High-Frequency, Low-Dose CPR Training Improves Provider Skills, Confidence - VHA SimLEARN
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High-Frequency, Low-Dose CPR Training Improves Provider Skills, Confidence

By Quentin Hart, BSN, RN
Clinical Nurse Educator and Simulation Center Coordinator
VA Southern Nevada Healthcare System

NORTH LAS VEGAS, Nev. - It’s no secret that poor-quality cardiopulmonary resuscitation (CPR) can lead to adverse patient outcomes. Compressions at an inadequate depth and rate, incomplete thoracic recoil, unnecessary interruptions or failure to properly use available equipment can lead to the lack of return of spontaneous circulation in patients experiencing cardiac arrest (Li et al., 2013). Without frequent and proper training, CPR providers often overestimate their effectiveness in achieving adequate CPR (Cheng et al., 2015).

Traditional Basic Life Support (BLS) certification is completed every two years and does not require follow-up training in between classes. Unfortunately, skills gained in programs such as BLS start to deteriorate just two weeks post training, with much of the skills completely extinguished within six months (Herbers & Heasers, 2016).  The implementation of the Resuscitation Quality Initiative (RQI) goes far to reinforce technical skills, but lacks the successful teamwork element and the use of backboards and automated external defibrillators (AED’s).   

High-frequency, low-dose (HFLD) CPR training (also known as “Go” or “First 5” training) reduces the deterioration in CPR skills that develops between biannual BLS classes and supplements the teamwork aspect and AED usage to support RQI. It allows health care providers an opportunity to practice the skills and teamwork necessary to resuscitate patients in cardiac arrest in a safe, nonthreatening environment (Wilson, Phelps, Downs, & Wilson, 2010). The VA Southern Nevada Healthcare System (VASNHS) initiated the use of HFLD CPR training in July 2018 to supplement the HeartCode BLS and RQI certifications offered in the Las Vegas valley. 

During HFLD CPR training, the instructor begins by giving a “pre-brief” to review CPR algorithms as defined by the American Heart Association (AHA) and the use of the equipment such as the bag valve mask, backboard and AED or monitor/defibrillator. The instructor also reviews what is expected of each member of the group, particularly the team leader. After questions are answered, the team (typically four to five members) is given a cardiac arrest scenario using an RQI mannequin attached to a skills recorder. The instructor gives feedback on CPR skills, proper use of backboard and step-stool, and AED as the scenario progresses. The scenario ends as the team leader provides a report to the instructor acting as an advanced responder after approximately four minutes. A final debrief is then conducted to reinforce learning. 

A key aspect of the HFLD CPR training is repetition. The first attempts at the CPR scenario are typically clumsy as people remember the locations of necessary equipment and determine their roles. The scenario is repeated three to five times to allow everyone to act as a team leader, develop leadership and followership skills and build confidence. With each cycle, team and individual performance improve as members develop cognitive abilities and muscle memory. The entire process, including pre-brief, up to four cycles and debrief generally takes about 30-35 minutes.

Feedback from the first 24 VASNHS staff members who participated in HFLD CPR training was very positive. When asked to report on their ability to perform CPR skill levels post-training, 96% of respondents reported increased confidence in delivering compressions and using an AED properly; 92% reported increased confidence in delegating roles and responsibilities during a cardiac arrest and ability to participate in a real cardiac arrest; and 88% reported increased confidence in using a bag valve mask to deliver ventilations. Additionally, none of the respondents reported feeling less confident in any of the CPR tasks.

The HFLD training improves CPR abilities and can increase the confidence felt by many providers in an actual cardiac arrest event (Kobras, Langewand, Murr, Neu, & Schmid, 2016). VASNHS currently offers HFLD CPR Training during regularly scheduled skills fairs and in place in the various departments.  


Cheng, A., Overly, F., Kessler, D., Nadkarni, V. M., Lin, Y., Doan, Q., ... Tofil, N. M. (2015). Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation, 87, 44-50. http://dx.doi.org/10.1016/j/resuscitation.2014.11.015

Herbers, M. D., & Heasers, J. A. (2016, September). Implementing an in-situ code quality improvement program. American Journal of Critical Care, 25(5), 393-399. http://dx.doi.org/http://dx.doi.org/10.4037/ajcc2016583

Kobras, M., Langewand, S., Murr, C., Neu, C., & Schmid, J. (2016). Short lessons in basic life support improve self-assurance in performing cardiopulmonary resuscitation. World Journal of Emergency Medicine, 7(4), 255-262. http://dx.doi.org/10.5847/wjem.j.1920-8642.2016.04.003

Li, H., Zhang, L., Yang, Z., Huang, Z., Chen, B., Li, Y., & Yu, T. (2013). Even four minutes of poor quality of CPR compromises outcome in a porcine model of prolonged cardiac arrest. BioMed Research International, 2013, 1-6. http://dx.doi.org/10.1155/2013/171862

Wilson, B. L., Phelps, C., Downs, B., & Wilson, K. (2010). Using human factors engineering in designing and assessing nursing personnel responses in mock code training. Journal of Nursing Care Quality, 25(4), 295-303. http://dx.doi.org/10.1097/NCQ.0b013e3181def0ba