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Does simulated CPR training improve field CPR quality?

The value of simulation is clear, but the link proving simulation training translates to real clinical outcomes has not been well documented

Updated July 27, 2016

CPR is the only intervention that demonstrates improved outcome in cardiac arrest, meaning patient survival to discharge is linked to high-quality CPR.

In a 2013 consensus statement, the American Heart Association established high-quality CPR target parameters:

  • Minimize interruptions in chest compressions.
  • Provide compressions at a rate of 100 to 120 per minute>
  • Provide compressions at a depth of ≥ 50 mm in adults.
  • Avoid excessive ventilation (only minimal chest rise).
  • Avoid leaning between compressions.[1]

Performance of CPR in the clinical setting is believed to be frequently inconsistent with the AHA guidelines and of low quality. Pre-hospital professionals often report that initial CPR and resuscitation training is void of effective instruction and application.

They also claim that continuing education regarding all aspects of resuscitation is infrequent and does not provide realistic psycho-cognitive experiences to improve their existing skills and critical thinking.

Use it or lose it
For many health care providers, CPR and resuscitation skills seem to be a “use it or lose it” proposition. Scientific research shows that CPR and resuscitation skills deteriorate quickly after initial training.[2],[3],[4]

Some skills such as lung sound interpretation and initiating compressions in a timely manner, decline in as little as a few weeks to 30 days. Others skills such as hand hygiene, correct hand placement and depth of compressions plummet by 90 days.

Clinical behaviors that require complex sets of psycho-cognitive skill competence and critical thinking show decline within weeks after initial training. This is particularly true for providers who respond to specific types of infrequent emergencies.

These include events such as pediatric trauma and resuscitation, OB/GYN emergencies, and toxicological emergencies to list a few. This may also be the case for cardiac arrest calls. However, the frequency of EMS calls that require CPR and resuscitation is difficult to estimate due to lack of standardized reporting.

The critical need for ongoing CPR and resuscitation remediation is strongly encouraged by the AHA.

“The quality of rescuer education and frequency of retraining are critical factors in improving the effectiveness of resuscitation. Ideally retraining should not be limited to two-year intervals. More frequent renewal of skills is needed."[5]

The role of simulation
Health care students have unique needs. They need to successfully combine all three domains of learning (cognitive, psychomotor and affective) to establish evidence-based clinical behaviors and effective critical thinking skills.

Simulation-based training involves immersion of a student in a realistic scenario created with a simulator (manikin and equipment) that replicates the high-stake environment with fidelity sufficient to achieve a realistic experience.

There are many types of simulation products on the market. Some are specifically designed to help the learner conquer the high-stakes scenario requiring CPR and resuscitation. They include computer simulation programs, low-fidelity manikins, and high-fidelity systems to name a few.

Health care learners prefer curricula that use high-fidelity simulation. Unfortunately, due to a wide variety of obstacles, educators report that simulation technology is still underused.

Research suggests four key values of simulation.

  • Learning and retention is maximized when it embraces hands-on practice in immersive-simulated medical environments.[6],[7]
  • Simulation provides learners with repetition and multiple experiences involving different and infrequent scenarios.
  • Simulation allows for the measurement of the AHA CPR target parameters.[1]
  • Simulation meets the AHA’s CPR quality improvement and development goal for health care stakeholders to “develop training equipment that provides rescuers with robust skills to readily and reliably provide quality CPR."[1]

The 2013 consensus statement from the AHA suggests the use of a report card that includes a general checklist and CPR quality analysis. Quality markers on the report card ask:

  • Was the team leader clearly identified?
  • Was the defibrillator applied quickly?
  • Was CPR started promptly?
  • Were pauses in CPR delivery minimized?
  • Was CPR of subjectively high quality?
  • Were peri-shock pauses minimized?
  • Was an airway secured efficiently?
  • What was the compression fraction (the proportion of time that chest compressions are performed during a cardiac arrest)?
  • What was the mean (average) compression depth (mm)?
  • What was the percentage of compressions without leaning?
  • What was the mean ventilation rate?[1]

Considering the markers listed on the AHA CPR report card, simulation is tailor-made for the evaluation of CPR. The markers can be used during high-fidelity simulation and most low-fidelity simulators can capture these markers with some modifications by an experienced simulation facilitator.

