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Stærk M, Vammen L, Andersen CF, Krogh K, Løfgren B. Basic life support skills can be improved among certified basic life support instructors. Resusc Plus 2021; 6:100120. [PMID: 34223379 PMCID: PMC8244352 DOI: 10.1016/j.resplu.2021.100120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background A correct visual skill demonstration is important when learning cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED). Basic life support (BLS) instructors are expected to master and demonstrate CPR/AED skills correctly. The aim of this study was to evaluate certified BLS instructors’ competencies in demonstrating CPR and the use of an AED. Methods Certified BLS instructors demonstrated CPR and the use of an AED on a resuscitation manikin. Skills were evaluated using data collected from the manikin and video recordings and compared to resuscitation guidelines. Further, instructors completed questionnaires on resuscitation guidelines and rating of their own CPR/AED skills. Results Overall, we analyzed data from 125 instructors. Of all chest compressions, only 22% were within guideline recommendations regarding depth. Instructors performed chest compressions with excessive depth (mean depth 64 mm (7.3)) and a mean rate of 115 min−1 (10.8). Only 25% of instructors placed the left AED electrode correctly (median distance 7.6 cm (5.0;10.5)), while the right AED electrode usually was placed correctly (median distance 2.9 cm (1.5;4.0), 85% placed correctly). Nearly half of the instructors failed to state correct answers regarding how to diagnose a cardiac arrest and where to place the AED electrodes. Despite their performance, instructors rated their BLS skills as good. Conclusion Certified BLS instructors’ have poor CPR/AED skills and several important knowledge gaps on CPR/AED guidelines in contrast to instructors’ self-reported skills. This highlights a need for improving BLS instructor education, including continuous faculty development to ensure optimal learning conditions for BLS course participants.
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Affiliation(s)
- Mathilde Stærk
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark.,Education and Research, Randers Regional Hospital, Randers, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lauge Vammen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Fuchs Andersen
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark.,Education and Research, Randers Regional Hospital, Randers, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Kristian Krogh
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bo Løfgren
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Donaldson L, Stevenson MA, Fletcher DJ, Gillespie Í, Kellett-Gregory L, Boller M. Differences in the clinical practice of small animal CPR before and after the release of the RECOVER guidelines: Results from two electronic surveys (2008 and 2017) in the United States and Canada. J Vet Emerg Crit Care (San Antonio) 2020; 30:615-631. [PMID: 32975359 DOI: 10.1111/vec.13010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/24/2019] [Accepted: 03/29/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether the clinical approach to CPR has changed following the publication of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines in 2012. DESIGN Internet-based survey. SETTING Academia and referral practice. SUBJECTS Four hundred and ninety-one small animal veterinarians in clinical practice in the United States and Canada. INTERVENTIONS An internet-based survey assessing the clinical approach to small animal CPR was circulated with the assistance of veterinary professional organizations on 2 separate occasions: prior to (2008) and following (2017) publication of the 2012 (RECOVER) guidelines. Survey questions identical to both surveys solicited details of clinician approaches to CPR preparedness, basic life support (BLS), and advanced life support (ALS). Respondents were grouped into level of expertise (board-certified specialists [BCS, n = 202] and general practitioners in emergency clinics [GPE, n = 289]), and year of response to the survey (2008, n = 171; 2017, n = 320). MEASUREMENTS AND MAIN RESULTS Compliance with the RECOVER guidelines pertaining to CPR preparedness (P < 0.01), BLS (P < 0.01), and ALS P < 0.01) was consistently higher in respondents to the 2017 survey compared to those of the 2008 survey. Being a BCS was associated with significantly higher compliance with the RECOVER recommendations than GPE in the domains of preparedness (P = 0.02), BLS (P < 0.01), and ALS (P < 0.01). Increases in age of the respondent had a negative effect on compliance with the BLS guidelines (P < 0.01), while gender had no effect. CONCLUSIONS Compared to 2008, current practices in small animal CPR in the North American emergency and critical care community shifted toward those recommended in the RECOVER guidelines across all CPR domains. This supports the notion that uptake of the RECOVER guidelines among veterinary emergency or critical care clinicians was sufficient to lead to a change in the practice of CPR.
