CPR Feedback Devices in Training (EIT #648): Systematic Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Greif R. and Breckwoldt J. are authors of one of the included studies {Pavo 2016 70}

CoSTR Citation

Duff JP, Shammet S, Damjanovic D, Bhanji F, Bigham BL, Bray JE, Breckwoldt J, Cheng A, Glerup Lauridsen KG, Gilfoyle E, Hsieh MJ, Iwami T, Lockey AS, Ma M, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn J, Greif R. - on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force.

CPR Feedback Devices in Training Draft Consensus on Science with Treatment Recommendations. International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2020, January 9. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) is an update on a previously conducted systematic review conducted by ILCOR task force in 2015.

We searched for studies investigating the use of CPR feedback or guidance device in CPR training published since the last search. We excluded studies that examined the use of CPR feedback devices in performance of CPR (either on real patients or in the simulated environment).

We considered both true feedback devices (systems that assess participant performance and provide corrective information) and guidance devices (systems that only provide prompts not based on participant performance - such as a metronome for CPR rate).

There was high heterogeneity among the studies in type of device used, learner demographics, and outcomes. We were unable to perform a meta-analysis and present the data narratively.

PICOST

PROSPERO Registration Submitted November 9^th, 2019

Consensus on Science

We identified 13 randomized studies {Griffin 2014 264; Wilson-Sands 2015 E1; Min 2016 158; Pavo 2016 70; Baldi 2017 480; Cortegiani 2017 e0169591; Navarro-Patón 2018 207; Sá-Couto 2018 e8; Katipoglu 2019 PMID 31565794; McCoy 2019 15; Smereka 2019 e15995; Wagner 2019 PMID 30700565; Zhou 2020 73} and one non-randomized study {Hafner 2015 43} examining the effects of CPR feedback/guidance devices on learning CPR skills. All studies were simulation-based studies, and none examined any patient outcomes or performance of teams in actual resuscitations. As a result, all studies were downgraded for indirectness.

Outcome: CPR Performance 1-year post-training [IMPORTANT]

We identified low certainty evidence (downgraded for risk of bias and indirectness) from 2 randomized controlled studies. The first {Zhou 2020 73} reported no difference in CPR performance between a group of laypeople trained with a CPR feedback device compared to a control group at 1 year post-training. In the second study of CPR training of health care providers {Griffin 2014 264}, both control and feedback groups improved from baseline at 1 year post-training, but there was no difference between the control and feedback groups.

Outcome: CPR Performance from training conclusion to 1-year post-training [IMPORTANT]

We identified 5 randomized controlled studies {Hafner 2015 43; Cortegiani 2017 e0169591; Katipoglu 2019 PMID 31565794; Smereka 2019 e15995; Zhou 2020 73} which addressed this outcome.

We identified low certainty evidence (downgraded for risk of bias and indirectness) from 4 randomized controlled trials which used true feedback devices {Cortegiani 2017 e0169591; Katipoglu 2019 PMID 31565794; Smereka 2019 e15995; Zhou 2020 73}. All of these studies were in laypersons or junior health care professionals, and they reported improvements in retention of CPR skills at 7 days to 3 months post-training.

We identified moderate certainty of evidence (downgraded for indirectness) for one study {Hafner 2015 43} which examined the use of a guidance device (a song for compression rate). This study reported an improved compression rate (RR of compression rate between 100-120 1.72 (1.17-2.55) compared to learners with no access to a guidance device.

Outcome: CPR Performance at end of training [IMPORTANT]

We identified low certainty evidence (downgraded for risk of bias and indirectness) from 8 randomized controlled studies {Griffin 2014 264; Wilson-Sands 2015 E1; Min 2016 158; Pavo 2016 70; Baldi 2017 480; Sá-Couto 2018 e8; McCoy 2019 15; Wagner 2019 PMID 30700565), and one observational study {Navarro-Patón 2018 207}. Five of the RCTs reported improvement in CPR skills at the end of training with the use of feedback devices compared to no feedback device {Griffin 2014 264; Wilson-Sands 2015 E1; Baldi 2017 480;McCoy 2019 15; Wagner 2019 PMID 30700565}. Two RCTs showed no difference in performance {Pavo 2016 70; Sa-Couto 2018 e8}. One RCT reported worse CPR performance at the conclusion of training although this study has a high risk of bias because of unclear outcome definitions and the use of the AV feedback system to replace an instructor {Min 2016 158}. The one observational study identified reported improvements in delivered chest compression rate (Intervention: 118.61 +/- SD 10.74 compressions/min vs 137.72 +/- 11.14 compressions/min; p<0.001), with the use of a feedback device during training of student teachers. {Navarro-Patón 2018 207}

Treatment Recommendations

We suggest the use of feedback devices that provide directive feedback on compression rate, depth, release, and hand position during CPR training (weak recommendation, low certainty evidence). If feedback devices are not available, we suggest the use of tonal guidance (examples include music or metronome) during training to improve compression rate only (weak recommendation, low-certainty evidence).

Justification and Evidence to Decision Framework Highlights

• In making this recommendation, the EIT Task Force noted that there have been a number of RCTs examining this topic in simulated settings but none examining patient-related outcomes. These studies have generally shown positive effects on retention of CPR skills, at least in the short term, though one study suggested harm.
• We recognize that effective feedback devices are only part of an efficient CPR educational strategy.

