Initial implementation of the resuscitation quality improvement program in emergency department of a teaching hospital in China

Introduction

Globally, there is an urgent increasing need to improve the survival of resuscitation among cardiac arrest patients. Hua et al. (2009) revealed that, in China, the survival rate of OHCA is less than 1% compared with 12% in the USA. Since 2010, continuous improvement of the survival rate in both in-hospital and out-of-hospital cardiac arrests has been demanded, and cardiopulmonary resuscitation (CPR), especially high-quality cardiopulmonary resuscitation (HQ-CPR), was critically important to patients and proved to save lives associated with good neurological outcomes (Meaney et al., 2013). The conventional instructor-led basic support life (BLS) course requires learners to attend an in-person class annually or every 2 years to obtain certification. However, certain limitations for the conventional BLS training have been identified, including the course implementations are often without objective quantitative measurement of the quality of CPR, too much time consumption when mass delivery, and labor intensive with poor long-term skills retention and knowledge, etc. Insufficient exposure to hands-on practice results in trainees unfamiliar with the psychomotor CPR skills (Braslow et al., 1997). CPR skills decay rapidly within short times, studies showed the skills were able to be retained for only 3–6 months (Meaney et al., 2012; Binkhorst et al., 2018; Cheng et al., 2018; Halm & Crespo, 2018). In addition, unexpected psychological barriers and distractions may arise in an unfamiliar environment (Liberman et al., 2000). Therefore, novel pedagogics based on educational theories might help trainees to improve their learning and master of CPR skills.

The International Liaison Committee on Resuscitation (ILCOR) 2015 and 2020 international consensus on resuscitation recommended that high-frequency training improves the quality of CPR delivery and the confidence of practitioners, and individuals that are likely to encounter cardiac arrest (e.g., emergency physicians and nurses), should be considered receiving BLS refresh training with a higher frequency (Finn et al., 2015; Greif et al., 2020).

Yan et al. (2020), reported a high willingness to attend cardiopulmonary resuscitation training and encouraged making efforts to optimize and standardize a national model of CPR delivery training. Chinese national consensus on quality control of IHCA adult cardiopulmonary resuscitation suggested implementing high-frequency training for reducing skills decay as a prevailing existence among the healthcare providers (Wang, Sun & Yangyang, 2018). Meanwhile, Chinese Medical Association Science Popularization Branch (2018) emphasis on physicians and nurses with a high frequency of implementing CPR in clinical practice cannot benefit enough from the conventional course.

The Resuscitation Quality Improvement (RQI) program was launched by the American Heart Association (AHA) since 2015. It is an educational CPR training system combining self-adaptive learning, real-time feedback training, and spaced training (Kuyt et al., 2021). The RQI program, unlike conventional BLS course, provides a high-reliable platform for simulation-based mastery learning and deliberate practice through low-dose, high-frequency quality improvement (Dudzik et al., 2019; Panchal et al., 2020). The RQI program is delivered in a mastery learning model theory, with both knowledge and skill baseline assessments conducted as the pretests, while each core skill training is delivered to allow the deliberate practice of learners, retraining of the skills and further repetition if needed (not passing certain high-achieving standards), and permitted to move to the next session only when achieving high standards of the post-assessment of the current learning unit.

Although it has been proved that high-frequency low dosage training is better than conventional training in CPR core skills learning, when compared with the accumulating data internationally, rare reporting of studies on the effect and quality improvement of CPR skills of RQI training program has been a challenge for its prevalence in China. We sought to deterimine whether effectiveness could be confirmed among Chinese trainees. Before 2021, Chinese clinicians were trained by a conventional training course for over 10 years and accumulated a massive population with BLS learning experience rather than RQI program. It was not clear whether RQI program was effective for both BLS initial certification and renewal training. Most of the previous studies (Dudzik et al., 2019; Panchal et al., 2020; Kuyt et al., 2021) examining the effectiveness of RQI were conducted in developed country. It is not clear whether the implementation of the RQI program was feasible and acceptable in a developing country with a different healthcare system (e.g., China). Is it possible for Chinese trainees to accommodate this innovative training modality? Therefore, we would like to investigate the implementation of RQI program in the Chinese setting. At the beginning of the study design, we realized that there may be differences in CPR performance between novices and experienced providers who have participated in conventional BLS training, as well as differences in confidence in CPR skills and satisfaction with RQI procedures. So we designed this study, with the following aims: 1. to compare the performance of CPR core technique between novice performance and trainees experienced in conventional BLS training post-RQI entry course; 2. to describe how the Chinese participants’ satisfaction with the RQI training program and whether the self-confidence on performing CPR could be improved.