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Affiliation(s)
- Liam Donaldson
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia
| | - Mark A Stevenson
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia
| | - Daniel J Fletcher
- College of Veterinary Medicine, Department of Clinical Sciences, Cornell University, Ithaca, New York
| | - Íde Gillespie
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia
| | | | - Manuel Boller
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia.,Translational Research and Clinical Trials (TRACTs), Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Australia
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Boller M, Fletcher DJ. Update on Cardiopulmonary Resuscitation in Small Animals. Vet Clin North Am Small Anim Pract 2020; 50:1183-1202. [PMID: 32798056 DOI: 10.1016/j.cvsm.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of ventilation and systemic perfusion, leads to discontinuation of tissue oxygen delivery and death if not quickly reversed. Reported resuscitation rates suggest that the heart can be restarted in 40% to 50% of dogs and cats treated with cardiopulmonary resuscitation (CPR). However, approximately 80% of these animals do not survive to hospital discharge. To minimize mortality due to CPA a broad strategy is required including preparedness and prevention measures, basic and advanced life support as well as post-cardiac arrest care. This article summarizes the current guidelines on the treatment of small animals with CPA..
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Affiliation(s)
- Manuel Boller
- Melbourne Veterinary School, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Daniel J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, DCS Box 31, Ithaca, NY 14853, USA
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Nishiyama C, Shimamoto T, Kiyohara K, Kawamura T, Kitamura T, Sakamoto T, Iwami T. Effectiveness of a One-minute Self-retraining for Chest Compression-only Cardiopulmonary Resuscitation: Randomized Controlled Trial. AEM EDUCATION AND TRAINING 2017; 1:200-207. [PMID: 30051035 PMCID: PMC6001494 DOI: 10.1002/aet2.10034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Although cardiopulmonary resuscitation (CPR) skills decay after training, little is known about appropriate retraining methods. Our aim was to evaluate the effectiveness of a 1-minute self-retraining (with automated assessment and feedback) at 3 months after the initial 45-minute chest compression-only CPR training in a simulated randomized controlled trial. METHODS After the initial 45-minute chest compression-only CPR training, participants were randomly assigned to either a 1-minute self-retraining group or a control group. Three months after the initial training, the self-retraining group individually attended the 1-minute self-retraining with a self-training device. The participants' resuscitation skills were evaluated by a 2-minute case-based scenario test 6 months after the initial training. The primary outcome was the number of correct chest compressions with appropriate depth. RESULTS A total of 109 subjects participated in this study. With regard to the primary outcome, the number of chest compressions performed at the appropriate depth, there was not a statistically significant difference between groups (136.5 [39.8-204.5] in the self-retraining group versus 88.0 [8.5-162.0] in the control group, p = 0.66). The number of total chest compressions in the self-retraining group was 214.0 (186.5-236.0), which was significantly greater (p = 0.01) than that of the control group (177.0 [117.5-215.0]). The time without chest compressions was significantly shorter in the self-retraining group (0 [0-5.3] seconds vs. 23.0 [0.5-47.0] seconds, p = 0.01). CONCLUSIONS The 1-minute self-retraining program with hands-on practice appears to help preserve certain chest compression skills. Further efforts to provide methods to maintain CPR skills should be considered.
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Affiliation(s)
- Chika Nishiyama
- Department of Critical Care NursingKyoto University Graduate School of Human Health ScienceKyotoJapan
| | | | - Kosuke Kiyohara
- Department of Public HealthTokyo Women's Medical UniversityTokyoJapan
| | | | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population SciencesDepartment of Social and Environmental MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Tetsuya Sakamoto
- Department of Emergency MedicineTeikyo University School of MedicineTokyoJapan
| | - Taku Iwami
- Kyoto University Health ServiceKyotoJapan
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Wang J, Zhuo CN, Zhang L, Gong YS, Yin CL, Li YQ. Performance of cardiopulmonary resuscitation during prolonged basic life support in military medical university students: A manikin study. World J Emerg Med 2015; 6:179-85. [PMID: 26401177 DOI: 10.5847/wjem.j.1920-8642.2015.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 05/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The quality of chest compressions can be significantly improved after training of rescuers according to the latest national guidelines of China. However, rescuers may be unable to maintain adequate compression or ventilation throughout a response of average emergency medical services because of increased rescuer fatigue. In the present study, we evaluated the performance of cardiopulmonary resuscitation (CPR) in training of military medical university students during a prolonged basic life support (BLS). METHODS A 3-hour BLS training was given to 120 military medical university students. Six months after the training, 115 students performed single rescuer BLS on a manikin for 8 minutes. The qualities of chest compressions as well as ventilations were assessed. RESULTS The average compression depth and rate were 53.7±5.3 mm and 135.1±15.7 compressions per minute respectively. The proportion of chest compressions with appropriate depth was 71.7%±28.4%. The average ventilation volume was 847.2±260.4 mL and the proportion of students with adequate ventilation was 63.5%. Compared with male students, significantly lower compression depth (46.7±4.8 vs. 54.6±4.8 mm, P<0.001) and adequate compression rate (35.5%±26.5% vs. 76.1%±25.1%, P<0.001) were observed in female students. CONCLUSIONS CPR was found to be related to gender, body weight, and body mass index of students in this study. The quality of chest compressions was well maintained in male students during 8 minutes of conventional CPR but declined rapidly in female students after 2 minutes according to the latest national guidelines. Physical fitness and rescuer fatigue did not affect the quality of ventilation.
