PUBLIC
HEALTH
BRIEFS
The
Efficacy
of
Lay
CPR
Instruction:
An
Evaluation
AMELIE
G.
RAMIREZ,
MPH,
FRANK
J.
WEAVER,
BA,
ALBERT
E.
RAIZNER,
MD,
SHARON
B.
DORFMAN,
MS,
K.
LEE
HERRICK,
BS,
AND
ANTONIO
M.
GOTTO,
JR.,
MD
Introduction
More
than
325,000
Americans
die
each
year
from
car-
diac
arrest
outside
the
hospital,
usually
within
two
hours
af-
ter
the
onset
of
symptoms.
1
Regardless
of
the
specific
cause,
effective
heart
contraction
and
breathing
cease.
Without
re-
suscitation,
cardiac
arrest
almost
always
results
in
death.2
Yet
a
reduction
in
the
mortality
rate
could
be
achieved
if
more
persons
in
the
general
community
were
trained
to
rec-
ognize
the
signs
of
cardiac
arrest
and
to
give
immediate
life-
saving
assistance
by
administering
cardiopulmonary
resusci-
tation
(CPR).2
3
Several
CPR
training
programs
conducted
under
the
auspices
of
the
American
Heart
Association
(AHA)
and
the
American
Red
Cross,
as
well
as
the
community-wide
efforts
of
the
Medic
I
and
II
programs
in
Seattle4'
5
have
indicated
that
medical
professionals
and
paraprofessionals
can
train
lay
persons
in
CPR
techniques.
However,
many
commu-
nities
do
not
have
sufficient
numbers
of
volunteer
medical
professionals
and
paraprofessionals
to
conduct
CPR
instruc-
tion
programs.
As
a
result,
communities
and
organizations
are
recruiting
lay
individuals
to
teach
CPR
to
the
general
public.
As
the
utilization
of
lay,
volunteer
instructors
increases
with
public
demand
for
CPR
training
programs,
it
becomes
important
to
evaluate
the
effectiveness
of
such
instructors
in
teaching
volunteer
adults to
perform
CPR.
Although
studies
have
been
conducted
among
captive
audiences
(i.e.
secon-
dary
school
students),4'6
little
is
known
about
the
ef-
fectiveness
of
lay
volunteer
instructors
in
providing
CPR
training
to
non-captive
audiences
(i.e.
adults
from
the
gener-
al
community).
During
the
six-month
study,
772
adults
from
business,
civic,
and
religious
organizations
and
the
general
community
participated
in
the
standard
AHA
Basic
Life
Support
course
offered
by
the
Junior
League
of
Houston
volunteer
instruc-
tors.t
One
principal
and
six
assistant
instructors
conducted
each
class
of
15-20
trainees.**
Evaluation
Three
procedures
were
developed
to
evaluate
the
ef-
fectiveness
of
utilizing
lay
instructors
in
providing
CPR
training
to
the
general
public.
Multiple-choice
cognitive
pre-
and
post-tests
measured
the
trainees'
ability
to
recognize
a
cardiac
arrest
and
their
knowledge
of
the
A-B-Cs
of
CPR.
The
questions
were
di-
vided
into
five
fundamental
areas:
recognition
(2
questions),
airway
(3
questions),
breathing
(5
questions),
circulation
(7
questions),
and
ventilation/cardiac
compression
ratio
(2
questions).
Identical
questions
were
used
for
both
the
pre-
and
post-tests,
but
the
order
of
presentation
was
reversed.
A
12-item
performance
test
of
the
one-person
CPR
tech-
nique
combined
the
instructor's
observations
with
the
data
from
the
Recording
Resusci
Anne
manikin's
printout
tape.
The
first
eight
test
items
incorporated
the
instructor's
assess-
ment
of
each
trainee's
performance
of
the
preliminary
and
sequential
behaviors
of
CPR
which
include:
establishing
that
a
cardiac
arrest
has
occurred,
readying
the
victim
for
receiv-
ing
CPR,
and
establishing
the
correct
position
for
adminis-
tering
CPR.