Knowledge Gaps

• Although there are a number of simulation studies that demonstrate improved CPR performance both immediately after training with a feedback device and short-term retention of CPR skills post-training, only two studies examined the effect of feedback devices on long-term retention and none looked at patient outcomes.
• The use of feedback devices is likely an important component of CPR training and how it should be integrated with other instructional design elements such as mastery learning and distributive practice needs to be better defined.
• It remains unclear how best to use these devices, how they interact with instructors and how timing of feedback may impact learning and retention.

Attachments

Evidence-to-Decision Table: EIT-648-CPR-Feedback-_TFSR

References

Baldi, E., Cornara, S., Contri, E., Epis, F., Fina, D., Zelaschi, B., Dossena, C., Fichtner, F., Tonani, M., Di Maggio, M., Zambaiti, E. and Somaschini, A. (2017). "Real-time visual feedback during training improves laypersons' CPR quality: a randomized controlled manikin study." CJEM 19(6): 480.

Cortegiani, A., Russotto, V., Montalto, F., Iozzo, P., Meschis, R., Pugliesi, M., Mariano, D., Benenati, V., Raineri, S. M., Gregoretti, C. and Giarratano, A. (2017). "Use of a Real-Time Training Software (Laerdal QCPR®) Compared to Instructor-Based Feedback for High-Quality Chest Compressions Acquisition in Secondary School Students: A Randomized Trial." PloS one 12(1): e0169591.

Griffin, P., Cooper, C., Glick, J. and Terndrup, T. E. (2014). "Immediate and 1-year chest compression quality: effect of instantaneous feedback in simulated cardiac arrest." Simul Healthc 9(4): 264.

Hafner, J. W., Jou, A. C., Wang, H., Bleess, B. B. and Tham, S. K. (2015). "Death before disco: the effectiveness of a musical metronome in layperson cardiopulmonary resuscitation training." J Emerg Med 48(1): 43-52

Katipoglu, B., Madziala, M. A., Evrin, T., Gawlowski, P., Szarpak, A., Dabrowska, A., Bialka, S., Ladny, J. R., Szarpak, L., Konert, A. and Smereka, J. (2019). "How should we teach cardiopulmonary resuscitation? Randomized multi-center study." Cardiology journal. PMID: 31565794

McCoy, C. E., Rahman, A., Rendon, J. C., Anderson, C. L., Langdorf, M. I., Lotfipour, S. and Chakravarthy, B. (2019). "Randomized Controlled Trial of Simulation vs. Standard Training for Teaching Medical Students High-quality Cardiopulmonary Resuscitation." West J Emerg Med 20(1): 15.

Min, M. K., Yeom, S. R., Ryu, J. H., Kim, Y. I., Park, M. R., Han, S. K., Lee, S. H., Park, S. W. and Park, S. C. (2016). "Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition." Clinical and experimental emergency medicine 3(3): 158.

Navarro-Patón, R., Freire-Tellado, M., Basanta-Camiño, S., Barcala-Furelos, R., Arufe-Giraldez, V. and Rodriguez-Fernández, J. E. (2018). "Effect of 3 basic life support training programs in future primary school teachers. A quasi-experimental design." Medicina Intensiva (English Version) 42(4): 207.

Pavo, N., Goliasch, G., Nierscher, F. J., Stumpf, D., Haugk, M., Breckwoldt, J., Ruetzler, K., Greif, R. and Fischer, H. (2016). "Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: a randomised simulation study." Scand J Trauma Resusc Emerg Med 24: 70.

Pavo, N., Goliasch, G., Nierscher, F. J., Stumpf, D., Haugk, M., Breckwoldt, J., Ruetzler, K., Greif, R. and Fischer, H. (2016). "Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: a randomised simulation study." Scand J Trauma Resusc Emerg Med 24: 70.

Sa-Couto, C., Ferreira, A. M., Almeida, D., Nicolau, A. and Vieira-Marques, P. (2018). "Evaluation of skills acquisition using a new low-cost tool for CPR self-training." Porto Biomed J 3(1): e8.

Smereka, J., Szarpak, L., Czekajlo, M., Abelson, A., Zwolinski, P., Plusa, T., Dunder, D., Dabrowski, M., Wiesniewska, Z., Robak, O., Frass, M., Sivrikaya G, U. and Ruetzler, K. (2019). "The TrueCPR device in the process of teaching cardiopulmonary resuscitation: A randomized simulation trial." Medicine 98(27): e15995.

Wagner, M., Bibl, K., Hrdliczka, E., Steinbauer, P., Stiller, M., Gröpel, P., Goeral, K., Salzer-Muhar, U., Berger, A., Schmölzer, G. M. and Olischar, M. (2019). "Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study." Pediatrics 143(2), PMID 30700565

Wilson-Sands, C., Brahn, P. and Graves, K. (2015). "The Effect of Instructional Method on Cardiopulmonary Resuscitation Skill Performance: A Comparison Between Instructor-Led Basic Life Support and Computer-Based Basic Life Support With Voice-Activated Manikin." Journal for Nurses in Professional Development 31(5): E1-7.

Zhou, X. L., Wang, J., Jin, X. Q., Zhao, Y., Liu, R. L. and Jiang, C. (2020). "Quality retention of chest compression after repetitive practices with or without feedback devices: A randomized manikin study." Am J Emerg Med. 38(1):73-8.