Effectiveness of a video lesson for the correct use in an emergency of the automated external defibrillator (AED).

BACKGROUND AND AIM OF THE WORK: Every year around 275 thousand people in Europe and 420 thousand in the United States are affected by sudden cardiac arrest. Early electrical defibrillation before the arrival of emergency services can improve survival. Training the population to use the AED is essential. The training method currently in use is the BLSD course, which limits training to a population cohort and may not be enough to meet the requirements of the proposed Law no. 1839/2019. This study aims to verify the effectiveness of an online course that illustrates the practical use of the AED to a population of laypeople.
METHODS: An observational study was conducted to compare a lay population undergoing the view of a video spot and a cohort of people who had participated in BLSD Category A courses. The performances of the two groups were measured immediately after the course and 6 months later.
RESULTS: Overall, the video lesson reported positive results. Six months later the skills were partially retained. The cohort that followed the video lesson showed significant deterioration in the ability to correctly position the pads and in safety.
CONCLUSIONS: Although improved through significant reinforcements, the video spot represents a valid alternative training method for spreading defibrillation with public access and could facilitate the culture of defibrillation as required by the new Italian law proposal.

Background

An estimated 17.9 million people died from cardiovascular diseases in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke (WHO, 2020) (1). In the same year, in Italy were recorded 221,914 deaths (ISTAT, 2019) (2).

Sudden cardiac arrest affects about 420 thousand people in the United States and 275 thousand in Europe annually (3).

Gräsner et al. (4) calculated in Europe an incidence rate of 84 cardiac arrests per 100 thousand inhabitants. Analyzing the primary heart rhythms, a quarter of the victims have initial ventricular fibrillation, which tends to evolve into asystole before extra-hospital rescuers arrive. This because rescue time after 5 - 8 minutes from the event makes the heart rhythm no longer shockable. (5). The presence of an automatic external defibrillator (AED) at the time of collapse could improve the prognosis by restoring a cardiac rhythm compatible with an effective circulation up to 76% of subjects affected by ventricular fibrillation (6).

Recent studies have shown that the use of the AED by unqualified people or with minimal training is safe and effective. Therefore, if a spectator can use an automatic defibrillator, this practice is recommended (7, 8).

In the last ten years, there has been an explosion of defibrillation programs in places with public access (PAD), in fact, even in Italy, the legislator, with its decree, established by law the presence of the AED in places with large numbers of visitors (9).

Yet despite the literature, the recommendations, the regulations, and the increase in the number of AEDs in public places, the portion of patients in cardiac arrest defibrillated before the rescue vehicle arrives, remains significantly low (10). Brooks et al. (11) and Smith et al. (12) have shown that in front of a collapsed person who is not responding, only 1.7-2.1% of viewers look for and use an AED before the ambulance arrives.

Since 2001, in Italy, a precise law grants the use of the semi-automatic defibrillator by non-healthcare personnel with specific training in cardio-pulmonary resuscitation activities (13). This rule does not seem to facilitate the use of the AED, as in the countries where the law allows all citizens to use the AED, their use is about 15-20% higher (8).

However, the Italian law, having requested the presence of the defibrillator in sports centers, highlighted an important first result. In 2015, were 123 the arrests reported in sports facilities with a return to spontaneous circulation for 62% of the victims after using the AED. This shows that the norm works, even if the device used only by specially trained people is not enough to reduce incidence in the general population (14). For this reason, we have made efforts to identify potential obstacles related to the use of AEDs by the lay public. The nature of obstacles turned out to be multifactorial and, among the causes, there is certainly the legal liability (4-38%); other relevant obstacles are the lack of knowledge about how the device works, not feeling comfortable in using it and the fear of causing harm to the victim (12).

A public access defibrillation program (PAD) (15) to be successful requires three requisites: firstly, there must be enough devices in the community; secondly, their position must be known or easily identifiable in an emergency, thirdly the public must have sufficient knowledge and confidence to use them. All these requirements must be met for a bystander to provide effective defibrillation. However, generally, national systems have so far focused on the first of these requirements, therefore greater use of public AEDs will not be achieved until the population has acquired greater knowledge and confidence with them (11).

The current classroom teaching methods, to acquire enough knowledge and confidence for the use of the AED, cannot be easily disclosed to the whole community and can present significant logistical, temporal and financial barriers, especially when it is necessary to form large groups. To cope with these difficulties, the scientific community has proposed alternative training methods for non-experts. Although not yet validated, these new methods present good results in their support (16). Remarkably, the testing of structured courses through video lessons and the use of the web has proven effective even in the physical absence of the instructor (17, 20). Recent studies conducted on school-aged students between 14 and 19 years old have shown a good efficacy of video-based training. This type of population seems to be particularly receptive to training in use the AED through this teaching method (21).

