What is the effective load in cpr

Training and implementation of resuscitation


The survival chain [1] was expanded to the formula of survival [2], because the declared goal of saving more lives depends not only on solid, high-quality research, but also on effective training for laypeople and professional helpers [3] . Ultimately, where cardiac arrest patients are being treated, resource efficient systems must be implemented to improve survival after cardiac arrest.

This chapter contains the 17 training-relevant PICO questions (population, intervention, control (control intervention), outcome (result)), which were created by the "Education, Implementation and Teams (EIT) Task Force" of the International Liaison Committee on Resuscitation (ILCOR) of 2011 to 2015 were evaluated. This assessment and evaluation process of the found evidence followed the "Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process", which was set out in the ILCOR Consensus Paper 2015 on the scientific nature and the training recommendations ("Consensus on Science and Training Recommendations 2015" - CoSTR) was published [4]. This publication summarizes the new recommendations for training and its implementation.

This chapter describes the principles of teaching and training in basic life saving measures (BLS) and extended cardiopulmonary resuscitation (CPR) measures. The teaching of non-technical skills (NTS), such as communication, team and leadership behavior, experiences a clear focus. In addition, the chapter contains the ERC portfolio of courses and ends with an outlook on research questions in the teaching area and possible developments of the ERC courses (ERC European Resuscitation Council).

The reasons for the late implementation of the last guidelines were delays in the provision of training materials and problems with the release of personnel for CPR training [5–7]. In order to facilitate the dissemination of the 2015 resuscitation guidelines and to carry them out on time, the ERC carefully planned the translations into the European languages ​​and the dissemination of the new guidelines and the training material for all course formats at an early stage. This chapter provides the foundation for successful teaching strategies that will improve training in CPR.

Summary of changes since 2010 ERC guidelines

The following is a summary of the main new assessments or changes in the training, implementation and team recommendations since the 2010 ERC guidelines:


  • Simulation dolls that are very close to reality (“High Fidelity”) are very much appreciated by learners, but are significantly more expensive than standard reanimation dolls (“Lower Fidelity”). Centers are recommended to use these high fidelity simulation dummies when the resources to purchase and maintain them are available. However, the use of lower fidelity resuscitation manikins is adequate for all levels of ERC CPR courses.

  • CPR feedback devices that provide instructions are useful for improving the rate and depth of compression, relief, and hand placement. Devices that only emit tones only improve the compression frequency. Since the helpers concentrate on the frequency, this has a worsening effect on the compression depth. There is currently no evidence to show that training with these sound-emitting devices in the ERC course actually leads to improved patient survival rates in an emergency.

  • The intervals for repetition training will be different depending on the course participants (e.g. lay or professional helpers). It is known that CPR skills deteriorate within months of training. Because of this, annual repetition training strategies may not be frequent enough. Even if the optimal interval is not clear, more frequent “low dose” repetition workouts seem to be a successful strategy.

  • Training in non-technical skills, such as communication, team leadership and the task of the individual in a team, are an essential addition to training technical skills. Such training should be integrated into all "life support" courses.

  • Control center staff play a critical role in providing guidance on lay CPR. In order to be able to give a layperson CPR instructions efficiently and clearly in a stressful situation, they need specific training.


  • The debriefing, which includes real resuscitation data and focuses on the resuscitation measures performed, showed clear improvements in the resuscitation teams. There is a strong recommendation that resuscitation teams should be debriefed.

  • Regional health care systems, including cardiac arrest centers, should be supported. They are related to increased survival and improved neurological status in patients after out-of-hospital cardiac arrest.

  • The use of innovative technologies and social networks informs first aiders earlier and helps them to reach out-of-hospital cardiovascular patients and the nearest AED more quickly. Any technology that ensures that first aiders can start CPR earlier, including AED application, must be supported.

  • “A system is needed to save lives” (http://www.resuscitationacademy.com/). Institutions (ambulance / ambulance organizations, cardiac arrest centers) that have health care responsibilities and manage cardiac arrest patients must evaluate their processes to ensure that the treatment provided has the best and highest levels of survival offers.

Training strategies for the basic measures

Who is to be trained?

BLS is the cornerstone of resuscitation. It is generally accepted that first-aid CPR is critical to cardiac arrest survival outside the hospital. Chest compressions and early defibrillation are the main determinants of survival in out-of-hospital cardiac arrest, and there is evidence that 30-day and 1-year survival has improved with the introduction of lay training [8, 9].

