Is AED Training Necessary ?

Is AED Training Necessary ? • Author: Deems Okamoto, M.D., FACEP, ABFM • Affiliation: American Heart Association • Regional Faculty: ACLS, PALS • Instructor: ACLS EP, BLS • Worksheet Author: ILCOR, CoSTR 2005, 2010

Conflict Of Interest Disclosure • Conflict of interest specific to this question • Does the author listed above have conflict of interest disclosures relevant to this presentation? No • Commercial/industry • None • Potential intellectual conflicts • None

In BLS providers (lay or HCP) requiring AED Training (P), are there any specific training interventions (I) compared with traditional lecture/practice sessions (C) that increase outcomes (eg. Skill acquisition and retention, actual AED use, etc.) (O)? • Worksheet identifier: EIT 13A • Author: Deems Okamoto, M.D. • Affiliation: American Heart Association • Taskforce: None

Worksheet identifier: EIT 013B Author: Joyce Yeung, Gavin Perkins Affiliation: ERC Taskforce: EIT Other Worksheet Authors: None In BLS providers (lay or HCP) requiring AED training (P), are there any specific training interventions (I) compared with traditional lecture/practice sessions (C) that increase outcomes (eg. skill acquisition and retention, actual AED use, etc.) (O)?

Studies are allocated a rating for methodological quality (Good, Fair or Poor) according to the presence of the quality items for that Level of Evidence: Good studies = have most/all of the relevant quality items Fair studies = have some of the relevant quality items Poor studies = have few of the relevant quality items (but sufficient value to include for further review).

Evidence Supporting Clinical Question A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Italics = Animal studies E1 Immediate skill acquisition E2 Superior skill acquisition E3 Skill retention E4 Cognitive acquisition E5 Willingness to use AED E6 Increased motivation E7 Acceptance E8 Cost and resource conservation

Evidence Neutral to Clinical Question A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Italics = Animal studies E1 Immediate skill acquisition E2 Superior skill acquisition E3 Skill retention E4 Cognitive acquisition E5 Willingness to use AED E6 Increased motivation E7 Acceptance E8 Cost and resource conservation

Evidence Opposing Clinical Question A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Italics = Animal studies E1 Immediate skill acquisition E2 Superior skill acquisition E3 Skill retention E4 Cognitive acquisition E5 Willingness to use AED E6 Increased motivation E7 Acceptance E8 Cost and resource conservation

Draft Treatment Recommendations • AED training may be successfully delivered by laypersons and healthcare professionals. • Strategies other than traditional 3-4 hour instructor-led training courses e.g. video self instruction, web-based courses, posters, can be effective and may be considered. • AED’s may be used effectively without formal training, however even brief (15 minute) training improves skill performance.

No Training – The Beginning • Small, low LOE studies have shown that the single human intervention of application of the defibrillator pads to arrest victims by lay or healthcare providers with no prior training resulted in an adequate outcome which was defined as the device assessment of a suspected sudden cardiac arrest followed by the successful defibrillation or no defibrillation of the victim [Beckers 2005] [Beckers2007] [DeJesus2005] [Eames2003] [Fleischhackl2004] [Mattei2002] [Monsieurs2005] [Richman2007][Wik2003].

No Training • Considering lay providers without prior training, one moderate sized LOE 1 study compared computer-based AED training, standard instructor based AED training and no AED training of high school students, finding up to 63% of the untrained, control group of students could initiate a required shock when directed by only the device. • This was in comparison to 98% in the trained group [Reder2006] and is a significant outcome when assessing the baseline capabilities of the next generation of AED providers.

No Training • Another study using a single commercially available device found that untrained lay providers were still able to defibrillate the mannequin testing subject 58% of the time although the comment made was that the overall failure rate to pass the four AHA qualifications of successful AED use among that group was 80% [Roccia2003].

No Training • It has also been proposed that the singular event of utilizing an AED with visual prompts for an arrest victim, with concurrent and automatic notification of the EMS, might result in improved numeric outcomes for SCA even without CPR [DeJesus2005].

