Resuscitation (2007) 75, 350—356

TRAINING AND EDUCATIONAL PAPER

A preliminary feasibility study of a shortDVD-based distance-learning packagefor basic life support�

Ian Jones, Anthony J. Handley ∗, Richard Whitfield,Robert Newcombe, Douglas Chamberlain

Pre-hospital Emergency Research Unit, Welsh Ambulance Services NHS Trust/School of Medicine CardiffUniversity, Finance Building, Lansdowne Site, Sanatorium Road, Cardiff CF11 8PL, United Kingdom

Received 10 January 2007; received in revised form 2 April 2007; accepted 6 April 2007

KEYWORDSBasic life support (BLS);Skill acquisition;Training;Distance-learning

SummaryObjective: To test the hypothesis that laypeople who learn CPR using an 8-min self-instructional DVD acquire a level of skill that is comparable to that achieved withconventional courses.Methods: Forty volunteers used a short DVD with replay facility, and a simpleinflatable training manikin, for self-instruction in basic life support. A further 40volunteers (control group) attended a conventional 1-h instructor-led course. Skillacquisition was measured for each group.Results: After training, the self-instructional group achieved remarkably similarresults compared with the control group for all measured skill variables exceptcompression depth, which was significantly greater for the control group.Conclusion: Very short, DVD-based, self-instructional packages may be suitable for

more widespread use, including distance-learning and other circumstances in whicheducational opportunities and resources are limited.

Ltd

© 2007 Elsevier Ireland

Introduction

The likelihood of survival after pre-hospital cardiacarrest may be increased up to three-fold if CPR is

� A Spanish translated version of the summary of this articleappears as Appendix in the online version at10.1016/j.resuscitation.2007.04.030.

∗ Corresponding author. Tel.: +44 1206 562642;fax: +44 1206 562642.

E-mail address: tony.handley@btinternet.com(A.J. Handley).

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0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rightdoi:10.1016/j.resuscitation.2007.04.030

. All rights reserved.

nitiated by a bystander before the emergency ser-ices arrive1; this is the rationale for encouragingidespread community resuscitation training pro-rammes.

Unfortunately, as is well documented, basicife support skills are imperfectly acquired and

apidly lost.2 Not only may traditional instructor-ed courses fail to address these problems,3 butuch courses are costly in terms of time, humanesources and organisation. They are also inflexible

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VTctrdhtion was excluded. Informed, written consent wasobtained from each volunteer, and his or her age,sex, ethnicity, educational level and any previousBLS training were recorded (Table 1).

Table 1 Demographic characteristics of volunteers

Control group DVD (SID) group

Age (years)Mean 38 38Median 38 41Range 20—58 20—62

Sex % (N)Female 50 (20) 53 (21)Male 50 (20) 47 (19)

Ethnicity % (N)White 80 (32) 78 (31)Black 20 (8) 18 (7)Asian 0 5 (2)

Education level % (N)Degree 30 (12) 20 (8)Diploma 20 (8) 8 (3)A Level 8 (3) 15 (6)AS Level 3 (1) 3 (1)GCSE 23 (9) 40 (16)Other 3 (1) 5 (2)None 15 (6) 10 (4)

Previous training % (N)

preliminary feasibility study of a short DVD-based

n that they have to be held at a given place at aiven time.

Video-based, instructor-facilitated or self-earning programmes have been described andave given promising results.4 Recently, a self-nstructional, semi-interactive programme, using

25-min video developed by the American Heartssociation (AHA), has been reported to result inkill acquisition superior to that of an instructor-ledourse (Portland study).5

As part of an EU-funded project (TEMPUS), thehen University of Wales College of Medicine biduccessfully to develop and test a distance-learningackage specifically for use in Egypt. The remitas to produce a simple, economical package

uitable for widespread distribution. A DVD wasroduced, based on a single, real-time sequencef adult CPR, edited, with permission, from orig-nal material used to produce the AHA 25-minideo.5 The sequence of actions followed thosef the European Resuscitation Council Guidelines005.6

The TEMPUS project required that the distance-earning package be validated; this paper reportshe results of the validation. The aim was to testhe hypothesis that lay people taught CPR by a short8-min) self-instructional DVD, with practice on aimple training manikin, are able to acquire skillshat are comparable to, or exceed, those taught byn instructor using a standard course.

aterial and methods

elf-instruct DVD (SID) and manikin

he video used for self-instruction is 8 min 12 sn duration, recorded on DVD. It is divided intoour sections. The first section comprises an intro-uction, consisting of a voice-over commentaryhat describes the purpose of the DVD and howt is structured (1 min 18 s). The second sectionrovides a demonstration, in real time, of theull sequence of CPR, starting with safety checksnd ending with CPR performed using a compres-ion:ventilation ratio of 30:2 (1 min 10 s). The thirdection repeats the demonstration, but this timeith a voice-over explanation of how CPR shoulde performed (4 min 25 s). The action is ‘frozen’s necessary to allow time for the narrative, whichollows closely the ‘Adult BLS sequence’ describedn the ERC Guidelines 2005.6 The final section is a

epeat of the second (real-time sequence of CPR)ithout commentary, the viewer being encouraged

o practise along with the demonstration (1 min9 s). The DVD is presented with a main menu list-

tance-learning package for BLS 351

ng the four sections. After each section has beenlayed, the DVD returns to the main menu. Theiewer has the option of replaying any of the fourections until he or she feels competent.

