Elsevier

Resuscitation

Volume 71, Issue 2, November 2006, Pages 237-247
Resuscitation

Training and Educational paper
Optimal refresher training intervals for AED and CPR skills: A randomised controlled trial

https://doi.org/10.1016/j.resuscitation.2006.04.005Get rights and content

Summary

Aim

To determine the optimal refresher training interval for lay volunteer responders in the English National Defibrillator Programme who had previously undertaken a conventional 4-h initial class and a first refresher class at 6 months.

Methods

Subjects were randomised to receive either two additional refresher classes at intervals of 7 and 12 months or one additional refresher class after 12 months.

Results

Greater skill loss had occurred when the second refresher class was undertaken at 12 compared with 7 months. Skill retention however, was higher in the former group, ultimately resulting in no significant difference in final skill performance. There was no significant difference in performance between subjects attending two versus three refresher classes.

On completion of refresher training all subjects were able to deliver countershocks, time to first shock decreased by 17 s in both groups, and the proportion of subjects able to perform most skills increased. The execution of several important interventions remained poor, regardless of the total number of classes attended or the interval between them. These included CPR skills, defibrillation pad placement, and pre-shock safety checks. Refresher classes held more frequently and at shorter intervals increased subjects’ self-assessed confidence, possibly indicating greater preparedness to use an AED in a real emergency.

Conclusions

This study shows that the ability to deliver countershocks is maintained whether the second refresher class is held at seven or 12 months after the first. To limit skill deterioration between classes, however, refresher training intervals should not exceed 7 months. The quality of instruction given should be monitored carefully. Learning and teaching strategies require review to improve skill acquisition and maintenance.

Introduction

The use of AEDs by trained lay responders has been shown to achieve a reduction in the delay to defibrillation and thereby increase the proportion of victims who survive out-of-hospital ventricular fibrillation. For example, security officers using AEDs in casinos in the USA have achieved an average time to first shock of 4.4 min, resulting in a survival to discharge rate of 53% for those patients with an initial rhythm of ventricular fibrillation.1 Moreover, the English Department of Health National Defibrillator Programme achieved a 25% survival after the first 250 AED deployments.2 Both studies report substantially higher survival than most traditional Emergency Medical Services, which rarely reach victims of collapse as quickly, with consequent poor outcomes. The European Resuscitation Council (ERC) has advocated the use of AEDs by ‘First Responders’, and the Department of Health in England has adopted this strategy as a core part of NHS service provision with AEDs used by lay volunteers who work at sites with ‘high risk’ of cardiac arrest.3, 4

AEDs in the ‘public access’ setting are likely to be used infrequently, with the result that deterioration in the responders’ skill levels may be a major problem,5 despite their simplicity of use. The most appropriate interval for refresher courses has not, however, been determined. The randomised controlled trial described in this paper compares performance after repeat refresher courses at seven or 12-month intervals in people given initial conventional training and one initial refresher class at 6 months.

Section snippets

Study design

This pragmatic randomised controlled trial (RCT) aimed to recruit all volunteer responders trained to use an AED in the Department of Health National Defibrillator Programme at Bristol International Airport who had taken part in a previous study and had agreed to undertake further refresher training.6

Sample size

A sample size calculation was performed prospectively. Previous research has reported a standard deviation of 34 s for the difference in time to first shock amongst lay trainees before and after

Data integrity

Twenty of the 77 subjects who had previously completed a first refresher class in the earlier study had either left their employment at the airport or declined to participate in the current trial. There were no significant differences between study participants and non-participants other than the greater proportion of males in the former group (74 versus 35%; 95% CI for difference −59 to −14%, P = 0.0017).

Thirty subjects were randomised to undertake a second refresher class at 7 months and a

Discussion

Frequency of retraining must be based on a balance between the need to maintain skills and the practicality of mandating refresher courses at frequent intervals. Providing refresher training at inappropriately long intervals may result in an unacceptable deterioration in skills between classes. However, providing training at short intervals may make volunteers less willing to attend, or their employers less willing to release them. This may result in an increased dropout rate from AED

Conclusion and recommendations

On completion of refresher training, all subjects maintained the ability to deliver countershocks; there was a clinically significant reduction in time to first shock of at least 17 s in both groups; and the proportion of subjects able to perform most skills increased. Further, refresher classes held more frequently and at shorter intervals seem to increase subject's self-assessed confidence – this may indicate increased likelihood of using an AED in a real emergency. Performance remains poor in

Conflict of interest statement

Douglas Chamberlain and Michael Colquhoun are members of the Department of Health (England) National Defibrillator Programme Advisory Committee. The trial reported in this paper was funded by the Department of Health, England.

Acknowledgements

The authors are particularly grateful to Siân Davies from the Department of Health, England, who provided significant practical and moral support, without which this study would not have been possible. We also gratefully acknowledge Jeremy Johnstone, David Morris, and Illtyd Hollard, all seconded from the Welsh Ambulance Services NHS Trust as Research Assistants, for their help with the assessments and George Murphy for releasing his staff. We thank Symon Clifford and Ivor Valentine of the

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A Spanish translated version of the summary of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2006.04.005.

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