to verbally (1,2). In fact, some studies confirm that if information is presented through multiple "channels" - aural, written, and visual - understanding and memory are substantially improved (3). It has been suggested by educational research data that the learning process itself is realized through the interaction between visual, actional, and linguistic communication (i.e. learning is multimodal) and involves the transformation of information across different communicative systems (modes), e.g. from speech to image (1). Studies also show that a learning environment that affords the learner choice of modalities and control over the sequence and tempo at which they are processed, is an optimal learning environment (3). This environment takes into account different learning preferences and styles, and varying needs to accomplish memorization of facts and sequences of information. The neurophysiology of memory supports the multimodal approach to learning, and the common practice of repetition to enhance memory (4). An independent multimodal learning environment such as on-line training affords the learner all of the above.

  The above findings can be applied to the field of CPR instruction. While tradition has dictated that Cardiopulmonary Resuscitation (CPR) skills be taught in a 4-6 hour classroom format with an instructor present, little evaluative work has been performed on this training method. The small number of studies that have been performed to measure effectiveness of the large scale programs authorized by the American Heart Association (AHA) and the American Red Cross (ARC) have raised concerns about the effectiveness of this traditional training format, in the areas of skill acquisition and skill retention.

  Successful skill mastery in traditional "hands on" CPR classes designed by the ARC and the AHA was studied by two emergency care professionals in 1998 (5). Half of the subjects performed 2% or fewer compressions correctly and half performed 10% or fewer of ventilations correctly. Additionally, 65% failed to achieve a compression rate of 80-100/minute. The results are unsettling, and point to the need for training method improvement through the application of current learning theories.

  Two related studies were conducted by a group of reputable scientists in the Division of Emergency Medicine at Emory University School of Medicine in Atlanta, Georgia. The studies were designed to test the hypothesis that video instruction is comparable in training outcome (skill acquisition) to traditional classroom CPR instruction. The two pieces of research, very similar in design, were performed on different subject groups; incoming freshman medical students (6) and church attendees (7). The same conclusion was reached: a 34 minute video instruction was at least if not more than effective in training outcome than a 4-6 hour American Heart Association class led by a certified instructor.
  
  It can be concluded that well designed video instruction (or an equivalent on-line training) provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may make CPR instruction available to greater populations.

  Studies have also been conducted to study the important issue of skill retention. One study on retention found maximum skill deterioration occurred within the first year, yet trainees re-tested at 13-14 months did not perform better than those re-tested later (8). The study suggests that review optimally would be made available well within the first year after initial training.

  Another study was conducted to assess duration and quality of CPR skill retention in trainees at the BBC (9). Eighty-seven percent (243 subjects) performed CPR ineffectively, and, of these, 45% were classified as potentially injurious (9). This study suggests that some form of regular retraining or thorough review is essential as early as 6 months post training in maintaining adequate CPR skills.

  We may infer from the above results that a new model of training is required to improve skill acquisition and retention. This model would include increased effectiveness and accessibility to training via CD-Rom or on-line training programs, and regular review of skills every 3 to 6 months made possible with the easy access nature of these programs. Social science research and current learning theory supports this direction of training. The Emergency University training program brings these research-supported innovations to the field of pre-hospital emergency care training. When these changes are implemented on a large scale, we can expect to see improved skill retention, trainee confidences, and competent performance of critical life saving skills in the area of pre-hospital emergency care.