No Training • In fact, some small studies have shown that the addition of CPR and other assessment skills to AED training has resulted in a subsequent reduction of overall BLS skills and AED use [Moore1987] [Rittenberger2006].

No Training • In addition, another study found that the intervention of human rhythm interpretation using a manual defibrillator improved the number of chest compressions per minute but at the expense of more inappropriate patient defibrillations when compared to the AED interpretation of the same rhythms [Pytte2007].

No Training • As appealing as it is to allow the device to direct the arrest scenario, a major confounder is the device scenario itself.

Device Scenario • Currently, there is neither a consistent universal language nor scenario driven voice prompt for all the devices on the market [Beckers 2005][Cummins 1985].

Device Scenario • This leads to different performance variables and outcomes by providers depending on the actual device used and points out the major current limitation of a device-driven resuscitation [Eames2003] [Fleischhackl2004].

Device Type • AEDs are currently of two types: Semi-automated and fully-automated. • Traditional instructor-led courses almost universally train on the former [Andresen2008] [Capucci2002] [Capucci2003] [Castren2004] [Christenson2007] [Cummins1985] [Cummins1987] [Mattei2002] [Riegel2006], but the latter is available in both the healthcare and public environment.

Device Type • A very early study found that semiautomatic AED’s without voice or visual prompts required intensive training and retraining of HCP’s for effective use [Walters1992], a problem resolved with later generations of AED’s intended for HCP and lay use.

Device Type • Three recent studies involving untrained lay providers found the FAED to have a longer time to defibrillation when compared to the SAED, but on final analysis, both performed equally well with minimal operator errors [Beckers 2005] [Beckers 2007] [Monsieurs2005].

Device Type • Two of those studies [Beckers 2005] [Fromm1997] also found that the FAED performed more consistently since human intervention cannot inadvertently turn the device off once the defibrillator pads are properly applied.

Device Type • An important study proposed that cognitive training and device driven instructions may result in better initial and long term performance with better skills and didactic knowledge retention, making the device the key element in the successful use of the AED [Roppolo2007].

Voice Prompts • In contrast to this, a study comparing the voice prompts of six AEDs found that performance differed according to the scenario presented by each device, leading to differing performance outcomes [Fleischhackl2004].

Voice Prompts • Another small study also found that voice prompts may be misunderstood, misinterpreted or may use terminology foreign to the provider, resulting in performance errors or inaction [Woolard2004].

Device Driven Scenario • One study noted that previously traditionally BLS trained HCPs had better performance outcomes when an arrest scenario was device driven [Fleischackl2004]

Visual Prompts and Deaf Lay Providers • Another study involving deaf lay providers found that visual prompts provided good cognitive instructions with good performance depending on the literacy of the provider and possibly negating the loudness of the surrounding ambient noise [Sandroni2004].

AED Use in Real Time Events • The largest, most comprehensive study, the North American PAD Trial, [Christenson2007] [Hallstrom2004] [Hedges2006] [Riegel 2006] demonstrated the effectiveness of standardized training for lay volunteer providers who responded to possible cardiac arrest events.

AED Use in Real Time Events • Numerous other small studies have shown that AED use under real time events can be successfully accomplished by both HCPs and lay providers [Capucci2002] [Capucci2003] [Davies2005] [deVries2004] [England2005] [Hanefeld2005] with little or no prior training and that their performance improves with subsequent traditional or non-traditional retraining [Jerin1998].

Retention • AED skill retention has been shown by numerous studies to be maintained over time, even at the expense of poor or no BLS skill acquisition and delivery [Andresen2008] [Beckers 2007] [Fromm1997] [Kelly2006] [Mahoney2008] [Riegel 2006] [Roppolo2007] [Woolard2004] [Woolard 2006] [Wik2003] [Zeitz2003].