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Affiliation(s)
- Juan Wang
- Department of Emergency Medicine, Southwest Hospital, Third Military Medical University, Chongqing, China ; Medical Training Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Chao-Nan Zhuo
- College of Bioengineering, Chongqing University, Chongqing, China
| | - Lei Zhang
- Department of Emergency Medicine, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yu-Shun Gong
- School of Biomedical Engineering, Third Military Medical University, Chongqing, China
| | - Chang-Lin Yin
- Department of Emergency Medicine, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yong-Qin Li
- School of Biomedical Engineering, Third Military Medical University, Chongqing, China
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Automated testing combined with automated retraining to improve CPR skill level in emergency nurses. Nurse Educ Pract 2015; 15:212-7. [DOI: 10.1016/j.nepr.2014.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 11/08/2014] [Accepted: 11/19/2014] [Indexed: 11/19/2022]
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Wang J, Tang C, Zhang L, Gong Y, Yin C, Li Y. Compressing with dominant hand improves quality of manual chest compressions for rescuers who performed suboptimal CPR in manikins. Am J Emerg Med 2015; 33:931-6. [PMID: 25937378 DOI: 10.1016/j.ajem.2015.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/30/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The question of whether the placement of the dominant hand against the sternum could improve the quality of manual chest compressions remains controversial. In the present study, we evaluated the influence of dominant vs nondominant hand positioning on the quality of conventional cardiopulmonary resuscitation (CPR) during prolonged basic life support (BLS) by rescuers who performed optimal and suboptimal compressions. METHODS Six months after completing a standard BLS training course, 101 medical students were instructed to perform adult single-rescuer BLS for 8 minutes on a manikin with a randomized hand position. Twenty-four hours later, the students placed the opposite hand in contact with the sternum while performing CPR. Those with an average compression depth of less than 50 mm were considered suboptimal. RESULTS Participants who had performed suboptimal compressions were significantly shorter (170.2 ± 6.8 vs 174.0 ± 5.6 cm, P = .008) and lighter (58.9 ± 7.6 vs 66.9 ± 9.6 kg, P < .001) than those who performed optimal compressions. No significant differences in CPR quality were observed between dominant and nondominant hand placements for these who had an average compression depth of greater than 50 mm. However, both the compression depth (49.7 ± 4.2 vs 46.5 ± 4.1 mm, P = .003) and proportion of chest compressions with an appropriate depth (47.6% ± 27.8% vs 28.0% ± 23.4%, P = .006) were remarkably higher when compressing the chest with the dominant hand against the sternum for those who performed suboptimal CPR. CONCLUSIONS Chest compression quality significantly improved when the dominant hand was placed against the sternum for those who performed suboptimal compressions during conventional CPR.
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Affiliation(s)
- Juan Wang
- Emergency Department, Southwest Hospital, Third Military Medical University, Chongqing 400038, China; Medical Training Center, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Ce Tang
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Lei Zhang
- Emergency Department, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yushun Gong
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Changlin Yin
- Emergency Department, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yongqin Li
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China.
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Sullivan NJ, Duval-Arnould J, Twilley M, Smith SP, Aksamit D, Boone-Guercio P, Jeffries PR, Hunt EA. Simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: A randomized controlled trial. Resuscitation 2015; 86:6-13. [DOI: 10.1016/j.resuscitation.2014.10.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/21/2014] [Accepted: 10/28/2014] [Indexed: 10/24/2022]
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Iserbyt P, Byra M. The design of instructional tools affects secondary school students' learning of cardiopulmonary resuscitation (CPR) in reciprocal peer learning: a randomized controlled trial. Resuscitation 2013; 84:1591-5. [PMID: 23831502 DOI: 10.1016/j.resuscitation.2013.06.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 06/11/2013] [Accepted: 06/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Research investigating design effects of instructional tools for learning Basic Life Support (BLS) is almost non-existent. AIM To demonstrate the design of instructional tools matter. The effect of spatial contiguity, a design principle stating that people learn more deeply when words and corresponding pictures are placed close (i.e., integrated) rather than far from each other on a page was investigated on task cards for learning Cardiopulmonary Resuscitation (CPR) during reciprocal peer learning. METHODS A randomized controlled trial. A total of 111 students (mean age: 13 years) constituting six intact classes learned BLS through reciprocal learning with task cards. Task cards combine a picture of the skill with written instructions about how to perform it. In each class, students were randomly assigned to the experimental group or the control. In the control, written instructions were placed under the picture on the task cards. In the experimental group, written instructions were placed close to the corresponding part of the picture on the task cards reflecting application of the spatial contiguity principle. RESULTS One-way analysis of variance found significantly better performances in the experimental group for ventilation volumes (P=.03, ηp2=.10) and flow rates (P=.02, ηp2=.10). For chest compression depth, compression frequency, compressions with correct hand placement, and duty cycles no significant differences were found. CONCLUSION This study shows that the design of instructional tools (i.e., task cards) affects student learning. Research-based design of learning tools can enhance BLS and CPR education.