  Bibliography

  1. Jewitt C, Kress G, Ogborn J, et al (2001): Exploring learning through visual, actional, and linquistic communication: The multimodal environment of a science classroom. Educaitonal Review Vol 53:1:5-18. (This paper explores the "full repertoire of meaning-making resources" available in a classroom. It describes how a group of students transformed a multimodal approach to a science experiment demonstration into their own learning. This paper discusses actional, linguistic, and visual resources, and also discusses the use of analogy as a learning tool. The conclusion of this paper is that "learning can no longer usefully be considered a purely linguistic accomplishment.")
  2. Braslow A, Brennan RT, Newman MM, et al: CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance and cardiopulmonary resuscitation. Resuscitation 1997; 34:207-220. (The first 18 minutes of the 34-minute video teaches ventilation and chest compression techniques. The last 12 minutes of the video describe indications for CPR, initial assessment of cardiac arrest, phoning for emergency help, lowering the victim to the floor to perform CPR, assessment of breath and pulse, clearing the airway of emesis, and recognition of a heart attack in a conscious person. Students are encouraged to practice their CPR skills as the tape runs. They do not receive educational materials to take home.)
  3. Plass J, Chun D, Mayer RE, et al (1998): Supporting visual and verbal learning preferences in a second-language multimedia-learning environment. Journal of Educational Psychology Vol 90:1:25-35. (English speaking college students studying German were tested on new vocabulary encountered in the context of a story read in German. For key words students were given a choice to see a translation in English (i.e. verbal annotation) or view a picture or video clip representing the word (i.e. visual annotation), or both. Students remembered word translation better when they had selected both visual and verbal annotations rather than one; students comprehended the story better when they had the opportunity to receive their preferred mode of annotation.)
  4. Umphred, D.A. (1995). Classification of treatment techniques based on primary input systems: Inherent and contrived feedback loop systems and their potential influence on altering a feed forward motor system. In Umphred, D.A. (Ed.), Neurological Rehabilitation (3rd ed.), (p. 118-178). St. Louis: Mosby. (Learning and memory are complex processes affected by learning preference, modality of the information presented, emotional state of the learner, and attitudes or affective relationship to the material/topic presented. Elements of memory, encoding and retrieval of information can be augmented by a multimodal approach to teaching, as memory traces are pulled then from several cortical areas. The reverberating circuits involved in laying down memory traces are supported and maximized by repetition when learning.)
  5. Braslow A, Brennan RT. Skill mastery in public CPR classes. Am J Emerg Med 1998; 16:653-657. (The subjects numbered 226 and were enrolled in 30 CPR classes open to the public. The evaluators were ARC and AHA instructors who were not involved in teaching the courses in the study. The measurement instruments were a 14- item checklist, a 5- point competency rating, and an instrumented manikin to assess compressions and ventilations. Fifty percent of subjects performed 2% or fewer compressions correctly (most common error was insufficient depth), and 50% performed 10% or fewer ventilations correctly (most common error was insufficient volume). Sixty-five percent failed to achieve a compression rate of 80-100/minute. Forty-five percent of the subjects failed to open the airway prior to a breath check, 50% failed to adequately assess breathing, and 53% did not perform an adequate pulse check (using the carotid check). Nearly half of all subjects made at least 4 errors in assessment and sequencing of skills).
  6. Todd KH, Braslow A, Brennan RT, et al: Randomized, controlled trial of video self instruction versus traditional CPR training. Ann Emerg Med March 1998; 31:364-369. (The total number of subjects was eighty-seven, and the subjects were randomly assigned to one of two groups. The experimental group viewed a 34-minute video in groups of 1 or 2 and received an inexpensive Family Trainer manikin with which to practice while viewing the video. No other training was made available to this group. The control group was given a traditional AHA Heartsaver CPR course. Skill acquisition was measured by blinded observers. The primary measurement instrument was a global competency assessment of the actual performance of CPR skills, rated on an ordinal scale 1-5 (1, not competent to 5, outstanding). Secondary measures of outcome were performance of (14) skill components of CPR, quality of compressions and ventilations (measured by an instrumented manikin), and CPR-related cognitive knowledge (derived from AHA tests) and attitudes about performing CPR. The global performance measurement indicated that the video self-instruction (VSI) group attained a median score of 3 (competent) versus a median score of 2 (questionably competence) attained by the traditionally trained group. Forty-three percent of the traditional trainees were judged not competent in performing CPR, compared with only 19% of the VSI trainees. In 11 of the 14 individual skills, VSI trainees performed comparably or better than the traditional trainees. For two of the skills, opening the airway after the first set of compressions and between subsequent sets, VSI trainees displayed markedly superior performance.)
  7. Todd KH, Heron SL, Thompson M, et al: Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation in an African American church congregation. Ann Emerg Med Dec 1999;34:6:730-737. (One hundred seven subjects completed the research. Subjects were randomly assigned to receive either video instruction or an AHA Heartsaver course. Two months after training, blinded evaluators assessed skills in a simulated cardiac arrest setting. In spite of the much shorter time required for training (34 minutes versus 4 hours), the VSI trainees demonstrated similar competency to the traditional trainees in global performance of CPR, as both groups achieved a median rating o f2 (questionably competent); however, the mean score was 2.3 for the VSI group and 1.9 for the traditional trainees. Additionally, 40% of the VSI trainees were judged competent or better in performing CPR, compared with only 16% of the traditional trainees.)
  8. Wilson E, Brooks B, Tweed WA. CPR skills retention of lay basic rescuers. Ann Emerg Med Aug 1983; 12:8:482-484. (The study was conducted on 950 telephone company personnel who were trained in an 8 hour class and tested on instrumented manikins. A random group of 40 was retested at varying intervals of time after the initial training, with the span of time between 11 and 30 months. While all of the subjects were able to perform at least 3 adequate ventilations and 15 adequate compressions immediately after the initial training, only 40% were able to perform these skills adequately during the retest. Additionally, trainees retested at 13-14 months did not perform better than those tested later.)
  9. C.L. Morgan, P.D. Donnelly, C.A. Lester, D. H. Assar. Effectiveness of the BBC's 999 training road shows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. British Medical Journal 1996 313: : 912-6. P
     Effectiveness of the BBC's 999 training road shows on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. (The research design included cold calling on a sampling of trainees in their homes six months after training. The subjects were instructed to read a hypothetical scenario and perform CPR on an instrumented manikin, and the European Resuscitation Council's guidelines provided test criteria. Eighty-seven percent (243 subjects) performed CPR ineffectively, and, of these, 45% were classified as potentially injurious.)
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• Defibrillators & CPR, Maximizing Skills Retention, Current educational theory supports online CPR training