Retention • Furthermore, this improves after retraining either by standardized instructor led courses, or by short retesting of kinesthetic skills. Other events may renew previous knowledge, such as by an EMS dispatcher during a 911 call [Andresen2008] [Beckers 2005] [Beckers2007] [Christenson2007] [Ecker2001] [Fromm1997] [Meischke2002] [Moore1987] [Riegel 2006] [Woolard2004] [Woolard2006].

Retention • Age may also play a part in retention. A small study in which seniors were given truncated instruction versus video training found that at retesting both groups at three months after the initial training, almost one fourth of them were unable to deliver a shock and almost one half of them were not able to properly attach the pads [Meischke2001]. This is a performance outcome associated with advancing age [Richman2007], despite frequent retraining [Moore1987].

Retention • Despite the issues of failing performance relative to age, it has been proposed by some that resources are better spent in other areas of BLS, such as in improving assessment and kinesthetic skills (CPR), rather than in devoting them to AED instruction. • It appears that initial AED training by almost any means results in retained performance both in testing and in real-time events [Beckers2007] [Christenson2007] [Hallstrom2004] [Riegel 2006] [Wik2003].

Retention • In contrast to this view, one small study found that both BLS skills and motivation improved with concurrent AED and BLS training and testing [Kooij2004] while another author found that AED skills are not retained or do not improve if the provider is poorly motivated [Harve2008].

Pad Placement • A recurrent problem in a number of small, good, studies have shown pad placement to be a problem,especially with the untrained HCP and lay providers [Eames2003] [Fromm1997] [Mattei2002] [Mieschke2001] [Monsieurs2005] [Richman2007]. • This problem appeared to improve with BLS training [Wik2003], • but another study assessing retention of AED-BLS skills after traditional training found that lay providers consistently placed the pads in less than their optimum location despite refresher courses [Woolard2004] [Woolard2006].

Pad Placement • This issue may have a resolution with better visual prompts. • One small study found that pad placement may be dependent on the pictographs of the pads and that correct positioning could be improved by showing the placement of the apical lead in a more visually descriptive lateral pictograph [Nurmi2005]. • Another study found that deaf providers reading the visual prompts of certain AEDs had an accuracy of 89% in pad placement without training, indicating that clearer visual prompts would improve lay provider performance [Sandroni2004].

Environment and Motivation • Lay and healthcare BLS providers also did equally well in courses without the attendant didactic content and in situations where there was no instruction, such as when they were instructed only by the device prompts. • In those events, the best performance was recorded by the most highly motivated providers [Beckers 2005] [Beckers 2007] [Christenson2007] [Eames2003] [Jerin1998] [Meischke2002] [Wik2003] and, again, in courses that attended to the personal needs and expectations of the trainee. • Enthusiasm and a desire to perform well was also noted in those courses which covered relevant content, skills and in which the instructor used specific techniques directed towards assisting the individual in operating the device [Timmons2007] [Uray2003].

Personal Issues • Personal issues, often involving trust of the machine, may have promoted or inhibited lay volunteer providers from using an AED in an emergency [Timmons2007] [Younas2006], even when previously trained on a mannequin. • Fear of harm [Kelly2006], fear of suit [Hedges2006] [Lubin2004] [Richardson2005], fear of involvement [Kuramoto2008], inability to understand or misinterpreting the language spoken by the device [Beckers 2005] [Groh2001] [Woolard2004] and distrust of the technology were other factors limiting its use [Cummins1985].

Cultural Issues • Culture is another issue affecting training. • A study carried out in Japan found that, despite a high percentage of individuals trained in CPR, participation in actual cardiac arrest events was very low. The authors comment that the presence of an AED stimulated interest in training and may be a way of overcoming reticence in participation [Kuramoto2008].

Physical Disabilities • Physical disabilities also need to be addressed. • One study found that deafness did appear not to be a deterrent in producing a competent AED provider. In fact, this may have been beneficial as the provider was obligated to follow the device prompts, resulting in a high level of compliance in proper placement of the defibrillation pads [Sandroni2004].