Materials and Methods

Results

Survey

Self-confidence evaluation

Trainees in BLS group had better confidence in the performance of adult chest compressions and ventilation (P < 0.01). Performance of adult ventilation had the highest rating of self-confidence in all participants. However, the performance of infant ventilation gained the lowest rating (Table 3). To explore the correlation between confidence and performance, Fig. 1 demonstrates no significant relationship between CPR performance (adult compression, adult ventilation, infant compression, and adult ventilation) after RQI training and their self-confidence.

Table 3:

Self-confidence rating on CPR post RQI entry course.

	Non-BLS group	BLS group	P value
Adult compression	8.74 (1.39)	9.44(0.99)	0.001*
Infant compression	8.26 (1.41)	9.00 (1.48)	0.004*
Adult ventilation	9.11 (1.19)	9.67 (0.63)	<0.001*
Infant ventilation	8.57 (1.31)	9.17 (1.38)	0.012*

DOI: 10.7717/peerj.14345/table-3

Notes:

* Statistically significant difference.

BLS, basic life support.

Discussion

Previous studies have reported on the excellent performance of RQI indicated the successful improvement of healthcare providers’ CPR psychomotor competence and confidence/satisfaction in different hospital settings (Kuyt et al., 2021; Dudzik et al., 2019). Our study enrolled 149 participants certificated in the entry course and all of the participants improved their performance in all of the core techniques. All of the participants achieved the training and be certificated, both groups showed high satisfaction with RQI entry course, which is consistent with those previous studies. Two strategies were introduced to improve the compliance of RQI program, that trainees were allocated in small groups and a team leader was set in each group to supervise the training.

Compared to the Non-BLS group, participants who had conventional instructor-led training experience had fewer attempts on achieving certification of core techniques. BLS group showed a higher confidence rating for both compression and ventilation compared to the Non-BLS group on adult CPR performance (P value < 0.05). The RQI training program had been well accepted in the group of BLS (fewer attempts and time consumption on core skills training, P value < 0.05 for compression and ventilation respectively). Trainees in our study achieved a qualified CPR performance in the RQI training as all trainees passed the training assessment. After RQI training, trainees in both groups demonstrated improvement among each core technique compared with baseline, most of the compression and ventilation outcomes have been significantly improved. With psychomotor CPR skills training, RQI program followed simulation-based mastery learning, facilitated program by deliberate practice to guarantee both novices and trainees with previous training experience meet the high quality of core skills performance. Conventional instructor-led CPR training has been proved to produce higher consumption in human resources, additional spending on training space renting and alternative demands for healthcare providers impacting on time of patient care. On the contrary, RQI program showed advantages compared to conventional BLS training in aspects of its lower cost, no instructor assistance, and real-time feedback (Dudzik et al., 2019; Oermann et al., 2020; Panchal et al., 2020; Schmitz et al., 2021; Kuyt et al., 2021; Donoghue et al., 2021). Furthermore, we found there was no significant correlation between the compression/ventilation score after RQI training and the self-confidence score. The medical staff may feel good about their self-perceptions of CPR quality, but they are often mismatched with the actual skills (Cheng et al., 2019; Troy et al., 2019). This further points to the need to use real-time feedback in CPR training.

The participants in BLS group are more senior, had longer careers, and showed abundant clinical experience in this study. However, these findings did not indicate superior CPR performance outcomes. Up to 60.2% of learners took participant in the BLS training according to the latest CPR guidelines within 3 months in this study, adult compression rate was faster in BLS group, and faster adult and infant ventilation rates than those in Non-BLS group. Kandasamy et al. (2019) also found that participants in the BLS training group were 2.5 times more likely to be over-compressed than the lay rescuers’ cohort group. Three explanations for the results of excessive compression and ventilation were: 1. The previous training emphasized the negative correlation between lower rates and the impact on the implementation of compression (Kandasamy et al., 2019). Compression rate during CPR had been corrected from over 100 bpm to 100–120 bpm since 2015 CPR guidelines (Travers et al., 2015). But the effect of emphasizing rapid compression at CPR may still exist. 2. Conventional BLS training seems to lack a reliable and efficient objective assessment. The quality of CPR in BLS course depends on the instructor’s subjective visual assessment (Cheng et al., 2015; Jones et al., 2015). visual assessment by instructors was found to be less reliable for CPR skills performance assessment after the course. 3. Studies have also shown that BLS skills will experience a decline over time, which can occur in 3–6 months post-training (Meaney et al., 2012; Binkhorst et al., 2018; Cheng et al., 2018; Halm & Crespo, 2018). The RQI program, with distributed practice, mastery learning and real-time feedback, could compensate for the deficiency of conventional BLS training programs. Lin et al. (2018) found that compare to the conventional BLS course, the distributed CPR training with real-time feedback in pediatric healthcare providers was able to improve chest compression metrics (depth, rate and recoil) at 3 months with retention of CPR skills throughout the study. In this study, we found that trainees in BLS group who went through RQI training required fewer attempts to pass the course, showing a steeper learning curve, and a faster re-mastery of CPR skills during retraining, reducing the total time spent on retraining. This result could be a rational explanation for conducting RQI program among the population with previous conventional instructor-led training representing most of the healthcare providers in Mainland China.