  by Odelia Braun, M.D. J.D.

  Education and social science research supports the shift from traditional lecture (aural) and text learning environments to one that includes visual representations of information, via pictures or videos. Studies show learning and retention significantly improve if information is communicated visually, as well as verbally. In fact, studies confirm the optimal learning environment affords the learner a choice of modalities and control over the sequence and pace of learning.

  These findings can be applied to the field of CPR instruction. While traditional CPR skills training classes utilize an instructor-led, four- to six-hour classroom format, little evaluative work has been done on this training method. The small number of studies that have been performed have raised concerns about the effectiveness of this approach, both in the areas of skill acquisition and retention. Two studies compare the CPR skill performance of students who completed traditional classroom, instructor-led, adult CPR classes with a self-instruction training program using video and manikins. In both studies, skill acquisition was evaluated by blinded observers. On a global competency scale of 1-5, the self-instruction group attained a median score of 3 (competent), while the traditional trained group attained a median score of 2 (questionably competent). Here, 43 percent of traditional trainees were judged not competent in performing CPR, compared with only 19 percent of self-instructed trainees. A second study performed on a church congregation found similar results.

  The researchers concluded adults performed better CPR after self-instruction than after traditional instruction and that self-instruction has the potential to reach individuals unlikely to participate in community CPR classes, because of its greater convenience and potentially lower cost.

  Research also has been conducted to study the quality and duration of CPR skill retention. One study found maximum skill deterioration occurred within the first year. Another study assessed duration and quality of CPR skill retention in trainees at the BBC. Six months after initial training, 87 percent (243 subjects) performed CPR ineffectively; of these, 45 percent were classified as potentially injurious. These studies suggest refresher training should occur within six months after initial training.

  Thus, well-designed, self-instructional media (including online training) provide a simple, quick, consistent, and inexpensive enhancement to traditional CPR instruction – and it may make CPR instruction available to wider audiences and refresher training more affordable.