The
remaining
four
items,
which
were
recorded
by
the
manikin,
measured
the
trainee's
ability
to
integrate
the
pre-
Program
Design
Twenty-one
members
of
the
Junior
League
of
Houston,
Inc.,
volunteered
to
become
CPR
instructors.
The
local
chapter
of
the
AHA
certified
them
as
CPR
instructors
fol-
lowing
their
successful
completion
of
the
four-hour
Basic
Life
Support
and
12-hour
instructor
training
course.*
From
the
National
Heart
and
Blood
Vessel
Research
and
Dem-
onstrator
Center,
Baylor
College
of
Medicine.
Address
reprint
requests
to
Frank
J.
Weaver,
Principal
Investigator,
Public
Educa-
tion
Section,
National
Heart
and
Blood
Vessel
Research
and
Dem-
onstration
Center,
Baylor
College
of
Medicine,
Texas
Medical
Cen-
ter,
1200
Moursund,
Houston,
TX
77030.
This
paper,
submitted
to
the
Journal
February
17,
1977,
was
revised
and
accepted
for
publica-
tion
June
20,
1977.
*Certification
standards
are
those
recommended
by
the
Nation-
al
Conference
on
Cardiopulmonary
Resuscitation
(CPR)
and
Emer-
gency
Cardiac
Care
(ECC),
May
16-18,
1973,
Washington
D.C.,
co-
sponsored
by
the
American
Heart
Association
and
National
Acad-
emy
of
Sciences-National
Research
Council.
4The
AHA
Basic
Life
Support
Course
consists
of:
a
film
en-
titled
"New
Pulse
of
Life"
7;
a
lecture
on
the
early
warning
signs
of
a
heart
attack,
local
emergency
facilities,
and
recognition
of
a
cardiac
arrest;
the
A-B-Cs
(Airway,
Breathing,
Circulation)
of
CPR,
a
dem-
onstration
of
one-
and
two-person
CPR
techniques
on
the
Recording
Resusci
Anne
Manikin
(a
life-size
manikin
which
simulates
the
phys-
iological
conditions
found
in
a
person
in
need
of
resuscitation).
Per-
formance
on
the
manikin
is
measured,
recorded,
and
printed
on
tapes.
In
addition,
special
infant
CPR
techniques
are
demonstrated
on
the
"baby"
manikin.
Course
demonstration
by
the
instructor
is
followed
by
trainee
practice
on
the
manikins.
For
a
complete
de-
scription
of
CPR
techniques,
see
Reference
#1.
**The
CPR
instructors
rotated
systematically
so
that
each
served
as
a
principal
instructor
during
the
program.
The
principal
instructor's
responsibilities
included
presenting
the
course
in-
troduction,
lecture,
and
CPR
demonstration.
The
assistant
instruc-
tors
were
responsible
for
supervising
small
groups
of
trainees
during
manikin
practice.
AJPH
November
1977,
Vol.
67,
No.
1
1
1093
PUBLIC
HEALTH
BRIEFS
liminary
and
sequential
behaviors
with
the
actual
administra-
tion
of
the
functional
techniques.
The
techniques
included:
the
number
of
the
ventilations
in
one
minute,
the
volume
of
the
ventilations
in
one
minute,
the
number
of
chest
compres-
sions
in
one
minute,
and
the
adequacy
of
deflection
of
the
chest
compressions.
In
order
to
comply
with
the
recom-
mended
AHA
standards,
all
12
items
had
to
be
performed
correctly
by
the
trainees.
An
instructor
and
course
evaluation
was
developed
to
measure
the
trainees'
assessment
of
the
instructors'
ef-
fectiveness
and
credibility,
the
course
content,
and
personal
confidence
in
administering
CPR.
This
instrument
was
ad-
ministered
following
the
cognitive
post-test.
Results
The
percentage
of
trainees
responding
correctly
to
the
cognitive
measures
of
recognition,
airway,
breathing,
and
compression/ventilation
ratio
questions
increased
substan-
tially
from
pre-
to
post-test
(Table
1).