RQI not only provide excellent CPR skills, but also established confidence for novice and experienced learners. Although the level of confidence before the RQI program training was not evaluated, the BLS group demonstrated better confidence post-training. This might be caused by the trainees who experienced both BLS training and also had more clinical practice to enhance their confidence than novices. However, in this study exposed trainees with previous learning experience had poorer performance of core techniques during baseline assessment, indicating that confidence might be a false trust in previously learned skills (Hopstock, 2008). Mismatching of “false self-confidence” and poor performance may lead to irrational compression, as well as ventilation, during CPR. Subsequent to this situation, improper clinical practice may affect the quality of patient care. Therefore, the emphasis on CPR training with mastery learning was important.

This study found that almost all participants are highly satisfied with the RQI program, indicating that it had a good acceptance and a subjective program success. These findings are congruent with similar research conducted in the USA by Dudzik et al. (2019), in which the RQI had higher satisfaction and increased confidence in CPR skills for health care providers at a community hospital. They found that 89 (67.4%) out of the 132 respondents agreed or strongly agreed that RQI was their preferred BLS training method compared with the traditional model or online HeartCode BLS options. Our findings demonstrated the highest satisfaction levels for RQI among respondents based on the unique features of the program, such as the form of a cart simulator in the BLS group and real-time feedback in the Non-BLS group. Trainees with previous experience of conventional BLS training were familiar with the process of training, and their attention was more likely to be drawn to the newer modality of the cart. The feedback system during CPR training can guide the real-time correction of CPR performance and can improve compliance of high quality. There are similar researches on non-conventional BLS training methods involving online eSimulation and real-time audiovisual manikin feedback technology (Yeung et al., 2009; Lin et al., 2018; Weston et al., 2019).

“No instructor-involvement during training” is one of the characteristics of the RQI program, but interestingly, among all of the participants’ ratings, such a feature received relatively lower satisfaction. The purpose of conventional training with instructor-involved training was targeting for assessing learners’ CPR skills and correcting errors to ensure high-quality performance. However, As we mentioned before, the instructor may not always be able to identify the appropriate chest compression depth and rescue breaths without real-time feedback (Hansen et al., 2019). Previous studies revealed no differences in terms of effectiveness, when comparing self-learning vs instructor-led teaching (Mpotos et al., 2011, 2012; Mardegan, Schofield & Murphy, 2015). Two trials found that self-learning is not inferior to instructor-led learning in the short term. However, trainees keep better performance of CPR practical skills for instructor-led learning after BLS training (Pedersen et al., 2018; Bylow et al., 2019). As the current model of BLS training is mainly dominated by classroom-based instructor-involved training in our country (Finn et al., 2015; Cheng et al., 2020; Wang, Meng & Yu, 2018), and RQI program may be one of the effective alternative courses.

Under the post-pandemic era, BLS training has been a challenge to Chinese clinicians, instructor led and classroom gathering has been restricted conducted in training site, calling for other training programs instead of conventional course for better implementation in China (Yan et al., 2020). It has been reported that the success rate for BLS among outpatients was significate lower than the data of the USA, and Chinese clinicians have been making a great effort on improving it (Wang, Meng & Yu, 2018; Wang, Sun & Yangyang, 2018). With a massive population having been training with a conventional course, it was equally important for us to explore the perception and effectiveness of training for both novice and experienced healthcare providers, because skill retention was a key content for all populations. In our study, we found the trainees with previous learning experience showed better improvement among the core skills practice and fewer numbers of attempts for passing the training with lower baseline scores compared with novice, they also reported better confidence aligned with training outcomes, which could be explained that for those with learning experience RQI program would be another option for BLS training, but the feasibility of this program should be discussed until it has been facilitated for one year considered other data should be involved into the measurements.

Conclusions

The RQI program can provide excellent CPR performance skills for participants. For trainees with previous experience in BLS training, the RQI program certificate the effectiveness of training while reducing the number of attempt for past the training, they also demonstrated higher confidence compared to the novice. For all participants, the RQI program showed a high rating of satisfaction. We might consider that RQI program could be an option for the prevalence of BLS training in mainland China, with broadly training of a conventional BLS course, but needed a large study to confirm.

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