  Facilitating Student Learning

  Studies suggest a multimedia, self-paced, online CPR training tool, when combined with instructor-led skills repetition, would improve skill acquisition and retention. Online training permits a consistent quality of instruction. It allows the student to learn at his own speed in a non-intimidating environment. The 365/24/7 availability of training permits employees and employers greater access and flexibility in their training schedules. It permits repetition on a quarterly or semi-annual basis and, thus, greater retention.

  Online training permits students to choose the learning environment in which they are most comfortable. This differs from the classroom style in which the instructor, not the student, chooses the learning methodology employed. Online programs typically incorporate text for the student who prefers to read information; audio for the student who learns by listening; photos for the visual learner; and animations for students who need to understand how things work to learn. In addition, online training programs are often interactive. Students are required to participate in the learning process (active learning, rather than passive learning). Clicking buttons or dragging icons requires the student to focus and engages yet another part of the brain necessary for the primarily "tactile" learner.

  Training modules are purposefully abbreviated to reflect the student's practical attention span for absorption of new material. New material is most efficiently integrated by repetitive presentation from different perspectives, so focused interactive activities are woven in emphasize the important concepts and principles of CPR. A tiered learning approach requires the learner to use increasingly higher orders of integration to solve the problem.

  Emergency University conducted a pilot research study to evaluate the effectiveness of the online training tool. The evaluators were blinded to the training methodology used. Sixty individuals were divided into three groups. The control group received a traditional four-hour, hands-on training class. A second group received the online CPR and AED training programs, followed by a one-hour, hands-on class. The third group received only online training. All groups performed equally with respect to skill acquisition. Students who received instructor-led skills training (irrespective of duration) were more confident.

  These previously unpublished findings suggest that, similar to the previous studies, well designed, self-instructional media can produce performance competence in CPR, but hands-on skill practice contributes to performance confidence. The researchers speculate quarterly online refresher training will contribute to competence and confidence during the period that previous studies have demonstrated a significant deterioration of skills.

  Cost Consideration

  Corporations have embraced Web-based training primarily because it is more cost-effective than conventional classroom training. With budgets tighter than ever, classroom training has become too expensive. Gartner analysts project the global market for e-learning will grow from $2.1 billion in 2001 to $33.6 billion in 2005, a 100 percent compound annual growth rate. IDC estimates that by 2004, more than 40 percent of total corporate training and education will occur using Internet technologies.

  What began in knowledge-intensive industries where employees were already familiar with technology has moved beyond merely the IT-saavy. Successes such as IBM’s Basic Blue management project, which achieved a 23-fold return on investment (Nuclear Research), led McDonald's to launch a major Web training pilot project in four languages across six countries to 3,000 employees. In fact, IBM said that "for every 1,000 classroom days converted to electronic courses delivered via the web, more than $400,000 can be saved." (Business Week Magazine, December 13, 1999)

  Industry consolidation has contributed to the explosion of e-learning. With more employees to train and new skills requirements, training costs skyrocketed. New hires would travel, often by plane, to the closest off-site training center. Employers would be required to foot the bill for travel, hotel, meals, and lost workdays. Web-based training has eliminated the need for travel and minimized time off. However the advantages of e-learning extend beyond the cost savings. Employers also cite the advantages of round-the-clock availability and flexibility. (E-learning Magazine, user survey 2001)

  More than 10 million workers are required to receive job-related CPR and other emergency medical training annually. This market is currently being driven by recent federal and state legislation, including the Cardiac Arrest Survival Act of 2000, the Rural Access to Health Care Act, the Federal Aviation Administration mandates to provide emergency training and equipment for all airlines, the CPR in the Schools Act, and OSHA mandates. Online CPR training can be combined with online training for the Automated External Defibrillator to meet new federal mandates enacted to support Public Access Defibrillation programs. Online training for CPR and AED requires approximately one hour of computer-based interactive learning followed by one hour of hands-on skills training.

