Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study

doi:10.5847/wjem.j.1920-8642.2023.070

Abstract

Abstract:

BACKGROUND: To evaluate whether a simplified self-instruction card can help potential rescue providers use automated external defibrillators (AEDs) more accurately and quickly.
METHODS: From June 1, 2018, to November 30, 2019, a prospective longitudinal randomized controlled simulation study was conducted among 165 laypeople (18-65 years old) without prior AED training. A self-instruction card was designed to illuminate key AED operation procedures. Subjects were randomly divided into the card (n=83) and control (n=82) groups with age stratification. They were then individually evaluated in the same simulated scenario to use AED with (card group) or without the self-instruction card (control group) at baseline, post-training, and at the 3-month follow-up.
RESULTS: At baseline, the card group reached a significantly higher proportion of successful defibrillation (31.1% vs. 15.9%, P=0.03), fully baring the chest (88.9% vs. 63.4%, P<0.001), correct electrode placement (32.5% vs. 17.1%, P=0.03), and resuming cardiopulmonary resuscitation (CPR) (72.3% vs. 9.8%, P<0.001). At post-training and follow-up, there were no significant differences in key behaviors, except for resuming CPR. Time to shock and time to resume CPR were shorter in the card group, while time to power-on AED was not different in each phase of tests. In the 55-65 years group, the card group achieved more skill improvements over the control group compared to the other age groups.
CONCLUSION: The self-instruction card could serve as a direction for first-time AED users and as a reminder for trained subjects. This could be a practical, cost-effective way to improve the AED skills of potential rescue providers among different age groups, including seniors.

Key words: Automated external defibrillator, Laypeople, Skill, Instruction card, Simulation

Qiang Zhou, Xuejie Dong, Wei Zhang, Rengyu Wu, Kaizhu Chen, Hongjuan Zhang, Zhijie Zheng, Lin Zhang. Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study[J]. World Journal of Emergency Medicine, 2023, 14(4): 265-272.

Figures/Tables 5

Figure 1.

Figure 2.

Table 1.

Table 2.

Comparison of laypeople AED operation skills between card group and control group, n (%)