The DVD was used in conjunction with a sim-le, inflatable manikin consisting of a head, necknd upper torso (Mini Anne,® Laerdal). The headas a soft plastic face similar to that of a standardaerdal manikin and the chest has a rigid plasticlate. A one-piece plastic airway and lungs are con-ected to the mouth. The lungs operate in a similarashion to a standard manikin by producing a visibleise in the manikin’s chest during ventilations.

tudy design

olunteer subjectshe validation study was conducted in 2006 in theity of Cardiff, Wales. Volunteers aged from 18o 65 were recruited from organisations that hadequested BLS training from the British Heart Foun-ation HeartStart UK training programme.7 Anyoneolding a first-aid instructor or similar qualifica-

First aid 18 (7) 15 (6)First aid at work 10 (4) 33 (13)Other 18 (7) 13 (5)None 55 (22) 40 (16)

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The volunteers were divided into two groups:a group that used the self-instruct DVD, and aninstructor-led (control) group that received a stan-dard HeartStart UK BLS course.

TrainingTraining took place at the requesting organisation’spremises on a date and time of their choosing.This limited the type of instruction that couldbe allocated to each particular organisation fortwo reasons. First, DVD training required a mini-mum of four rooms to allow the participants to beon their own for training, whereas the instructor-led training required only two rooms. Second,the date and time of the training determinedthe availability of instructors. The participants ateach training location were, therefore, pseudo-randomized into control or SID group dependanton instructor availability and training facilities(Table 2).

Self-instruct DVD (SID) groupEach subject was taken into a separate room whichcontained a Mini Anne® manikin and a laptop com-puter for playing the self-instructional DVD. He orshe was instructed in the operation of the DVDplayer and the structure of the BLS DVD. It wasexplained to the subject that the four sections ofthe DVD should be watched in turn, but that anysection could be repeated as often as needed untilhe or she felt competent in performing BLS, or fora maximum of 30 min.

Instructor-led (control) groupThe control group trained using a half-body-lengthmanikin consisting of a head, neck and full torso

(Little Anne®, Laerdal). HeartStart UK instruc-tors provided BLS instruction. The training givenwas the CPR component of the HeartStart Emer-gency Life Support training programme and was

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Table 2 Allocation of volunteers to training group

Training session Instructor-led (control)group (participants)

1 Corus steel works (6)2 Salvation Army (6)4 Care home staff (5)7 Care home staff (5)9 County Council Staff (6)

14 Nursing Agency* (5)17 Nursing Agency* (4)18 Care home staff (3)

* Nursery agency staff contained a mixture of nursing and clerica

I. Jones et al.

pproximately 1 h in duration.7 The training ses-ion comprised theory, instructor demonstrationnd approximately 30-min hands-on practice forhe subjects. Each control group contained a max-mum of six subjects with a 1:1 ratio of student toanikin.

ssessmentach subject’s BLS skills were assessed against theRC Guidelines 20056 before and after immediatelyfter training. For the assessment the subject waslaced in an isolated room that contained a Laerdalesusci Anne® SkillReporterTM manikin connectedo a laptop computer, with a telephone (uncon-ected) located nearby. The following statementas then read to the subject:

‘You have been called to assist a person reporteds having collapsed. You are the only person in theoom beside the casualty. Do whatever you wouldo if you found yourself in a similar situation in realife. Please treat the manikin as if it were a realerson.’’

It was explained to the subject that the assessorould not give any advice, and could only answeruestions relating to the casualty’s condition.

The method of assessment (Appendix A) was alightly modified version of the CPR performanceuidelines described by Lynch and colleagues.5

hese guidelines are themselves based on an assess-ent approved by the American Heart Association,eveloped by Brennan et al.8 and adapted byirnbaum et al.9 CPR performance data were col-ected using a calibrated Laerdal Resusci Anne®

killReporterTM manikin, connected to a Dell Lat-tude D510 laptop computer running Laerdal PC

killReporterTM software (version 2.0).

The assessment lasted 30 min once CPR had beennitiated. If the subject did not initiate any actionshe assessment was terminated after 2 min.