For these reasons, the primary goal of resuscitation training is to train laypeople in CPR. The evidence shows that BLS layperson training increases the number of first aiders who use BLS in a real situation [10–12]. The term “layperson” is broadly defined and means both people without any formal training in a health profession as well as those who are expected to be competent in CPR (lifeguards, first aid paramedics or sports and security personnel). Despite improved access to CPR training for laypeople, there are considerable reservations that prevent the use of real CPR. The main reasons for this are: fear of infection, fear of doing something wrong or being prosecuted [13].

When family members of high-risk patients are trained in CPR, it reduces their and the patient's anxiety, improves emotional outlook, and increases the feeling of being able and willing to start CPR when needed. In high-risk populations (high risk of cardiac arrest and low first-aid rate), specific factors could be identified that suggest targeted training that is geared to the special needs and characteristics of those affected [14, 15]. Unfortunately, potential first responders from these communities do not seek such training on their own initiative, but when they attend they gain good BLS skills [16–18]. They are definitely willing to be trained and share their experiences with others [16, 17, 19–21].

Most of the research on resuscitation training has been done in adult rescuers in adult CPR. It can be assumed that children and young people will need other forms of teaching. Therefore, further research is needed to find the best method for teaching BLS to children and adolescents [22].

One of the most important steps to increase the first aid rate and thus the worldwide survival after resuscitation is to educate school children. The American Heart Association advocated compulsory resuscitation training in American schools as early as 2011 [23]. Prior to that, experience from Seattle showed that teaching school children significantly increased first aid rates and survival over the past 30 years. Similar rates of increase in CPR have been reported by Scandinavian resuscitation school programs [24]. It would be sufficient to teach school children from the age of 12 2 hours per year in resuscitation measures [22]. From this age onwards, they have a positive attitude towards learning such skills. Both medical professionals and school teachers need special training so that they can fully utilize the children's potential to learn CPR [25]. Schoolchildren and their teachers are resuscitation multipliers both in private and in public. They pass on the CPR skills they have learned to their family members. The proportion of CPR-trained people in society can increase substantially, and in the long term this leads to a considerable increase in the CPR first-aid rate [26].

Professional helpers in all areas of health care, from ambulance and rescue organizations to the general wards of hospitals to the areas of emergency and intensive care medicine, must be trained in CPR. Interruptions in chest compressions, in addition to poor chest compression (incorrect compression depth and frequency), contribute significantly to ineffective CPR [27]. Since poorly performed CPR is associated with poor survival, these core components need to be emphasized in any CPR training.

Well-trained and trained control center staff are able to instruct laypeople in CPR by telephone and thus improve patient survival [28]. The difficulty here is to recognize cardiac arrest, especially if there is agonal breathing [29]. The training of control center personnel must focus on the importance of recognizing agonal breathing and also seizures as an aspect of cardiac arrest [30]. The control center staff needs special training in conveying the instructions with which they instruct first aiders in CPR [30].

How to train

BLS / AED training courses should be tailored to the needs of the trainees and should be as simple as possible. The increasingly easy access to a wide variety of training methods (digital, online, self-directed learning, lessons designed by instructors) offers various alternatives to CPR lessons for laypeople as well as professional helpers. The effectiveness of these different possibilities of so-called integrated learning ("blended learning") is unfortunately still unclear and the impact must be urgently researched directly after a course. Ultimately, it should also be clarified whether such CPR training methods actually improve survival rates in real cardiac arrest.

The CPR training must be adapted to the different needs of the trainee. The variety of teaching methods is necessary to ensure that CPR knowledge and skills can be acquired and retained. Self-instructing programs seem to be an efficient alternative to traditional instructor-led courses for both laypeople and professional helpers [31–35]. They are available with or without simultaneous practical exercises ("hands-on practice", such as video, DVD, online training or a computer that gives feedback directly during the training).

Rescuers who are expected to perform CPR on a regular basis must be able to draw knowledge from the current guidelines and apply them effectively as part of a multi-professional team. These helpers require more complex training, which includes both technical and non-technical skills (working in a team, management responsibility, structured communication) [36, 37].