Operation skills		Total			18-24 years			25-54 years			55-65 years
Operation skills		Card group	Control group	P-value^c	Card group	Control group	P-value	Card group	Control group	P-value	Card group	Control group	P-value
Fully baring the chest
	Baseline ^a	72 (88.9)	52 (63.4)	<0.001	27 (90.0)	24 (82.8)	0.47	26 (89.7)	22 (73.3)	0.11	19 (79.2)	6 (26.1)	<0.001
	Post-training ^a	83 (100)	82 (100)	-	30 (100)	29 (100)	-	29 (100)	30 (100)	-	24 (100)	23 (100)	-
	Follow-up ^b	61 (96.8)	71 (92.2)	0.29	29 (100)	27 (96.4)	0.49	12 (100)	27 (93.1)	1.0	20 (90.9)	17 (85.0)	0.66
Correct electrodes placement
	Baseline	27 (32.5)	14 (17.1)	0.03	13 (43.3)	9 (31.0)	0.33	9 (31.0)	3 (10.0)	0.04	5 (20.8)	2 (8.7)	0.42
	Post-training	63 (75.9)	61 (74.4)	0.82	25 (83.3)	23 (79.3)	0.69	22 (75.9)	21 (70.0)	0.61	16 (66.7)	17 (73.9)	0.59
	Follow-up	37 (58.7)	36 (46.8)	0.16	18 (62.1)	15 (53.6)	0.52	7 (58.3)	18 (62.1)	1.0	12 (54.5)	3 (15.0)	0.01
Clearing while AED analyzes the rhythm
	Baseline	70 (84.3)	63 (76.8)	0.22	27 (90.0)	24 (82.8)	0.47	23 (79.3)	23 (76.7)	0.81	20 (83.3)	16 (69.6)	0.32
	Post-training	81 (97.6)	74 (90.2)	0.06	30 (100)	25 (86.2)	0.035	28 (96.6)	28 (93.3)	1.0	23 (95.8)	21 (91.3)	0.61
	Follow-up	62 (98.4)	71 (92.2)	0.13	29 (100)	25 (89.3)	0.11	12 (100)	29 (100)	-	21 (95.5)	17 (85.0)	0.33
Clearing while AED delivers the shock
	Baseline	78 (94.0)	75 (91.5)	0.57	28 (93.3)	28 (96.6)	1.0	28 (96.6)	29 (96.7)	1.0	22 (91.7)	18 (78.3)	0.25
	Post-training	82 (98.8)	81 (98.8)	1.0	30 (100)	29 (100)	-	28 (96.6)	30 (100)	0.49	24 (100)	22 (95.7)	0.49
	Follow-up	63 (100)	74 (96.1)	0.25	29 (100)	28 (100)	-	12 (100)	29 (100)	-	22 (100)	17 (85.0)	0.10
Successful defibrillation ^d
	Baseline	26 (31.1)	13 (15.9)	0.03	13 (43.3)	8 (27.6)	0.21	8 (27.6)	3 (10.0)	0.08	5 (20.8)	2 (8.7)	0.42
	Post-training	63 (75.9)	61 (74.4)	0.83	25 (83.3)	23 (79.3)	0.69	22 (75.9)	21 (70.0)	0.61	16 (66.7)	17 (73.9)	0.59
	Follow-up	37 (58.7)	36 (46.8)	0.16	18 (62.1)	15 (53.6)	0.52	7 (58.3)	18 (62.1)	1.0	12 (54.5)	3 (15.0)	0.01
Resuming CPR after shock
	Baseline	60 (72.3)	8 (9.8)	<0.001	18 (60.0)	3 (10.3)	<0.001	23 (79.3)	3 (10.0)	<0.001	19 (79.2)	2 (8.7)	<0.001
	Post-training	83 (100)	71 (86.6)	0.001	30 (100)	26 (89.7)	0.11	29 (100)	26 (86.7)	0.11	24 (100)	19 (82.6)	0.13
	Follow-up	62 (98.4)	44 (57.1)	<0.001	29 (100)	20 (71.4)	0.002	12 (100)	21 (72.4)	0.08	21 (95.5)	3 (15.0)	<0.001

Table 2.

Table 3.