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Affiliation(s)
- Peter Iserbyt
- Research Group for Physical Activity, Sports & Health, KU Leuven, Tervuursevest 101, BE-3001 Leuven, Belgium.
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Fletcher DJ, Boller M. Updates in small animal cardiopulmonary resuscitation. Vet Clin North Am Small Anim Pract 2013; 43:971-87. [PMID: 23747269 DOI: 10.1016/j.cvsm.2013.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
For dogs and cats that experience cardiopulmonary arrest, rates of survival to discharge are 6% to 7%, as compared with survival rates of 20% for people. The introduction of standardized cardiopulmonary resuscitation guidelines and training in human medicine has led to substantial improvements in outcome. The Reassessment Campaign on Veterinary Resuscitation initiative recently completed an exhaustive literature review and generated a set of evidence-based, consensus cardiopulmonary resuscitation guidelines in 5 domains: preparedness and prevention, basic life support, advanced life support, monitoring, and postcardiac arrest care. This article reviews some of the most important of these new guidelines.
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Affiliation(s)
- Daniel J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, DCS Box 31, Ithaca, NY 14853, USA.
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Mpotos N, Yde L, Calle P, Deschepper E, Valcke M, Peersman W, Herregods L, Monsieurs K. Retraining basic life support skills using video, voice feedback or both: A randomised controlled trial. Resuscitation 2013; 84:72-7. [DOI: 10.1016/j.resuscitation.2012.08.320] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 07/16/2012] [Accepted: 08/09/2012] [Indexed: 11/24/2022]
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Mpotos N, De Wever B, Valcke MA, Monsieurs KG. Assessing basic life support skills without an instructor: is it possible? BMC MEDICAL EDUCATION 2012; 12:58. [PMID: 22824338 PMCID: PMC3461425 DOI: 10.1186/1472-6920-12-58] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 07/23/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Current methods to assess Basic Life Support skills (BLS; chest compressions and ventilations) require the presence of an instructor. This is time-consuming and comports instructor bias. Since BLS skills testing is a routine activity, it is potentially suitable for automation. We developed a fully automated BLS testing station without instructor by using innovative software linked to a training manikin. The goal of our study was to investigate the feasibility of adequate testing (effectiveness) within the shortest period of time (efficiency). METHODS As part of a randomised controlled trial investigating different compression depth training strategies, 184 medicine students received an individual appointment for a retention test six months after training. An interactive FlashTM (Adobe Systems Inc., USA) user interface was developed, to guide the students through the testing procedure after login, while Skills StationTM software (Laerdal Medical, Norway) automatically recorded compressions and ventilations and their duration ("time on task"). In a subgroup of 29 students the room entrance and exit time was registered to assess efficiency. To obtain a qualitative insight of the effectiveness, student's perceptions about the instructional organisation and about the usability of the fully automated testing station were surveyed. RESULTS During testing there was incomplete data registration in two students and one student performed compressions only. The average time on task for the remaining 181 students was three minutes (SD 0.5). In the subgroup, the average overall time spent in the testing station was 7.5 minutes (SD 1.4). Mean scores were 5.3/6 (SD 0.5, range 4.0-6.0) for instructional organisation and 5.0/6 (SD 0.61, range 3.1-6.0) for usability. Students highly appreciated the automated testing procedure. CONCLUSIONS Our automated testing station was an effective and efficient method to assess BLS skills in medicine students. Instructional organisation and usability were judged to be very good. This method enables future formative assessment and certification procedures to be carried out without instructor involvement. TRIAL REGISTRATION B67020097543.
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Affiliation(s)
- Nicolas Mpotos
- Emergency Department, Ghent University Hospital, De Pintelaan 185, Ghent, B-9000, Belgium
| | - Bram De Wever
- Department of Educational Studies, Ghent University, H. Dunantlaan 2, Ghent, B-9000, Belgium
| | - Martin A Valcke
- Department of Educational Studies, Ghent University, H. Dunantlaan 2, Ghent, B-9000, Belgium
| | - Koenraad G Monsieurs
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, Ghent, B-9000, Belgium
- Emergency Department, Antwerp University Hospital, Wilrijkstraat 10, Edegem, B-2650, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, B-2610, Belgium
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