The BLS and AED course program (basic measures)

There is enough evidence that laypeople not only learn effective CPR, but can also be trained to use an AED [38]. The introduction of public access defibrillators demonstrated that laypeople can defibrillate effectively [39]. The question of whether they need AED training or whether the AEDs can be used without further explanation has not yet been adequately answered [40]. Training programs for BLS / AED must be tailored to the needs of the trainee and kept as simple as possible. Regardless of the type of teaching, the following core elements must be part of the BLS / AED courses:

  • The willingness to start CPR in an emergency and an understanding of personal and environmental risks.

  • Detecting unconsciousness, snapping, or agonal breathing in unresponsive people, checking normal reactions, opening airways, and checking for breathing to confirm cardiac arrest [41, 42].

  • High quality chest compression (maintaining the compression frequency and depth, complete relief between compressions, minimal times without compression (“hands-off time”) and external ventilation (time and volume of ventilation).

  • Feedback, either from helpers during CPR and / or from equipment, can help ensure that newly acquired skills are better retained in the context of BLS training [43].

Teaching Standard CPR vs. Continuous Chest Compression

The role of standard CPR vs. CPR with continuous chest compression is discussed in the BLS chapter of these ERC guidelines [42]. In order to make CPR training palatable to all fellow citizens, it is recommended that the training content be conveyed as simply as possible:

  • As a minimum, all citizens should be able to perform effective chest compressions in the end.

  • Ideally, everyone should learn the full range of CPR skills (chest compression and ventilation at a ratio of 30: 2).

  • If the available training times are limited or the circumstances of the lesson do not allow otherwise (e.g. CPR guided by the control center by people who happen to be present, mass events and public campaigns, videos distributed on the Internet), one should rely on CPR with continuous chest compression restrict. Local programs must incorporate considerations of the local population composition, cultural norms and the frequency of first responders.

  • Anyone who initially only learned continuous chest compressions should subsequently also be instructed in ventilation. Ideally, after CPR training with continuous chest compression, standard BLS training is offered, which teaches chest compression and ventilation in one training unit.

  • Lay helpers with care tasks in the broadest sense (first aid staff, sports facility attendants or lifeguards, school, home and monitoring staff) must be trained in standard CPR (chest compression and ventilation).

  • For child resuscitation, rescuers should learn to apply what they have learned in CPR courses about treating adults, since doing nothing is definitely the worst thing for survival. Laypeople who are responsible for children (parents, teachers, educators, sports trainers) and who want to learn child reanimation can be taught in modified adult BLS courses. These lessons are intended to convey that, before help is called, 5 initial ventilations, followed by 1 min CPR, should be given if no one is around to alert [44].

BLS / AED training methods

There are a variety of BLS / AED training methods for laypersons and healthcare professionals. Traditionally, instructor-led courses are the most common [45]. A very efficient alternative to these courses are well-planned self-learning programs (e.g. videos, DVDs, computer-aided feedback), which are supported by short instructions from the instructors, v. a. for lay training on the AEDs [18, 33, 34, 46–49].

Even if there are no instructors available, these self-study programs are an acceptable and pragmatic solution for teaching the use of an AED. Short video / computer self-learning programs with minimal or no instructor help, but which offer practical exercises with the AED (“practice-while-you-watch”), can be viewed as an effective alternative to traditional instructor AED courses [48, 50 , 51].

Ultimately, it is known that first responders can use AEDs without any formal training. But just having an AED nearby is no guarantee that it will be used [52]. The advantage of the training is certainly to increase awareness of the use and benefits of AEDs.At the same time, incorrect myths and ideas, such as the misconception that they can cause damage, can be dispelled.

Duration and frequency of BLS / AED courses with instructors

The optimal duration of such BLS / AED trainings, which are led by instructors, has not yet been found. This will depend more on the particularities of the participants (laypersons, professional helpers, pre-training), the program, the relationship between instructor and participants, the possibility of practical exercises and the review of BLS / AED skills at the end of the course. Most studies show that CPR skills decline rapidly 3 to 6 months after exercise [33, 46, 53–55]. In contrast, AED knowledge is retained a little longer [56, 57].

Although there is evidence that frequent and short refresher training may strengthen BLS training and somewhat slow down forgetting of skills, more studies are needed to confirm it [53, 55–57].