References 28

1	Bækgaard JS, Viereck S, Møller TP, Ersbøll AK, Lippert F, Folke F. The effects of public access defibrillation on survival after out-of-hospital cardiac arrest: a systematic review of observational studies. Circulation. 2017; 136(10): 954-65. doi: 10.1161/CIRCULATIONAHA.117.029067 pmid: 28687709
2	Deakin CD. The chain of survival: not all links are equal. Resuscitation. 2018; 126: 80-2. doi: S0300-9572(18)30080-7 pmid: 29471008
3	Perkins GD, Handley AJ, Koster RW, Castrén M, Smyth MA, Olasveengen T, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015; 95: 81-99. doi: 10.1016/j.resuscitation.2015.07.015 pmid: 26477420
4	Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132(18 Suppl 2): S414-S435.
5	Agerskov M, Nielsen AM, Hansen CM, Hansen MB, Lippert FK, Wissenberg M, et al. Public access defibrillation: great benefit and potential but infrequently used. Resuscitation. 2015; 96: 53-8. doi: 10.1016/j.resuscitation.2015.07.021 pmid: 26234893
6	Deakin CD, Shewry E, Gray HH. Public access defibrillation remains out of reach for most victims of out-of-hospital sudden cardiac arrest. Heart. 2014; 100(8): 619-23. doi: 10.1136/heartjnl-2013-305030 pmid: 24553390
7	Kitamura T, Kiyohara K, Sakai T, Matsuyama T, Hatakeyama T, Shimamoto T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med. 2016; 375(17): 1649-59. doi: 10.1056/NEJMsa1600011
8	Hawkes C, Booth S, Ji C, Brace-McDonnell SJ, Whittington A, Mapstone J, et al. Epidemiology and outcomes from out-of-hospital cardiac arrests in England. Resuscitation. 2017; 110: 133-40. doi: S0300-9572(16)30547-0 pmid: 27865775
9	Dong XJ, Zhang L, Yu YL, Shi SX, Yang XC, Zhang XQ, et al. The general public’s ability to operate automated external defibrillator: a controlled simulation study. World J Emerg Med. 2020; 11(4): 238-45. doi: 10.5847/wjem.j.1920-8642.2020.04.006
10	Yeung J, Okamoto D, Soar J, Perkins GD. AED training and its impact on skill acquisition, retention and performance - A systematic review of alternative training methods. Resuscitation. 2011; 82(6): 657-64. doi: 10.1016/j.resuscitation.2011.02.035
11	Maes F, Marchandise S, Boileau L, Le Polain de Waroux JB, Scavée C. Evaluation of a new semiautomated external defibrillator technology: a live cases video recording study. Emerg Med J. 2015; 32(6): 481-5. doi: 10.1136/emermed-2013-202962 pmid: 25082717
12	Foster AG, Deakin CD. Accuracy of instructional diagrams for automated external defibrillator pad positioning. Resuscitation. 2019; 139: 282-8. doi: S0300-9572(19)30150-9 pmid: 31063839
13	Carballo-Fazanes A, Jorge-Soto C, Abelairas-Gómez C, Bello-Rodríguez J, Fernández-Méndez F, Rodríguez-Núñez A. Could mobile apps improve laypeople AED use? Resuscitation. 2019;140: 159-60.
14	Andersen LW, Holmberg MJ, Granfeldt A, James LP, Caulley L. Cost-effectiveness of public automated external defibrillators. Resuscitation. 2019; 138: 250-8. doi: S0300-9572(19)30097-8 pmid: 30926453
15	Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 3. Adult advanced life support. Resuscitation. 2015;95: 100-47.
16	Mosesso VN Jr, Shapiro AH, Stein K, Burkett K, Wang H. Effects of AED device features on performance by untrained laypersons. Resuscitation. 2009; 80(11): 1285-9. doi: 10.1016/j.resuscitation.2009.07.016 pmid: 19720444
17	Roccia WD, Modic PE, Cuddy MA. Automated external defibrillator use among the general population. J Dent Educ. 2003; 67(12): 1355-61. pmid: 14733268
18	Bødtker H, Rosendahl D. Automated external defibrillators and defibrillation electrodes from major manufactures depict placement of the left apical defibrillation electrode poorly!. Resuscitation. 2018; 125: e11-e12. doi: 10.1016/j.resuscitation.2018.01.046
19	Bødtker H, Rosendahl D. Correct AED electrode placement is rarely achieved by laypersons when attaching AED electrodes to a human thorax. Resuscitation. 2018; 127: e12-e13. doi: 10.1016/j.resuscitation.2018.04.002
20	Kiyohara K, Kitamura T, Sakai T, Nishiyama C, Nishiuchi T, Hayashi Y, et al. Public-access AED pad application and outcomes for out-of-hospital cardiac arrests in Osaka, Japan. Resuscitation. 2016; 106: 70-5. doi: 10.1016/j.resuscitation.2016.06.025 pmid: 27373223
21	Savastano S, Vanni V, Burkart R, Raimondi M, Canevari F, Molinari S, et al. Comparative performance assessment of commercially available automatic external defibrillators: a simulation and real-life measurement study of hands-off time. Resuscitation. 2017; 110: 12-7. doi: S0300-9572(16)30509-3 pmid: 27780740
22	Nurmi J, Castrén M. Layperson positioning of defibrillation electrodes guided by pictorial instructions. Resuscitation. 2005; 64(2): 177-80. pmid: 15680526
23	Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010; 3(1): 63-81. doi: 10.1161/CIRCOUTCOMES.109.889576
24	Ringh M, Hollenberg J, Palsgaard-Moeller T, Svensson L, Rosenqvist M, Lippert FK, et al. The challenges and possibilities of public access defibrillation. J Intern Med. 2018; 283(3): 238-56. doi: 10.1111/joim.12730 pmid: 29331055
25	Zhang L, Li BY, Zhao XF, Zhang YQ, Deng YT, Zhao AQ, et al. Public access of automated external defibrillators in a metropolitan city of China. Resuscitation. 2019; 140: 120-6. doi: S0300-9572(19)30184-4 pmid: 31129230
26	Medicine CSoE. Expert consensus on AED layout and launch in China. Chin J Emerg Med. 2020; 29(8):1025-31.
27	Global Resuscitation Alliance. Public Access Defibrillation Program in Shenzhen, China. Ten Programs. Available at: https://www.globalresuscitationalliance.org/wp-content/uploads/2019/12/China_PAD.pdf
28	Lei CY, Qin HW, Dong XJ, You JL, Zhang L. Layperson’s performance on an unconversant type of AED device: a prospective crossover simulation experimental study. World J Emerg Med. 2022; 13(2): 98-105. doi: 10.5847/wjem.j.1920-8642.2022.024