An
improvement
in
the
circulation
fundamental
is
also
noted
but
the
increase
is
not
as
great
as
in
other
fundamentals.
On
the
psychomotor
performance
evaluation,
84.3
per
cent
of
the
trainees
performed
all
eight
preliminary
and
se-
quential
behaviors
correctly
(Table
2).
Strong
performance
on
the
first
eight
questions
is
indicated
by
the
fact
that
at
least
95
per
cent
of
the
trainees
completed
each
item
cor-
rectly.
The
remaining
four
items
specifically
measured
the
in-
tegration
of
the
preliminary
and
sequential
behaviors
with
performance
of
the
functional
techniques
during
the
train-
ees'
best
one
minute
segment
on
the
Recording
Resusci
Anne
(Table
2).
Unlike
the
high
percentage
correct
shown
for
the
first
eight
items,
only
2.8
per
cent
of
the
trainees
(n
=
382)
performed
all
of
the
last
four
items
adequately
ac-
cording
to
recommended
standards
established
by
the
AHA
for
correct
performance
of
the
one-person
CPR
technique.
When
the
preliminary
and
sequential
skills
were
combined
TABLE
1-CognItive
Evaluation
of
CPR
Fundamentals
Percentage*
of
Trainees
CPR
Fundamentals
Pre-Test**
Post-Test**
Recognition
(2
questions)
36.8
95.5
Airway
(3
questions)
53.1
91.1
Breathing
(5
questions)
3.6
52.2
Circulation
(7
questions)
3.2
12.3
Ventilation/Compression
ratio
(2
questions)
12.1
76.1
*Percentage
of
trainees
who
responded
correctly
to
all
questions
related
to
each
of
the
five
fundamentals.
Percentages
are
adjusted
for
the
valid
num-
ber
of
cases
for
each
group
of
questions.
"There
was
a
significant
increase
in
the
mean
percentage
correct
for
all
trainees
(n
=
724)
from
pre-test
to
post-test
(means
=
46.6
and
83.3,
respec-
tively;
t
(723)
=
-46.15,
p
<
.001).
On
the
pre-test,
males
scored
significantly
higher
than
the
females
(means
=
50.5
and
45.6,
respectively;
t
(339)
=
2.8
p
<
.01).
Analysis
of
the
post-test
means
revealed
no
significant
differences
between
males
and
females
(means
=
84.2
and
82.9,
respectively;
t
(354)
=
1.25,p
>
.05).
TABLE
2-Psychomotor
Performance
Evaluation
Percentage*
Behaviors
of
Trainees
1.
Establish
unresponsiveness
98.7
2.
Open
airway
95.9
3.
Establish
breathlessness
95.9
4.
Initiate
artificial
ventilation
with
four
breaths
97.8
5.
Demonstrate
technique
for
artificial
ventilation
95.8
6.
Establish
pulselessness
95.9
7.
Demonstrate
technique
for
external
cardiac
compression
96.6
8.
Administer
chest
compression:
ventilation
ratio,
15:2
99.0
Items
1-8
All
Correct
84.3
9.
Administer
8
or
more
ventilations
given
in
one
minute
19.6**
10.
Administer
8
or
more
ventilations
greater
than
.8
liters
16.4
11.
Administer
60
or
more
chest
compressions
in
one
minute
16.4
12.
Administer
60
or
more
chest
compressions
greater
than
38mm
(11/2")
deflection
8.0
Items
9-12
All
Correct
2.8
Items
1-12
All
Correct
1.0
*Percentage
of
trainees
who
correctly
performed
each
behavior.
Per-
centages
are
adjusted
for
the
number
of
valid
cases
for
each
item.
"Measurement
of
items
9-12
was
based
on
the
manikin
printout
tape.
Due
to
equipment
and
some
data
collection
problems,
the
number
of
valid
tapes
was
reduced
to
n
=
382.
The
Psychomotor
performance
mean
percentage
correct
for
all
trainees
was
71
per
cent,
or
an
average
of
8.5
out
of
the
12
questions
correct.