The current evidence shows that the use of AEDs (quick and correct placement of electrodes) can be improved by brief training sessions for laypeople and professional helpers [49, 58–60]. Short bedside BLS refresher training sessions lasting 2 minutes showed a higher CPR quality in simulated resuscitation, regardless of how the training was carried out (instructor or automatic feedback or both) [61] and improved steadily with each further training [62].

Resuscitation training, guided by peers, is also a very effective BLS teaching method. These colleagues are competent trainers and examiners, often available in larger numbers and at lower costs than clinically employed staff. Student instructors can also acquire skills in teaching, reviewing and evaluating, organizing and researching. The sustainability of such programs is possible through planning future instructor training and constant leadership. A 15-year review of a BLS fellow student program at a major medical school demonstrated that participants were just as satisfied with the learning success as they were with the previous lecture-based teaching [63].

Frequent exercise has been shown to improve CPR skills, rescuer confidence, and willingness to perform CPR. It is recommended that every organization and helper consider the need for more frequent CPR retraining, based on the likelihood of cardiac arrest in their life or workplace. In any case, repetition training should take place every 12-24 months for every BLS course participant. In certain circumstances, more frequent, low-dose boosters or repetitions may also be considered. It is recommended, however, that helpers who are confronted with cardiac arrest more often should attend refresher courses with a higher frequency. It is known that BLS skills decrease within 3–12 months after exercise, [33, 46, 53, 54, 56, 64] that frequent exercise improves CPR skills [34, 65–69] and improves self-confidence the rescuer [65] as well as their willingness to perform CPR strengthens [34].

Use of CPR feedback equipment during exercise

CPR feedback devices can be used for training laypeople and professional helpers. Some devices emit signals, e.g. B. like a metronome to indicate the compression frequency, or verbal cues. Others provide post-event feedback based on the actions taken (e.g., compression depth is shown on a visual display), or the devices provide both feedback. If such feedback devices are used in training, CPR skills can improve [70]. Instructors and rescuers must be aware that some of these devices overestimate the compression depth on compressible patient pads (mattresses) [71, 72].

A systematic review of the available literature on studies on dolls and patients showed that audiovisual feedback devices during resuscitation lead the rescuers to more guideline-compliant chest compressions, but no evidence was found that this leads to an improvement in patient survival [73] . However, substantial discrepancies in the improvement in CPR performance between different CPR feedback devices have been discovered [74–76].

Training strategies at the advanced level

Advanced Life Support (ALS) courses are primarily aimed at those who work in the healthcare sector. Generally speaking, it covers the knowledge, skills and attitudes necessary to function efficiently as a member or leader in a resuscitation team.

Course preparation and alternative strategies to improve CPR training

Many different methods can be used to prepare participants in advanced life saving courses. This can be reading material in the form of brochures and / or e-learning. A test as part of the preparation before the course strengthens the working through of these documents [77–82]. An e-learning program with CD before the ALS course was appreciated by the participants as it improved their understanding of the core elements of the ALS course. Unfortunately, the program was not found to be superior in terms of cognitive and psychomotor skills during standardized resuscitation simulations [83].

Different integrated learning models ("blended learning"), in which z. B. electronic teaching media are combined with shortened instructor-led course parts, were carried out as a pilot experiment for ALS courses. This led to a 5.7% lower pass rate in the CAS tests ("Cardiac Arrest Scenario Test" - the examination of the participants' competence to guide a simulated cardiac arrest according to the guidelines). Participants had similar scores on knowledge and skill assessments, and there was no difference in passing at the end of the course, all with a cost reduction of more than half [84]. This e-learning ALS course format was introduced nationwide in Great Britain and its equivalence to traditional, exclusively instructor-based courses was demonstrated to 27,170 participants [85]. The 6 to 8 hour online e-learning program was completed by the participants before the modified, instructor-led one-day ALS course. The e-ALS test scores were significantly higher on the multiple choice test before and after the course. The pass rate for the first CAS test for the e-learning course was also higher than for the standard course, but the overall pass rate remained the same. When the benefits in terms of increased participant autonomy in learning, better cost-effectiveness, reduced instructor workload and improved standardization of teaching materials are considered, this report encourages further dissemination of such CPR training e-learning courses.

The principles of teaching skills

CPR skills can be taught step-by-step by showing their components in real time, explaining the facts and demonstrating them by the participants. Practical practice of the skills is intended to promote visual imagination, understanding and cognitive processing as well as the exercise of the skills. In spite of the described and impressive theoretical concept, no study was able to show any advantage of different step-by-step approaches to imparting skills [86, 87].