  Online CPR and AED training provides employers with a solution that satisfies these legislative requirements in a cost-efficient and –effective manner. Instructor-led CPR courses are taught over four hours. The employer is required to pay the cost of instruction materials, instructor time, and four hours of employee time per trainee. Integrating online self-instructional media, certification can be achieved by combining a half hour online training module with one hour of instructor-driven, hands-on skill training. Integrating online training is financially advantageous to the employer because employee costs are decreased by 50 to 75 percent.

  Streamlined Administration

  One of the most challenging aspects of any corporate training program is administration of the program. Online training programs often have a state-of-the-art learning management system to alleviate the administrative burden.

  These secure administrative databases simultaneously track the amount of time each student spends on each training session, the specific material received during the training session, the number of practice scenarios reviewed, performance on each practice scenario, and responses to the times sequence test. Real-time reports provide the administrator with the most up-to-date data available. This information can be used for quality improvement within the organization by pinpointing frequently missed questions and highlighting those skills at the next hands-on training session.

  Students receive automatic e-mails informing them they are scheduled for training are due for refresher training. The e-mails contain direct links to the training programs. The administrator receives reports detailing which employees have successfully trained and tested.

  Automation of monitoring and reporting substantially reduces administrative time and expense. The company administrator has complete autonomy and control over who has “access rights” to the site. Additionally, the reports can be fully customized to meet the regulatory compliance needs of each company.

  Conclusion

  Well-designed, self-instructional media incorporate the essential educational elements necessary for successful adult learning. Qualified instructors are essential to provide the personal experience, expertise, and encouragement necessary to develop the confidence required to respond to a sudden cardiac arrest.

  This integrated training approach addresses the deficiencies highlighted in previous CPR training research and reduces employers’ costs. Online training also has the potential to reach people unlikely to participate in community CPR classes, resulting in more CPR-trained citizens. More CPR trained citizens should mean more lives get saved – and that is a good thing.

  Odelia Braun, M.D., is President of Emergency University, Emerald Hills, Calif., which has partnered with American Safety and Health Institute and its 25,000 authorized instructors to provide CPR certification integrating an online training component. For information, visit www.emergencyuniversity.com and www.ashinstitue.com.
  

  References

  1. Jewitt C, Kress G, Ogborn J, et al. (2001): Exploring learning through visual, actional, and linguistic communication: The multimodal environment of science classroom. Educational Review, Vol. 53:1:5-18.
  2. Braslow A, Brennan RT, Newman MM, et al: CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation, 1997; 24:207-220.
  3. Plass J, Chun D, Mayer RE, et al. (1998): Supporting visual and verbal learning preferences in a second-language multimedia-learning environment. Journal of Educational Psychology, Vol. 90:1:25-35.
  4. Todd KH, Braslow A, Brennan RT, et al.: Randomized, controlled trial of video self-instruction versus traditional CPR training. Ann Emerg Med, March 1998; 31:364-369.
  5. Todd KH, Heron SL, Thompson M, et al.: Simple CPR: A randomized controlled trial of video self-instructional cardiopulmonary resuscitation in an African American church congregation. Ann Emerg Med, December 1999; 34:6:730-737.
  6. Wilson E, Brooks B, Tweed WA. CPR skills retention of lay basic rescuers. Ann Emerg Med, August 1983; 12:8: 482-484.
  7. C.L. Morgan, P.D. Donnelly, C.A. Lester, D. H. Assar. Effectiveness of the BBC's 999 training road show on cardiopulmonary resuscitation: video performance of cohort of unforewarned participants at home six months afterwards. British Medical Journal, 1996; 313: : 912-6
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• CPR Education that Works: A Web-based Blending Learning Approach

  Anthony C Gallagher, MA Research & Product Development, American Red Cross, 8111 Gatehouse Rd, Falls Church, VA 22042 and Patricia Bonifer-Tiedt, ScM, MS Educational Program Evaluation, National Headquarters, American Red Cross, 8111 Gatehouse Rd, Falls Church, VA 22042-1203, 703-206-7713, boniferp@usa.redcross.org.