Training session DVD (SID) group(participants)

3 Salvation Army (6)5 Salvation Army (3)6 Transport service (3)8 Transport service (3)

10 Nursing Agency* (4)11 Innovate Trust (6)12 Nursing Agency* (6)13 Office Staff (2)15 Transport service (3)16 Office Staff (2)

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5% of the control group carried out the required

preliminary feasibility study of a short DVD-based

After training, each subject’s BLS skills wereeassessed using the same scenario and procedurehat was used before training.

tatistical analysis

ata were entered into a statistical software pack-ge (SPSS Version 12.0.2, SPSS Inc., Chicago, IL,SA). Summary statistics were used to provide theasic analysis of the data. The non-parametricann—Whitney U-test was used to determine if

here were differences between the two groups.

esults

orty subjects were recruited into each trainingroup, with an even split between females andales. The mean age in each group was 38 and

he ethnic composition was similar, with each groupaving an approximate 4:1 ratio of white to black

articipants. The differences between the groupsere: the SID group included two Asian subjectshilst the control group had none; the SID group

ncluded a smaller percentage of subjects who had

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Table 3 Skills before and after training: comparison betwe

Train

Instr

Pre-trainingN 23Ventilation rate 3Mean ventilation volume (ml) 490Mean compression rate (S.D.) 81 (Mean compression depth (S.D.) mm 39 (Correct compression/ventilation ratio % 0Mean duty cycle % 47Compressions with correct hand placement % 57Compression correctly released % 96Hands-off time total (s) 102Hands-off time average (s) 10

Post-trainingN 40Ventilation rate 3Mean ventilation volume (ml) 876Mean compression rate (S.D.) 101 (Mean compression depth (S.D.) mm 48 (Correct compression/ventilation ratio % 48Mean duty cycle % 46Compressions with correct hand placement % 67Compression correctly released % 88Hands-off time total (s) 66Hands-off time average (s) 10

tance-learning package for BLS 353

eceived a higher education (28%), compared with0% for the control group; the SID group includedore participants who had received previous BLS

raining (60%), compared with the control group45%), but this difference was not statistically sig-ificant; 8% of the SID group and 5% of the controlroup had received BLS training in the 12 monthsrior to the study.

ssessment of CPR skills before and afterraining (Table 3)

f the eighty subjects who participated, 24 (60%)f the SID group and 23 (58%) of the control groupade an attempt to perform CPR during the pre-

raining assessment; all of the subjects performedPR after training. During the assessment, thearticipants’ actions were recorded and checkedgainst a set list of required actions (Appendix A).

Before training, only 8% of the SID group and

ctions in the correct sequence. After training thisncreased to 50% of the SID group and 53% of theontrol group, with no statistically significant dif-erence between the groups.

en instructor-led (control) and DVD (SID) groups

ing group Differencebetween groups

uctor-led DVD (SID) P-value

241 0.12

254 0.09825) 92 (35) 0.3016) 39 (11) 0.61

442 0.1860 0.8191 0.96

109 0.4814 0.33

403 0.55

835 0.7120) 100 (21) 0.6410) 39 (13) 0.003

4644 0.1466 0.8091 0.5572 0.09513 0.018

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Ventilation rate and volume

Before training, the SID group achieved an averageventilation rate of 1 per min compared with 3 permin for the control group. Comparing ventilationvolumes, the SID group achieved an average vol-ume of 254 ml, whereas the control group attainedan average volume of 490 ml. After training, thetwo groups achieved comparable levels of perfor-mance, with an average ventilation volume of 835and 876 ml for the SID and control groups, respec-tively, each with an average ventilation rate of 3breaths per min. There was no statistical differencebetween the groups (rate p = 0.55; volume p = 0.71).

Hand position

There was no statistical difference between thegroups before or after training with regard to cor-rect hand positioning, as indicated by the manikinsensors. Before training, the SID group achieved amean percentage of correct hand placements of60% and the control group a mean of 57%; theserose to 66 and 67%, respectively, after training.

Before training, 25% of the SID group and 18%of the control group achieved 80% correct handplacement or greater; after training, this rose to50% of the SID group and 55% of the control group.Before training, only 10% of each group achieved100% correct hand positioning over the duration ofthe assessment, whereas after training this rose to28% of the SID group and 35% of the control group.There was no statistical difference between the twogroups with regard to correct release of compres-sion.

Compression rate

The correct compression rate was defined as90—110 per min. Before training, the average ratewas 92 per min for the SID group and 81 per min forthe control group. There was no statistical differ-ence between the groups (p = 0.30). After training,both groups displayed comparable performances,with the SID and control groups achieving averagecompression rates of 100 and 101, respectively: 19(48%) of the SID group and 16 (40%) of the controlgroup achieved the correct compression rate. Therewas no statistical difference between the groups(p = 0.64). Both groups maintained a consistent rateduring the 3 min of CPR.