Also, with some creative monitoring from the facilitator, the CPR quality analysis markers can be measured as well. The CPR report card can then be used to launch a very effective participant debriefing following the simulation experience.

Student debriefing
The student-led debriefing period is perhaps the most important learning activity of the simulation experience. In high-fidelity simulation participants are recorded by video and asked to evaluate their team’s performance after they have completed a simulation.

It is similar to a sports team reviewing video footage of a game to take notes on their own performance. Because the team knows their own thoughts and behaviors better than the coach, they are better suited to identify areas of improvement.

During debriefing, participants use the process of reflection and self-discovery to evaluate their own teamwork, clinical skills, judgment, communication, and compliance with evidence-based practice. Most importantly, it provides each student with the understanding that the whole team is responsible for patient outcome, not just the team leader.

Although the value of simulation is clear, the most important questions remain unanswered. Does simulation result in acceptable levels of clinical compliance and improve patient outcome?

Unanswered question
One study attributes increased pediatric survival rates from cardiopulmonary arrest to high-fidelity simulation exercises.[8] However, the link proving that skills learned during simulation training translates to real clinical experiences has not been well documented in the literature.[9]

In 1761, John Adams once said, “Practice makes perfect.” Vince Lombardi revised the age old advice and said, “Practice does not make perfect. Only perfect practice makes perfect.” High-fidelity simulation makes perfect practice more perfect.

As we continue to collect data, high-fidelity simulation may offer the most promise towards developing a confident and competent learner and provide the opportunity to remediate CPR skills and gain resuscitation experience.


1. Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., Caen, A. R., Bhanji, F., ... Leary, M. (2013). Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation, 128(4), 417-435. doi: 10.1161/CIR.0b013e31829d8654

2. Anderson, G. S., Gaetz, M., & Masse, J. (2011). First aid skill retention of first responders within the workplace. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 19(1), 11. doi: 10.1186/1757-7241-19-11

3. Hamilton, R. (2005). Nurses’ knowledge and skill retention following cardiopulmonary resuscitation training: A review of the literature. Journal of Advanced Nursing, 51(3), 288-297. doi: 10.1111/j.1365-2648.2005.03491.x

4. Brown, T. B., Dias, J. A., Saini, D., Shah, R. C., Cofield, S. S., Terndrup, T. E., ... Waterbor, J. W. (2006). Relationship between knowledge of cardiopulmonary resuscitation guidelines and performance. Resuscitation, 69(2), 253-261. doi: 10.1016/j.resuscitation.2005.08.019

5. Field, J. M., Hazinski, M. F., Sayre, M. R., Chameides, L., Schexnayder, S. M., Hemphill, R., ... Hoek, T. L. (2010). Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3), S640-S656. doi: 10.1161/CIRCULATIONAHA.110.970889

6. Eyck, R. P., Tews, M., & Ballester, J. M. (2009). Improved Medical Student Satisfaction and Test Performance With a Simulation-Based Emergency Medicine Curriculum: A Randomized Controlled Trial. Annals of Emergency Medicine, 54(5), 684-691. doi: 10.1016/j.annemergmed.2009.03.025

7. Guhde, J. (2010). Combining Simulation, Instructor-Produced Videos, and Online Discussions to Stimulate Critical Thinking in Nursing Students. CIN: Computers, Informatics, Nursing, 28(5), 274-279. doi: 10.1097/NCN.0b013e3181ec2540

8. Andreatta, P., Saxton, E., Thompson, M., & Annich, G. (2011). Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates*. Pediatric Critical Care Medicine, 12(1), 33-38. doi: 10.1097/PCC.0b013e3181e89270

9. Sahu, S., & Lata, I. (2010). Simulation in resuscitation teaching and training, an evidence based practice review. Journal of Emergencies, Trauma, and Shock, 3(4), 378-384. doi: 10.4103/0974-2700.70758

Dean Meenach, MSN, RN, CNL, CEN, CCRN, CPEN, EMT-P, has taught and worked in EMS for more than 24 years. He currently serves as an advanced nurse clinician and EMS program director at Mercy Hospital South in St. Louis, Missouri. He has served as a paramedic instructor/program director, Paramedic to RN Bridge Program instructor, subject matter expert, author, national speaker and collaborative author in micro-simulation programs. He can be reached at