The basics of simulation in ALS course teaching

Simulation is an integral part of resuscitation training. A systematic review and meta-analysis of 182 studies, which included 16,636 participants in resuscitation training with simulation training, showed improved knowledge and skill execution compared to training without simulation [88].

Simulation training can be widely used in a variety of situations, from lay and first aiders to training entire resuscitation teams, including their team leaders. Thus, individual participants as well as team behavior can be trained. The essential part of this form of learning is the debriefing following the scenario training with a critical discussion and processing of what has been experienced in order to enable further learning.

When not working with acting patients, most simulation training courses take place with very realistic simulation dummies. The vital parameters, physiological data and findings as well as reactions to interventions are controlled by computers. In addition, skills such as mask ventilation, intubation and intravenous or intraosseous vascular access can be performed and practiced on these dolls [89]. Simulation training on these so-called high-fidelity dolls seem to be slightly superior to those on low-fidelity dolls with regard to the skills learned in the course [90].

These high-fidelity simulation dolls are popular with course participants and instructors because of their closeness to reality, but they have very high acquisition and maintenance costs. There is no evidence that ERC course participants learn more or better when such mannequins are used. Nevertheless, they should be used in CPR lessons, if available. But if there are only low-fidelity resuscitation dolls, these are also sufficient for standard ALS courses.

Maintaining the real 2-minute resuscitation cycles during the ALS simulation is essential to make the scenario realistic. Reality is lost during practice if the duration of the CPR cycles is arbitrarily shortened in order to allow more scenarios to be practiced [91].

Many of the new approaches to teaching hold promise, but more and better research into their effectiveness is needed before these methods can be used on a large scale. An example of this is the incorporation of connections such as “statement - action” into courses. The statement “There is no pulse. I start with chest compression ”leads to the“ chest compression ”campaign [92]. Or the so-called "Rapid Cycle Deliberate Practice", which improved the CPR skills of pediatricians in training [93]. After a scenario with debriefing without interruption, the following scenario is shorter and is briefly stopped at predetermined points in order to give direct feedback on actions or measures.

The training of non-technical skills ("non-technical skills", NTS) including team management and team training to improve resuscitation

Performing successful resuscitation is in most cases a team effort and, as with any other skill, effective teamwork and team leadership must be practiced [94, 95]. The implementation of a team training program led to an improved hospital survival rate after resuscitation in children [96] and surgical patients [97].

The training in the simulation of non-technical skills (effective communication, situation awareness, behavior as a team member and leader) and the use of principles from "Crisis Resource Management" could show that what has been learned from these trainings can be transferred to clinical practice [ 98, 99]. The performance of resuscitation teams improves in real resuscitation, but also in simulated ALS hospital scenarios if special team or leadership training is integrated into the ALS courses [100–104]. If these trainings are as close as possible to the participants' working reality, these team collaboration concepts can also be discussed at the individual level [105, 106].

Specific team training sessions increase the team's performance, leadership behavior and task management, and these effects can last for up to 1 year [94, 95, 100, 101, 107–111]. Training leadership behavior in addition to CPR skills does not improve CPR skills [112].

Assessment tools (mainly checklists) have been developed, validated and recommended for individual team members. Existing rating scales for team performance can also be used well for feedback to the team [113–116].

Training intervals and the assessment of competencies

Unfortunately, there is little evidence on retention of ALS knowledge after the courses [117]. It is assumed that participants with more clinical experience will better memorize their knowledge and skills over a longer period of time [118, 119]. The written ALS course tests say little about the practical implementation of skills and should not be used as a substitute for demonstrating these clinically relevant skills [120, 121]. The test at the end of the training seems to have a positive effect on later performance and the duration of retention [122, 123].

Frequent repetitive training at work in small doses on the CPR manikins save costs, reduce the total training time and seem to be preferred by the learners [124, 125]. Repetition training is undoubtedly necessary to retain knowledge and skills, but the optimal frequency for such refresher courses is unclear [124, 126–128].

A simulation-supported refresher program 9 months after neonatal resuscitation training showed improved performance in skills and better teamwork 15 months later [129]. Team behavior was further improved when the assistants were involved in clinical resuscitation or had free exercise opportunities on the simulator.

The use of checklists, feedback devices and on-site training