Compression depth

The correct compression depth was defined as38—51 mm. Before training, both groups had an

tstt

I. Jones et al.

verall average compression depth of 39 mm: 1230%) of the SID group and 11 (28%) of the con-rol group achieved the correct depth. There waso statistical difference between the groups. Afterraining, the average compression depth achievedy the SID group (39 mm) was significantly lesshan that of the control group (48 mm) (p = 0.003),lthough still within the pre-defined and acceptableange. Thirteen (33%) of the SID group achieved theorrect compression depth compared with 15 of theontrol group (38%).

ompression:ventilation ratio and dutyycle

he correct compression-to-ventilation ratio,ccording to the European Resuscitation Council005 Guidelines, is 30:2; this study defined theorrect ratio as 30:2 ± 2 compressions. Beforeraining, only one subject from the SID groupchieved the correct ratio whilst none was success-ul in the control group. After training, 18 (45%)f the SID group and 19 (48%) of the control groupchieved the correct ratio.

There was only a small, non-significant differ-nce in mean duty cycle (time spent in compressions a proportion of each compression-relaxationycle) between the two groups both before andfter training.

ands-off time

he hands-off time was defined as the time dur-ng which no chest compressions were performed.efore training, there was no statistical differenceetween the two groups. After training, there was amall difference with respect to the average hands-ff time that just reached statistical significance;he SID group averaged 13 s whereas the controlroup averaged 10 s (p = 0.018).

iscussion

his study was conducted as a validation exercise toetermine whether a short, self-instructional, DVD-ased BLS training programme (SID) was as goods a traditional, instructor-led course (control).fter training, the SID group displayed remarkablyimilar skill acquisition compared with the controlroup for most of the measured variables. Aver-ge compression depth was significantly less for

he SID group than for the control group, althoughtill within the acceptable range. Average hands-offime was 3 s longer for the SID group than the con-rol group; this is clearly not desirable, but such

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preliminary feasibility study of a short DVD-based

small difference is of debatable clinical signifi-ance.

It should be noted that, although the SID group’sverage compression depth was shallower than thatf the control group, it was still just within thecceptable range. A possible explanation for theifference may be that the control group trainedsing Laerdal Little Anne® manikins, whereas theID group used Laerdal Mini Anne® manikins.aerdal Little Anne® manikins have an audible feed-ack device to indicate when the correct depthf compression is reached, and this was used dur-ng training. Although Laerdal Mini Anne® manikinsave a similar device, the DVD did not includenstruction on its use and it was not used duringraining. Thus, the control group received feedbackn compression depth during training, whereas theVD group did not.

The overall findings suggest that the shortID training package was as effective as thenstructor-led training course. These results areonsistent with previous research into video-basedelf-instruction.4

The Portland Study5 used a 22-min video, andllowed 30 min for self-instructional training. In theresent study, the DVD lasted less than 9 min, andhe subjects were allowed a maximum of 30-minnstructional time. In practice, it was noted thatost subjects completed the programme in less

han 15 min. In retrospect, it is unfortunate thatn accurate record was not kept of how long eachndividual elected to practise.

The value of this programme lies particularly inhe ease with which the DVD can be produced.nly a single, real-time, video sequence of CPR

s needed. This can be used as the initial demon-tration and repeated for use by the student whenractising. The sequence-with-explanation stagean be produced by adding ‘freezes’ to the video atppropriate points to allow time for the narrative.s the narrative is ‘voice-over’, it is relatively easynd cheap, to produce versions of the DVD in dif-erent languages or formats. Using a simple, cheapanikin also helps to reduce costs.This study has limitations that should be noted.

hese include: small group population size; lackf full randomisation due to imposed restrictionseyond the research team’s control; no follow-up toetermine any differences between the two groupsith regard to skill retention; failure to recorduration of practice time, as mentioned above.

Several questions about self-instructional, DVD-

r video-based BLS programmes in general remainnanswered: what is the best programme format forchieving optimal acquisition? Do the skills, oncecquired, decay at the rapid rate known to occur

tance-learning package for BLS 355

fter instructor-led courses? Is self-instruction bestuited to initial or refresher training, laypersons orealthcare professionals?

The promising results of the present study posene additional question: whether or not the shortVD that was used is as effective as the longer 22-in video that has previously been validated.

onflict of interest

one. DAC is supported for work in Cardiff by anxpenses-only grant from the Laerdal Foundation.

cknowledgements

e thank the American Heart Association andaerdal Medical for permission to edit and use theirideo material; the Video Unit Media Resourcesentre, Cardiff University, for assistance withhe editing process; Kevin Heath, Video Direc-or/Producer; Welsh Ambulance Services NHS Trust;ll the HeartStart Instructors.

ppendix A

ssessment checklist

1

2

3

4

5

6

7

8

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