Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital Discharge: A Multicenter Pragmatic Trial

Prompt delivery of cardiopulmonary resuscitation (CPR) increases the probability of survival from sudden cardiac arrest (SCA) by 2- to 3-fold, yet >60% of SCA victims in the United States do not receive bystander CPR.^1–4 Despite the availability of CPR certification programs for the lay public, a recent investigation documented that training rates in the United States are strikingly low.⁵ Given that >75% of SCA events occur in the home environment, training family members of patients with at-risk cardiac conditions could have a significant impact on initial care and survival from SCA, which leads to >200 000 out-of-hospital deaths each year in the United States.^4,6–8 Highlighting the public health burden of SCA, the Institute of Medicine recently published a report entitled Strategies to Improve Cardiac Arrest Survival: A Time to Act that includes a call for increased engagement of the lay public as SCA first responders.⁹

Many key barriers are inherent in the prevailing approach to layperson CPR training; these include the need for CPR-certified instructors, logistical constraints (such as course duration and costs), and low motivation for CPR training among the general public.^10,11 Recent investigations have evaluated methods to disseminate CPR education that are simpler, less costly, and more expedient. These approaches have included the use of hands-only CPR (chest compressions [CC] with no rescue breaths), video self-instruction (VSI) kits, and highly abbreviated training programs.^12–18 The minimum training curriculum that reduces training barriers and provides adequate long-term CPR skill retention is unknown.

To address this knowledge gap, we conducted a multicenter, pragmatic randomized trial of 2 educational strategies for CPR training of the lay public. Family members of hospitalized patients with cardiac risk factors were offered either standard training via a kit that included a video along with an inflatable manikin (VSI), or video-only training without a manikin for psychomotor practice (VO). We hypothesized that trained laypersons who receive VO training would perform CCs 6 months post training, at a rate that is noninferior to those who trained using a VSI kit. As a secondary outcome, we assessed the mean difference in CC depth between cohorts. If a VO CPR strategy yielded similar long-term skill retention, it would have important implications for dissemination to millions of potential layperson trainees worldwide.

In a pragmatic, randomized multicenter trial of family CPR education, we assessed quantitative measures of CPR skill retention 6 months after training with either a standard VSI kit or a VO education, without the use of a manikin for psychomotor practice. CC rate for the 2 cohorts demonstrated noninferiority of the VO training approach, with mean CC rate difference of <2 cpm and an upper bound on the difference of 5.2 cpm. By contrast, the difference in mean CC depth was 5.6 mm, with an upper bound (95% CI) of 7.6 mm. These results suggest that psychomotor practice with a manikin improves layperson CC depth during long-term skills assessment. To our knowledge, this represents the largest prospective trial of CPR training and long-term retention among lay providers. Findings from this investigation have important implications for future policy and education initiatives to improve layperson CPR, as VO training could be broadly disseminated at low cost.

A recent epidemiological study demonstrated low CPR training incidence in the United States, likely contributing to low bystander CPR delivery rates in most communities.⁵ Previous works have suggested that numerous barriers, including training access and logistics, have hampered public access to CPR training.^10,11 To address these challenges, the American Heart Association developed a low-cost approach to CPR education that relies on video-facilitated learning in the form of a self-contained VSI kit. The promise for broad implementation using these kits has been demonstrated in several large-scale training experiences, yet public uptake of the VSI kits has been variable, and kit costs may still be prohibitive for large-scale training of the US public.²⁰ Other work has suggested that barriers to training might be further reduced by brief VO training, eschewing the use of training kits altogether, and adding to the potential for greater scalability of CPR education.¹⁸ It has been generally thought that psychomotor practice of CPR skills during training represents a crucial factor in long-term skill retention although this hypothesis had never been prospectively tested in a randomized trial. Our work suggests that psychomotor practice may yield small benefits with regard to retention of adequate CC depth, but these differences in depth may be small when compared with the enormous dissemination potential inherent in VO education. That is, our work highlights a public health trade-off between somewhat better CPR skills or a tool with much broader implementation potential. Further work will be required to model this trade-off and to determine whether training a greater proportion of the population would result in more lives saved compared with our current paradigm that seems to yield somewhat higher CPR quality among a smaller population of trained individuals.

Our work also demonstrates an important CPR training opportunity that has been largely untapped, namely, hospital-based CPR education of the families of patients with cardiac disease before discharge. More than 1 million people in the United States are admitted for acute coronary syndromes and myocardial infarction annually, yet no system exists to offer CPR training to spouses or other family members during the point of capture opportunity afforded by hospital admission.¹⁴ This gap is especially relevant given that patients with coronary events have a much higher annual risk of subsequent cardiac arrest than the general population.^25,26 Estimates of annual SCA incidence in this population range from 3% to 11% compared with the overall cardiac arrest annual incidence in the United States of ≈0.1%.^27–32 Because >70% of arrest events occur in private residences, survival is dependent on the prompt action of spouses and other family members to deliver CPR until prehospital personnel arrive on scene.^33–35 Our previous work has shown that CPR training is well received by families who reported satisfaction using the hospital environment to offer such education before discharge.¹⁴

Other venues for CPR education could become feasible through VO education, such as in clinic waiting rooms, public locations such as motor vehicle licensing facilities, or in transit system locations such as train stations or airports. In addition, VO training may allow for other methods of dissemination that remove the need for appropriate environmental settings. For example, the video curriculum could be incorporated into a mobile application for dissemination via mobile technology or integrated into video education programs on television channels. In addition, the video could be disseminated through the internet or various social media platforms.