Characteristics	Baseline and post-training			3-month follow-up
Characteristics	Card group (n=83)	Control group (n=82)	P-value	Card group (n=75)	Control group (n=77)	P-value
Male, n (%)	38 (45.8)	37 (45.1)	0.71	36 (48.0)	36 (46.7)	0.91
Age group, n (%)			0.89			0.78
18-24 years	30 (45.8)	29 (35.4)		29 (38.7)	28 (36.4)
25-54 years	29 (34.9)	30 (36.6)		24 (32.0)	29 (37.7)
55-65 years	24 (28.9)	23 (28.0)		22 (29.3)	20 (26.0)
Education status, n (%)			0.26			0.19
High school/ Junior college and below	37 (44.6)	27 (32.9)		33 (44.0)	26 (33.8)
College/ University	40 (48.2)	44 (53.6)		36 (48.0)	42 (54.5)
Master and above	6 (7.2)	11 (13.4)		6 (8.0)	9 (11.7)

Variables		Total					18-24 years					25-54 years					55-65 years
		Card group		Control group		P-value	Card group		Control group		P-value	Card group		Control group		P-value	Card group		Control group		P-value
		n	Time intervals	n	Time intervals	P-value	n	Time intervals	n	Time intervals	P-value	n	Time intervals	n	Time intervals	P-value	n	Time intervals	n	Time intervals	P-value
Time to power-on ^a
	Baseline	26	35 (18-89)	13	51 (17-107)	0.79	13	74 (34-109)	8	80 (42-172)	0.45	8	21 (14-78)	3	23 (12-72)	0.83	5	18 (10-30)	2	18, 39	0.33
	Post-training	63	28 (11-48)	61	22 (11-51)	0.96	25	36 (16-50)	23	29 (11-52)	0.48	22	34 (17-44)	21	17 (9-43)	0.08	16	9 (6-14)	17	33 (12-58)	0.019
	Follow-up	37	36 (17-52)	36	28 (16-50)	0.49	18	40 (20-52)	15	31 (19-53)	0.72	7	54 (35-71)	18	31 (17-50)	0.07	12	27 (9-38)	3	15 (10-31)	0.67
Time to shock ^a
	Baseline	26	113 (92-146)	13	107 (101-131)	0.25	13	125 (113-171)	8	129 (103-198)	0.72	8	91 (80-140)	3	109 (102-122)	0.38	5	95 (72-112)	2	85, 92	1
	Post-training	63	72 (63-78)	61	80 (69-88)	<0.001	25	75 (66-80)	23	74 (64-88)	0.59	22	68 (63-78)	21	81 (70-90)	0.009	16	65 (56-74)	17	79 (77-86)	0.001
	Follow-up	37	74 (66-87)	36	80 (71-94)	0.05	18	76 (68-83)	15	81 (69-92)	0.31	7	100 (77-143)	18	78 (69-93)	0.05	12	68 (60-74)	3	92 (75-106)	0.006
Time to resume CPR after shock ^b
	Baseline	23	10 (7-13)	5	12 (11-15)	0.06	10	8 (5-13)	2	10, 11	0.39	8	13 (10-14)	2	12, 15	0.60	5	8 (5-10)	1	16	0.14
	Post-training	63	7 (3-10)	51	10 (8-11)	<0.001	25	4 (2-8)	16	9 (6-10)	0.003	22	10 (6-11)	21	9.5 (8-11)	0.87	16	6 (3-9)	14	10 (7-12)	0.002
	Follow-up	36	9 (8-12)	27	9 (7-12)	0.33	18	11 (9-14)	10	8 (6-19)	0.36	7	9 (8-16)	16	9 (8-12)	0.66	11	9 (8-10)	1	9	0.88