In Italy, a bill proposed at the end of July 2019 called “Progetto Life” provides that it is allowed to be able to use an AED even without specific training.. However, rescuers must follow the instructions given by the 112 emergency center health professionals. (22).

Aim

Assess of level of the learning in the use of the AED, through the viewing of a video spot and the subsequent practice on a static simulator

Research questions

1. In remote training courses, does the lesson through video spots compared to traditional BLSD courses provide the necessary skills for using the defibrillator?

2. Which skills, acquired through the video lesson and the BLSD courses, remain in the learner after months from the end of the training?

Materials and Methods

Study design and participants

Prospective and retrospective observational studies were conducted in 2019. The research involved the 1st year students of the Degree Course in Nursing at the University of Bologna and a cohort of operators from some metalworking companies in northern Italy. Our convenience sample of 91 lay people, 44 students, and 47 workers never held CPR courses or early defibrillation courses and had no clinical subject knowledge. We divided the sample into two groups according to the training method. The students attended the video lesson, while the workers were trained with the BLSD course certified IRC ©.

The video spot production was carried out by medical instructors and nurses experienced in cardiopulmonary resuscitation and with IRC certification. The video creation took inspiration from three videos found on the web: “How to Use a Defibrillator (AED) - First Aid Training” by St John Ambulance, “Emergency CPR / AED Emergency Response Update” and “HeartStart Field Defibrillator (AED) Video of training “by Philips.

1ª Phase of the study

The prospective study took place in this phase. The students were divided into groups with an instructor and learner ratio of approximately 1: 6. The learners were shown twice, 5 minutes apart, the video in which the use of the AED was explained in 4 minutes. The video instructions included six essential steps: 1. the 112/118 call; 2. switching on the AED; 3. how to uncover the victim’s chest; 4. the positioning of the defibrillator pads; 5. how to comply with the rules for using the AED safely; 6. the delivery of the shock if indicated.

After watching the videos, the students were asked to immediately perform the procedure on the manikin under the supervision of the instructors, who immediately proceeded to evaluate the performance through a specific form that summarized the video steps. As regards the retrospective survey, 47 workers were randomized through the database of BLSD courses carried out in metalworking companies in a province of northern Italy and their performances were obtained from the forms. The BLSD courses had been held a few months earlier by the same instructors enrolled for the prospective study with the video lesson (Figure 1).

Figure 1.

Phase 1 of the study

2ª Phase of the study

After 6 months, 1st year nursing students were recalled. Of these, 34 responded to the invitation, 10 fewer than in the first phase. Without viewing any video or repeating the instructors’ instructions, they were asked to repeat the procedure for using the AED on the manikin.

After 6 months, the 47 randomized workers were also asked to use the AED on a manikin without any revision of the IRC © procedures.

The performance of the two groups was assessed by the same instructors, with the same tool used in the first phase.

Ethical considerations

All the sample involved in the study gave their written consent after learning the purpose and method of conducting the research. The anonymity and confidentiality of the participants were guaranteed. The research was authorized by the Bioethics Committee of Bologna University and by the Coordinator of the Degree Course in Nursing in Faenza, Italy.

Statistical analyses

The data were collected through Office Excel; the statistical analysis was conducted with SPSS software, version 26. Descriptive statistics calculations (mean, standard deviation, frequency, percentages) were performed. Significances were analyzed through Pearson’s Chi-square.

Results

Nursing students evaluated immediately after the video lesson are 90.9% (n = 40) females, with an average age of 21.32 ± 5.59 and all with a high school diploma without further degrees.

The workers who achieved the BLSD certificate are 95.7% (n = 45) male, with an average age of 38.51 ± 11.69 and all with a high school diploma. Overall, the results of the video lesson are positive. Compared to the performances provided by the BLSD course, which provides for the knowledge of all the passages (100%), the video lesson achieved an average performance percentage of 89.77% ± 15.75. As regards the 6 single performances provided by the video: 79.5% call 112 or 118, 95.5% correctly turn on the AED, 97.7% correctly discover the patient’s chest, 81.8% attacks the plates in the correct position, 88.8% follow the safety instructions and 95.5% deliver the shock if required (Graphic 1).

Graphic 1.