The
t
test
computed
for
the
differences
between
means
for
females
and
males
indicated
no
significant
difference
(means
=
70.6
and
71.6,
respectively;
t
(228)
=
1
.12,
p
>
.05).
with
the
functional
skills,
only
1
per
cent
of
the
trainees
scored
correctly
on
all
12
items.
Ninety-four
per
cent
of
the
trainees
rated
the
instruc-
tors'
effectiveness
in
teaching
the
CPR
course
as
excellent
or
very
good,
94
per
cent
thought
the
instructors
knowledge-
able,
and
95.9
per
cent
indicated
that
the
Recording
Resusci
Anne
manikin
practice
was
the
most
helpful
component
of
the
course.
Overall,
98
per
cent
of
the
trainees
stated
that
the
course
fulfilled
their
expectations
and
88
per
cent
of
the
trainees
felt
confident
in
administering
CPR.t
Discussion
The
trainees'
inability
to
integrate
the
cognitive
infor-
mation
and
selected
performance
skills
with
the
functional
techniques
raises
serious
questions
about
lay
CPR
educa-
tion.
Although
84.3
per
cent
of
the
trainees
were
capable
of
correctly
performing
all
eight
preliminary
and
sequential
be-
haviors,
only
2.8
per
cent
were
able
to
administer
adequate
ventilations
and
compressions
as
well
as
integrate
these
tAt
the
time
that
the
trainees
rated
their
confidence,
they
did
not
know
their
performance
scores.
AJPH
November
1977,
Vol.
67,
No.
11
1094
skills
in
the
proper
ratio
according
to
AHA
standards.
The
fact
that
only
1
per
cent
of
all
trainees
correctly
performed
all
behaviors
indicates
that
a
major
dichotomy
exists
not
on-
ly
between
the
cognitive
knowledge
and
performance
skills
but
also
between
the
preliminary
and
functional
performance
techniques.
Even
more
alarming,
88
per
cent
of
the
trainees
felt
confident
in
their
ability
to
administer
CPR.
At
the
present
time,
there
are
no
rigid
pass/fail
criteria
for
Basic
Life
Support
courses.
Consequently,
trainees
certi-
fied
for
completing
the
course
feel
that
they
are
capable
of
effectively
administering
CPR,
regardless
of
their
actual
per-
formance
ability.
At
the
very
least,
this
study
emphasizes
the
importance
of
establishing
more
objective
pass/fail
cri-
teria
for
Basic
Life
Support
CPR
instruction
and
under-
scores
the
need
for
more
specific
assessment
of
trainee
knowledge
and
performance
skills.
A
quantitative
evaluation
procedure
which
is
easy
to
administer
would
strengthen
lay
CPR
instruction
programs.
As
more
and
more
CPR
training
programs
are
launched
throughout
the
United
States,
the
importance
and
timeliness
of
further
research
is
emphasized.
Many
questions
remain
unanswered:
Are
the
recommended
standards
of
CPR
per-
formance
too
difficult
for
the
average
lay
individual
to
attain?
If
so,
should
the
standards
be
modified,
and
to
what
degree?
What
specific
areas
of
CPR
training
need
reinforcement
through
additional
manikin
practice
and/or
supplemental
lit-
erature?
Is
the
Recording
Resusci
Anne
an
appropriate
simu-
lator
of
a person?
Further,
questions
concerning
the
reten-
tion
of
knowledge
and
psychomotor
skills
must
be
answered:
Are
mandatory
refresher
courses
needed?
And,
how
can
they
be
appropriately
implemented?
Although
this
study
documents
that
lay
CPR
instructors
are
capable
of
providing
for
and
facilitating
the
transfer
of
cognitive
and
selected
performance
skills,
a
more
systematic
approach
to
lay
CPR
training
is
needed.
The
concept
of
lay
PUBLIC
HEALTH
BRIEFS
CPR
instruction
should
not
be
abandoned,
but
rather
refined
to
incorporate
a
standardized
evaluation
of
trainee
perform-
ance
and
to
stress
attainment
and
retention
of
adequate
func-
tional
psychomotor
performance
skills.