  Theories of adult learning state that education is most effective when lessons are self-directed, build on life experiences, apply to "real life" situations, and capitalize on learners’ understanding of their own knowledge gaps (Knowles, Holton and Swanson, 1998). We applied these concepts to a blended-learning CPR curriculum.

  The blended course used online lessons followed by instructor-led skill practice and assessment. The online experience started with a diagnostic pre-test to assess student baseline knowledge, resulting in a personalized lesson plan. Highly interactive online lessons utilized problem solving exercises. Two-hour instructor-led skill sessions allowed students to practice CPR skills with performance feedback.

  In a 15 city evaluation, we measured student knowledge and self-efficacy before and after each course segment. Students made significant gains using the online lessons (p<0.005), with no decline between finishing the online lessons and starting the skill practice and assessment session (p>0.5, n.s.).

  We also compared outcomes from online learners to students in traditional classroom education. On all five outcome measures, online learners outperformed their classroom counterparts (p<0.009).

  Adult learners preferred the blended course to traditional classroom education. The research was hampered by the limits of the computerized system, which was better suited for presenting content than collecting data. Lessons learned for successful implementation will be discussed. Blended-learning is an effective, convenient and affordable way to impart safety information. Because it was built on general principles of adult education, blended learning could be effectively applied to other public health topics, such as, AED training, HIV/AIDS, home safety or bioterrorism.

  Learning Objective: 1. Discuss the advantages of a blended-learning approach to public health education. 2. Describe the method used to evaluate the blended-learning course. 3. Apply principles of adult education to web-based blended learning.

  Keywords: Distance Education, Public Health Education

  Related Web page:

  Presenting author's disclosure statement:
  Organization/institution whose products or services will be discussed: None I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session

  The 131st Annual Meeting (November 15-19, 2003) of APHA

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• Satisfy OSHA Requirements Conveniently On-Line with Emergency University's Blood Borne Pathogens Training Program

  Emergency University (EU), the premier provider of clinically focused, cost-efficient, interactive online emergency medical training programs offers a convenient way to satisfy your OSHA Blood Borne Pathogens requirements. EU's Blood Borne Pathogen training and testing modules are OSHA compliant and were designed to provide medical and non-medical personnel with the knowledge and skills to respond appropriately to potentially contaminated exposures. Developed by medical professionals and innovative educators, EU's clinically based Blood Borne Pathogen training course reflects decades of experience with real life-threatening emergencies.

  EU's web-based Blood Borne Pathogen training course incorporates audio, text, photographs, and clinical animations to educate the trainee about universal precautions, the risks and types of infectious diseases contracted through exposure, the proper safeguards to prevent exposure and proper methods of handling potential contaminants. EU's Blood Borne Pathogen training course includes a multiple-choice test to ensure the trainee has achieved the basic knowledge required to prevent and properly handle potential exposures. EU's Blood Borne Pathogen training and testing modules can be completed in approximately 30 minutes.
  
  Also included with Emergency University's Blood Borne Pathogen training course is access to EU's proprietary learning management system or end-to-end administration package that automatically tracks the students’ training and testing results, documents regulatory compliance and manages the enrollment process. Training administrators will appreciate having the most up-to-date training records available in one database without additional expense.

  EU's training courses are used at over 3,000 corporations, hospitals, EMS systems, airlines, schools, physician offices, and government facilities. Enroll today and satisfy OSHA's Blood Borne Pathogen training requirements cost-effectively online!

  For more information about Emergency University's online emergency medical training programs, please contact us at 866-AED-HELP or 650-365-3310.

¹ Jewitt C, Kress G, Ogborn J, et al. Exploring learning through visual, actional, and linguistic communication: The multimodal environment of a science classroom. Educational Review. 2001;53:1:5-18.

² Braslow A, Brennan RT, Newman MM, et al. CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance and cardiopulmonary resuscitation. Resuscitation. 1997;34:207-220.