When comparing the CPR skill retention within the 2 study cohorts, mean CC rate were almost identical, and yet CC depth was deeper in the VSI cohort (difference of 5.6 mm). Although current studies examining CC rates and depths from in and out of hospital providers demonstrate poor CPR quality, few studies have gathered data from actual layperson CPR performance. When comparing our findings with that of clinical studies of CPR performance, our VO cohort’s mean CC depth was similar to that of CC depth as delivered during clinical care.^23,36 Specifically, the CPR performance in our cohort was remarkably similar to actual professional CPR performance during clinical care (mean depth in one prehospital cohort was 42 mm compared with 40 mm in our VO cohort).³⁶

Although VSI training may yield improved psychomotor retention, VO training may afford cost savings and broad dissemination potential. Given the large effect size inherent in the delivery of bystander CPR and the presumably increased likelihood that a layperson will perform CPR if trained in these skills, our work suggests that VO training may be a useful method to ensure a basic CPR competency to a broad swath of the public who might otherwise remain untrained.

Several limitations are important to note on our investigation. Given our pragmatic design to test a low-cost generalizable approach to hospital-based CPR training, we did not embed research staff and CPR testing equipment at each training site. Thus, we did not test CPR skills at baseline immediately after training and could not compare these skills to the subsequent skills assessment at 6 months. Therefore, it is unknown whether shallow CC depths at 6 months represented skill deterioration or initial CPR quality with VO training. The work of Stiell et al^23,36 has shown that inadequate CC depth is pervasive during CPR provision by prehospital professionals during actual cardiac arrest resuscitation; shallow depth performance in our cohort may be consistent with the physical limitations of CPR delivery. Another limitation of our work was the lack of clinical outcomes from any actual SCA events among the hospitalized patient cohort. Assuming a 5% annual incidence arrest rate among patients with high-risk cardiac disease after hospital discharge, it is possible that 20 to 30 arrest events occurred among the families who received training in our study. Although cardiac arrest events and successful resuscitations were reported by families to our team at follow-up, we did not design our work to allow verification of these reports by clinical prehospital records nor would such verification have adequate statistical power to detect differences in the 2 arms. Furthermore, the study was powered to detect noninferiority in CC rate, but not in CC depth.

Questions about generalizability also arise in our study because of the large loss to follow-up. Our study was powered to detect noninferiority in CC rate for a sample size of 500 evaluable subjects. Despite the loss to follow-up, baseline characteristics of the original cohort and those evaluated at 6 months were reasonably similar. Using IPW to account for the missing data yielded similar conclusions to using only complete cases. This sensitivity analysis suggests that our work has reasonable generalizability to the population of interest, specifically family members of patients hospitalized with a cardiac diagnosis, who agree to volunteer-initiated CPR training.

The enormous promise inherent in VO education will require further work to test implementation models. Whether VO training could be embedded into modern communication tools such as mobile tablets, smartphones, or other delivery approaches remains to be assessed in clinical investigations. Recent investigations have demonstrated the potential promise of using smartphone apps in the domain of SCA.³⁷ The appropriate timing of CPR training for families before discharge, and the optimal model for staff proctoring of such training, also requires further study.

VO training yielded statistically indistinguishable CC rates and somewhat shallower CC depths compared with those trained with a VSI kit. If appropriate practical questions are further addressed, offering VO CPR training to families before hospital discharge could become a routine patient and family-centered health educational opportunity in >4000 acute care hospitals that care for patients with cardiac disease in the United States³⁸ If implemented broadly, CPR education could be well matched to a large population at high risk of subsequent cardiac arrest, establishing an opportunity to make important gains in survival from cardiac arrest. Furthermore, being able to train individuals with VO may allow for broader, more scalable dissemination of CPR training to the lay public; however, shallower CC depth at 6 months suggests that additional work to optimize VO strategies may be required.

We thank the nurse and student volunteers at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, Crozer-Chester Medical Center, Taylor Hospital, Temple University Hospital, Albert Einstein Medical Center Philadelphia, and The Chester County Hospital. Additionally, we thank Daniel Ikeda for his assistance with editing the article, and the reviewers for their careful review and excellent suggestions.

This work is submitted on behalf of the CHIP (CPR Hospital-Initiated Project Study Group): University of Arizona, Sarver Heart Center: Bentley J. Bobrow, MD; Einstein Medical Center Philadelphia: Kenneth Deitch, DO, FACEP and Kathia Damiron, MD; Penn Presbyterian Medical Center: James Kurtz, MPH, BSN, RN and Ryan Dos Reis, BSN, RN; The Chester County Hospital: Donna Taylor, BSN, RN, Janice Baker, MSN, RN, and Shannon Delany, MSN, RN.