ACKNOWLEDGMENTS
This
project
was
conducted
by
the
Public
Education
Section
of
the
National
Heart
and
Blood
Vessel
Research
and
Demonstration
Center,
Baylor
College
of
Medicine,
Houston,
Texas,
a
grant
sup-
ported
project
of
the
National
Heart,
Lung,
and
Blood
Institute,
Na-
tional
Institutes
of
Health,
Grant
No.
HL
17269.
The
authors
wish
to
thank
The
Junior
League
of
Houston
and
the
American
Heart
Association,
Houston
Chapter,
for
their
out-
standing
cooperation
and
assistance
in
conducting
the
study.
Also,
we
wish
to
thank
Robert
M.
Chamberlain,
PhD,
for
his
assistance
on
the
earlier
drafts
of
this
manuscript.
REFERENCES
1.
American
Heart
Association,
National
Academy
of
Sciences-
National
Research
Council.
Standards
for
cardiopulmonary
re-
suscitation
(CPR)
and
emergency
cardiac
care
(ECC).
Journal
of
the
American
Medical
Association
227
(Supplement):
833-866,
1974.
2.
Katser,
A.
D.,
Norman,
G.
C.,
and
The
AHA
Task
Force
on
CPR
Instructional
Material.
CPR,
Cardiopulmonary
Resuscita-
tion:
Overview
1.
American
Heart
Association:
1-10,
1975.
3.
Lund,
I.,
and
Skulberg,
A.
Cardiopulmonary
resuscitation
by
lay
people.
The
Lancet
2:702-704,
1976.
4.
Cobb,
L.
A.,
Alvarez,
H.,
III,
Kopass,
M.
K.
A
rapid
response
system
for
out-of-hospital
cardiac
emergencies.
Medical
Clinics
of
North
America
60
(2):283-293,
1976.
5.
Alvarez,
H.,
III,
Cobb,
L.
A.
Experiences
with
CPR
training
of
the
general
public.
Proceedings
of
the
National
Conference
on
Standards
for
Cardiopulmonary
Resuscitation
and
Emergency
Cardiac
Care,
American
Heart
Association,
33-37,
1975.
6.
Vanderschmidt,
H.,
Burnap,
T.
K.,
Thwaites,
J.
K.
Evaluation
of
cardiopulmonary
resuscitation
course
for
secondary
schools.
Medical
Care
13
(9):763-774,
1975.
7.
Pyramid
Films:
New
Pulse
of
Life,
University
of
Southern
Cali-
fornia
School
of
Medicine,
Los
Angeles,
CA,
1975.
Application
of
a
Data
Collection
Method
To
Ensure
Confidentiality
ROGER
B.
WHITE,
MSW,
DRPH
A
study
to
estimate
the
incidence
and
prevalance
of
child
abuse
and
neglect
among
a
Native
American
popu-
lation
was
recently
conducted.
The
double
blind
data
collec-
tion
method
described
assisted
in
obtaining
data
access
from
Address
reprint
requests
to
Dr.
Roger
B.
White,
Assistant
Pro-
fessor,
Department
of
Maternal
and
Child
Health,
Johns
Hopkins
University,
School
of
Hygiene
and
Public
Health,
615
N.
Wolfe
St.,
Baltimore,
MD
21205.
This
paper,
submitted
to
the
Journal
January
17,
1977,
was
revised
and
accepted
for
publication
May
31,
1977.
AJPH
November
1977,
Vol.
67,
No.
11
the
federal,
state,
tribal
and
private
agencies
since
it
pro-
vided
a
means
to
protect
individual
identification.
Applica-
tion
of
this
method
required
minor
modifications
to
accomo-
date
the
various
agency
interpretations
of
the
Federal
Pri-
vacy
Act
(P.L.
93-579)
or
their
own
data
confidentiality
provisions.
Two
data
collection
instruments
were
devised,
here-
inafter
referred
to
as
the
Patient
Information
Form
(PIF)
and
the
Master
File
Form
(MFF).
The
PIF
contained
sociode-
mographic
and
medical
data
relevant
to
the
study
questions.
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