³ Plass J, Chun D, Mayer RE, et al Supporting visual and verbal learning preferences in a second-language multimedia learning environment. Journal of Educational Psychology. 1998;90:1:25-35.

⁴ Umphred, D.A. Classification of treatment techniques based on primary input systems: Inherent and contrived feedback loop systems and their potential influence on altering a feed forward motor system. In Umphred, D.A.(Ed.), Neurological Rehabilitation. 1995;3rd ed.:118-178. St. Louis: Mosby.

⁵ Lorenzo RA, Abbott CA. Effectiveness of an adult-learning, self-directed model compared with traditional lecture-based teaching methods in out-of-hospital training. De, Department of emergency Medicine. Brooke Army Medical Center Acad Emerg Med. 2004 Jan;11(1):33-7.

⁶ Jerin JM, Rea TD. Web-based training for EMT continuing education. Public Health-Seattle and King County, Emergency Medical Services Division prehosp Emerg Care. 2005 Jul-Sep;(3):333-7.

⁷ Hubble MW, Richards ME. Paramedic student performance: comparison of online with on-campus lecture delivery methods. Prehsoptial Disaster Med. 2006 Jul-Aug;21:(4):261-7.

⁸ Halstead JA, Coudret NA. Implementing Web-based instruction in a school of nursing: implications for faculty and students. J Prof. Nurs. Sep-Oct 2000;16(5):273-81.

⁹ Zwolski K. Student satisfaction with a Website designed for three nursing courses. College of New Rochelle School of Nursing CIN Plus. 2000 Jan 1;3(1):12,6-7.

¹⁰ Yom YH. Integration of Internet-based learning and traditional face-to-face learning in an RN-BSN course in Korea. Department of Nursing, Hallym University Kangwon Province, South Korea Compu Inform Nurs. 2004 May-Jun;22(3):145-52.

¹¹ Broudo M., Walsh C. MEDICOL: online learning in medicine and dentistry. Division of Educational Support and Development. Acad Med. 2002 Sep;77(9):926-7.

¹² Schultze-Mosgau S, Zielinski T, Lochner J. Web-based, virtual course units as a didactic concept for medical teaching. Med Teach. 2004 Jun;26 (4):336-42.

¹³ Wiecha JM, Vanderschmidt H, Schilling K. HEAL: an instructional design model applied to an online clerkship in family medicine. Department of Family Medicine Boston University School of Medicine, Acad Med. 2002 Sep;77(9):925-6.

¹⁴ Lynch B, Einspruch E, Nichol G, Becker LB, et al. Effectiveness of a 30 min. CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation. October 2005;67 (1):31-43.

¹⁵ Lynch B., Einspruch E., Nichol G., Becker LB., et al. Effectiveness of a 30 min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation. October 2005;67(1):31-43.

¹⁶ Reder S., Cummings P. Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students. Resuscitation. Jun 2006;69(3):443-53.

¹⁷ Jerin JM, Ansell BA, Larsen MP, Cummins RO. Automated external defibrillators: skill maintenance using computer-assisted learning. King county EMS Division, Acad EMerg Med. 1998 Jul;5(7):709-17.

¹⁸ Baskett PJ, Nolan JP, Handley A, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 9. Principles of training in resuscitation. Resuscitation. 2005;(Suppl 1):181-89.

¹⁹ Ann Britt Thoren, Asa B. Axelsson, Johan Herlitz. DVD-based or instructor-led CPR education-A comparison. Institute of Medicine Goteborg, Sweden. Resuscitation. 2007 Feb;72(2):333-4.

²⁰ Kelly J, Richman PB, Ewy GA, et al. Eighth grade students become proficient at CPR and use of an AED following a condensed training programme. Mayo Clinic Arizona, Department of Emergency Medicine Resuscitation. 2006 Nov;71 (2):229-36.

²¹ Isbye D, Rasmussen LS, Lippert FK, et. al. Laypersons may learn basic life support in 24 min. using a personal resuscitation manikin. Resuscitation. 2006;69(3)435-442.

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