Distribution of students performance in the first phase

After six months, the average percentage of performance retention is significant for both training modalities (p = < .0001). The BLSD course sustains a performance of 81.21 ± 15.39, with an average difference of 18.79 respect to the certification phase. The video lesson maintains a 63.73 ± 15.05 losing a 26.04. However, both students and workers have maintained positive performances in skills 1, 2 and 3 with a range that varies from 64.7 to 94.1%. Skill 4 suffered a worsening for both groups with an average percentage value of 48.1%, while for performances 5 and 6 there were significant differences. Workers trained with the BLSD responded positively to the “follow instructions safely” ability for 63.8% (n = 30) of the sample, against 2.9% (N = 1) of the student group. In skill 6, although recording a significant difference between the video lesson and the BLSD, the performances remain above 88% (Table 1).

Table 1.

Performance evaluation after 6 months. Comparison between the two cohorts.

	BLSD Course		Video lesson		Total
	n = 47		n = 34		N = 81
Performance	n	%	n	%	N (%)	p
1. Call 118 or 112	35	74.5	22	64.7	57 (70.4)	.342
2. Use the AED and turn it on	47	100	32	94.1	79 (97.5)	.092
3. Uncover the victim’s chest	46	97.9	30	88.2	76 (93.8)	.075
4. Attach the pads in the correct position	24	51.1	15	44.1	39 (48.1)	.537
5. Follow the safety instructions	30	63.8	1	2.9	31 (38.3)	.000**
6. Dispense shock if required	47	100	30	88.2	77 (95.1)	.016*

* p = < .05; ** p = < .01

The difference in performance between the video lesson and the BLSD is also highlighted by a significant loss in the performance of the video lesson (activities 4 and 5) in the period immediately after viewing the videos (T0) and its subsequent verification after 6 months (T1) (Table 2).

Table 2.

Evaluation of students’ performance after 6 months from the administration of the video lesson.

	T0		T1
	n = 44		n = 34
Performance	n	%	n	%	Δ	p
n. 1	35	79.5	22	64.7	-14.8	.143
n. 2	42	95.5	32	94.1	-1.4	.791
n. 3	43	97.7	30	88.2	-9.5	.090
n. 4	36	81.8	15	44.1	-37.7	.001**
n. 5	39	88.6	1	2.9	-85.7	.000**
n. 6	42	95.5	30	88.2	-7.3	.235

* p = < .05; ** p = < .01

In graphic 2, after 6 months, there is a good holding of the skills acquired in the video lesson, the curve becomes significantly negative in skills 4 and 5 with a loss of 28.9% in the first and 85.7 in the second.

Graphic 2.

Retention of skills with the video lesson at T0 and T1.

Discussion

The study, by what has been highlighted in the literature (17-20), shows that a short video lasting some minutes, which illustrates simply the fundamental steps of the use of a semiautomatic defibrillator and which uses an easy to understand language, can be a valid training method for a “non-professional” public of health (layman).

The video allows the desired message to reach many people, especially as regards the youth population (21).

The use of the AED requires specific training and simulation is a tool highly appreciated by learners (23-25), but it is also the method that allows you to prevent accidents and promote safety (26). Simulate the use of the AED through a video lesson could be a valid strategy considering a possible future application of the legislative proposal no. 1839 (2019) (22); distance learning could guarantee the minimum skills needed to effectively use the AED (7, 8). The study, however, noted a certain difficulty for the students in maintaining their performances. After 6 months, statistically significant differences were pointed out, especially as regards the safety of the scene, significantly less guaranteed by the students compared to the BLSD sample.

However, even the workers trained through the BLSD course have shown a decrease in performance in the application of adhesive pads on the chest and in the safe execution of the procedure. The skills gaps months after defibrillation courses are confirmed in the literature. Educational reinforcements following certification are recommended to maintain the standards acquired during training (27, 28).

Conclusions

Unlike the BLSD courses that require the physical presence of the students and a certain economic and organizational commitment both in the certification courses and in the retraining, the video lesson can be carried out remotely, at low prices, easily accessible to a large population. A video spot of this kind, related to the law currently under approval, could empower the population. The statements of the video should be passionate and highly engaging on the emotional side, so the main concepts could thus be better retained in the population that receives them (29).

As exemplified by this study, videos need training reinforcement; a simple solution could be to administer them as spots of the Ministry of Health, using both traditional and social information channels; so they could represent a valid tool to spread the culture of defibrillation and encourage citizens to use it effectively, as required by the new Italian law proposal and literature.

The main limitations of the study are the size and characteristics of the sampling. The research takes into consideration a limited sample relating to two cohorts that are not entirely equivalent by age, gender and professionalism: the average age of 20 years, female prevalence, university students for video lessons; an age < 40 years, male prevalence, workers for BLSD courses. To confirm our results further studies with a larger sampling are needed, including subjects randomly assigned to cohorts with comparable age, professionalism and personal characteristics.