[1]	Chao-yu Lei, Heng-wei Qin, Xue-jie Dong, Jia-lin You, Lin Zhang. Layperson’s performance on an unconversant type of AED device: A prospective crossover simulation experimental study [J]. World Journal of Emergency Medicine, 2022, 13(2): 98-105.
[2]	Xin Lu, Shi Feng, Shi-gong Guo, Mu-bing Qin, Xiang-ning Liu, Shi-yuan Yu, Li-na Zhao, Zeng-zheng Ge, Jing-jing Chai, Sheng-yong Xu, Di Shi, Ji-hai Liu, Hua-dong Zhu, Yi Li. Development of an intensive simulating training program in emergency medicine for medical students in China [J]. World Journal of Emergency Medicine, 2022, 13(1): 23-26.
[3]	Ryan W. Horton, Kian R. Niknam, Viveta Lobo, Kathryn H. Pade, Drew Jones, Kenton L. Anderson. A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study [J]. World Journal of Emergency Medicine, 2022, 13(1): 18-22.
[4]	Xue-jie Dong, Lin Zhang, Yue-lin Yu, Shu-xiao Shi, Xiao-chen Yang, Xiao-qian Zhang, Shuang Tian, Helge Myklebust, Guo-hong Li, Zhi-jie Zheng. The general public’s ability to operate automated external defibrillator: A controlled simulation study [J]. World Journal of Emergency Medicine, 2020, 11(4): 238-245.
[5]	Avir Mitra, Asaf Gave, Kelsey Coolahan, Thomas Nguyen. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting [J]. World Journal of Emergency Medicine, 2019, 10(4): 210-214.
[6]	Israel Olatunji Gabriel, Joel O. Aluko. Theoretical knowledge and psychomotor skill acquisition of basic life support training programme among secondary school students [J]. World Journal of Emergency Medicine, 2019, 10(2): 81-87.
[7]	Mario Kobras, Sascha Langewand, Christina Murr, Christiane Neu, Jeannette Schmid. Short lessons in basic life support improve self-assurance in performing cardiopulmonary resuscitation [J]. World Journal of Emergency Medicine, 2016, 7(4): 255-262.
[8]	Chik Leung Ho, Ka Wai Cheng, Tze Hang Ma, Yau Hang Wong, Ka Lok Cheng, Chak Wah Kam. Characterization of available automated external defibrillators in the market based on the product manuals in 2014 [J]. World Journal of Emergency Medicine, 2016, 7(2): 138-146.
[9]	Endale Gebreegziabher, Adugna Aregawi, Habtamu Getinet. Knowledge and skills of neonatal resuscitation of health professionals at a university teaching hospital of Northwest Ethiopia [J]. World Journal of Emergency Medicine, 2014, 5(3): 196-202.