Government and Politics • Political issues also constrained AED training to only certain individuals for whom use of the device was part of their duty to treat. • These individuals were generally health care providers, police, fire and other governmentally designated providers. • The consequences of these assignments were to inhibit or prohibit AED use by the remainder of the general lay public [Uray2003].

Government and Politics • Other programs created a cadre of designated lay providers with and without a duty to treat [Davies2005] [deVries 2004] [Groh2001] [Riegel2006], often with good results but occasionally preceded with some initial administrative hesitancy [Capucci2002]. • Such political mandates also dictated that specific types of training be utilized and that they be delivered by specified training agents for those designated lay and healthcare providers [Davies2005] [deVries2004] [Destro1996] [Woolard 2006].

Summary • For lay and healthcare BLS providers requiring AED training, the simpler the better [Beckers 2005] [Beckers2007] [Eames2003] [Flieschhackl2004] [Fromm1997] [Kelly2006] [Roppolo2007] both for performance and retention [Wik2003]. • Because of the cognitive nature of AED training [Roppolo2007] and the guidance provided by the device itself, the only significant effect of instructor intervention was in the placement of the pads [Woollard2006] and the encouragement given to the providers to actually use the device [Timmons2007] [Uray2003].

Summary • Concurrent CPR training might have mitigated the effectiveness of AED training and consideration should then be given to separating them as AED training alone resulted in better retention than concurrent CPR-AED training [Capucci2002] [Capucci2003] [Cummins 1985] [Harve2007] [Rittenberger2006].

Summary • Traditional, instructor-led AED training [Christenson2007] [Cummins1985] [Cummins1987] worked as well as video or computer-based courses [Jerin1998] [Meischke2001] and they all have been shown to be slightly to moderately better than no training[Reder2006] [Wik2003], considering the device used [Eames2003] [Fleischhackl2004].

Summary • No training had only the cost of the machine to consider but at the risk of differing outcomes based on the scenario driven by the voice prompts of the device [Beckers 2005] [Eames2003] [Flieschhackl2004] [Mattei2002] [Riegel 2006]. • Another major drawback of AED use by untrained HCP and lay providers was inappropriate pad placement and safety issues [Fromm1997] [Mattei2002] [Mieschke2001] [Monsieurs2005] [Reder2006] [Woolard2004] [Woolard2006]. • Yet, one study found that changing the visual image on the pad dramatically improved the proper placement of the defibrillator pads[Nurmi2005], perhaps answering this issue.

Summary • The kinesthetic skill of operating the device [Eames2003] [Flieschhackl2004] [Fromm1997], once learned, was rarely forgotten and may even have been improved by remote or direct assistance, retraining and by the increased frequency of use of the device [Beckers2005] [Beckers2007] [deVries2004] [Ecker2001] [Mattei2002] [Riegel 2006] [Woolard2004] [Zeitz2003].

Summary • Regardless of training method, the use of the AED in an actual Sudden Cardiac Arrest event is the defining measure of training success. • Traditional training of HCP and lay providers has shown excellent outcomes, but alternative training modalities have also been highly successful. • For the largest group of providers, the untrained lay bystanders witnessing an SCA event, use of an AED has been shown to be minimally successful due to numerous personal, political and legal constraints [Kuramoto2008].

Summary • Regardless of the means of training, the overall outcome of survival from an SCA depends not on the method of training but on who, when, where and what type of device is present and whether it is used. • The HCP and lay providers must be convinced that the AED is effective, trustworthy and should be used [Timmons2007] by whatever means available. • Ultimately, that is the goal of training.

Conclusion • In 1985, Cummins, RO; Eisenberg, MS; et. al. identified, in a landmark paper, the need for AED resuscitation, the challenges of implementation and the training, psychologic barriers, etc. to be overcome if recovery from out of hospital cardiac arrest was to be successful. Twenty five years later, we are still only partway to answering that call [Cummins1985].

Is AED Training Necessary ?