One-Hour CPR Training
The American Heart Association and American Red Cross have successfully taught
citizen/bystander CPR courses for more than 20 years. As a result, cardiac arrest victims
treated in the prehospital setting have experienced an increased survival rate when
trained bystanders come to their aid. 1-3
The shorter the period between cardiac arrest, CPR and defibrillation, the faster
patients regain consciousness. 4,5 Thus, when well-trained citizens take the first step in
resuscitation by initiating CPR and activating EMS, early defibrillation and ALS units
have an improved chance of preserving the quality of a patients life.5 But many citizens
hesitate when it comes to taking CPR. A 1983 Gallup poll revealed that time and
inconvenience are key deterrents for potential CPR student. Traditional 4- or 8-hour
courses are often perceived as too time consuming, and class locations often involve a
30-minute commute each way.
We have evaluated successful CPR courses and have designed an original field study. Our
goal was to discover whether effective CPR techniques could be somehow reconfigured and
taught in a shorter course. By using adult-education principles, through which students
receive immediate visual feedback on their efforts, we developed a 1-hour, video enhanced
teaching system. This system not only maintains the same level of quality content
associated with longer courses, but also encourages student participation and allows
instructors to teach more students with less stress.
Our study shows that and enhanced 1-hour CPR class produces equal or higher evaluation
scores than those found in traditional 4- or 8-hour courses. Objective documentation
generated by the same enhanced manikin used in traditional CPR training offers proof of
the course's effectiveness.
One hundred students were divided into two groups: control and experimental. Each group
was further divided into six individual classes of approximately eight students each; thus
performance of the control and experimental groups was actually and average of the six
The individuals chosen to participate in the study were employees of the Los Angeles
Times, who were selected by the newspaper's safety officer. They represented both sexes,
were of random ages, and included various ethnic and educational backgrounds. The group
mix was intended to reflect a cross section of the population at large.
The control group was trained in CPR by instructors from a Los Angeles AHA-authorized
CPR center. Members of this group were taught the accepted 4-hour AHA Heartsaver course
(Module 1, 1987, BLS manual).
Each of the six control-group classes was led by a different instructor, each of whom,
followed the course structure as outlined in the BLS instructors manual. Approximately 3
hours of verbal instruction were followed by a demonstration of manikin* use, student
practice and data collection from each student's second run-through. Two students shared
one manikin, and each received approximately 8 minutes of practice. The instructor watched
the student, evaluated performance and provided verbal feedback. This usually took about 4
hours. The independent evaluator documented each student's results.
The experimental group was trained via a 43-minute video lecture that concisely covered
the verbal portion of the one-rescuer AHA Heartsaver course. A Los Angels AHA Affiliate
faculty member (a registered nurse) was the featured instructor in the videotape. This
instructor monitored the tape and assisted students in manikin practice after they viewed
As in the control group, students were paired, with each allotted approximately 8
minutes of mannequin practice. Data were similarly collected after the students' second
run-throughs. The key difference in the course was that the students themselves watched
the Skillmeter, thus receiving immediate, comprehensive feedback for each compression or
Practice sessions were monitored. The total program time was approximately 1 hour.
This study utilized the acceptable CPR performance results established by the AHA's
Emergency Cardiac Care (ECC) Committee, which are set at 90% accuracy in chest
compressions and 92% in ventilations.
Testing for one-rescuer CPR, according to the AHA instructors manual (1987), must be
uncoached and conducted in the presence of a CPR instructor. If the student fails,
retesting should occur after remedial practice.
- Initial assessment,
- Four cycles of compressions/ventilations,
- Resumption of CPR.
Within this framework, four CPR categories are evaluated: sequencing, timing,
compressions, and ventilations.
To ensure credibility, we engaged a local law firm to administer and collect data. The
firm's representative acted as the "independent evaluator," and objective data
collector during class meetings.
Overall, the experimental group averaged 85% compliance with the ECC standards,
compared to 41% from the control group.
Six of the vital sequencing criteria recorded on the Skillmeter.
Differences between the experimental and control groups occurred as follows:
- Patient responsiveness was checked by only 12% of the control group, as compared with
96% of the experimental group.
- First and second pulse checks were done 8% and 0% of the time, respectively, in the
control group, and 63% and 60%, respectively, in the experimental; group.
The differences between the two groups in the number and rate of compressions were
minimal, but the percentage of correct compressions differed greatly. The experimental
group performed at 88%,while the control group's correct compressions reached only 6%.
"Too little" pressure was the only category in which both groups performed
For other compression errors, the experimental group had a maximum of three errors in
64 compressions, while the control group made up to 51 mistakes in 62 compressions.
Note; In a few of the control-group classes, instructors told to err by compressing too
much rather than too little, which may have increased some students' aggressiveness.
Again, the experimental group performed at a higher level, with 86% correct, as
compared to 44% in the control group.
The control group gave approximately four ventilations out of 10 that were too hard or
fast, resulting in stomach distention. This group also gave four of 10 ventilations with
too much volume.
The experimental group had fewer than one of 10 ventilations with either of these
Other Indicators The experimental group performed at the recommended rate of
15:2, while the control group performed at 14:2.
As for the total time taken to perform the recommended sequencing, the experimental
group took an average of 122 seconds, while the control group averaged 104. The ECC
recommends a maximum of 111 seconds.
The clinical significance of both of these results has never been discussed, and the
difference noted here are most likely of no consequence.
When the data were analyzed, greater swings were apparent in the scores of the control
group. For example, the percentage of correct ventialtions between two control-group
classes differed by 42%, whereas the greatest swing among experimental-group classes was
These results could indicate that video instruction is more consistent. Indeed, this
conclusion is supported by various comments made by individual instructors in this study.
One anecdote regarding compression depth nay have significantly affected some students'
performance scores. When an approved and concise video presentation is accompanied by
experienced instructor monitoring, it may be concluded that fewer of these variables will
affect student training.
There was a time factor to consider with the experimental group. Even though the length
of the video presentation remained the same, practice and test time caused the class to
exceed 1 hour of more than six students attended.
On the other hand, the video presentation could be shortened even further, as
introductory information on "prudent heart living" and "signs and
symptoms" could be deleted, with little anticipated change in performance results.
One may argue, however, that this preventive material is valuable.
This study illustrates that the traditional and effective skills of CPR can be taught
more efficiently. In the 1-hour enhanced course, students interact directly with the CPR
feedback screen that monitors their techniques. The course actually trains students in the
use of the screen, allowing instructors to troubleshoot as students practice.
The course structure in the study resulted in higher scores for the experimental group.
It appears the 1-hour enhanced course can produce equal or better skill development than
that associated with the longer course.
- Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community:
Importance of rapid provision and implications for program planning. JAMA 241:1905-1907,
- Copley DP, Mantle JA, Rogers WJ, et al. Improved outcomes for prehospital
cardiopulmonary collapse with resuscitation by bystanders. Circulation 56:901-905, 1977.
- Cummins RO, Eisenberg MS, Hallstrom AP, et al. Survival of out-of-hospital
cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med
- Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external
defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med
- Cummins RO, Ornato JP, Thies WH, et al. Improving survival from sudden cardiac
arrest: The chain of survival concept. Circulation 83:1832-1847, 1991.
Author; Robert S. Ambrose, BS, Paramedic is a CPR instructor and 15-year veteran
of Washington State EMS. Samuel J Stratton, MD, is the medical director of the Los Angeles
County EMS Agency Paramedic Training Institute and an emergency physician at St. Mary's
Medical Center in Long Beach, CA.