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C2005 Evidence Evaluation Template - Nov.11, 2003 i.CPRPrompts.DLR.10Jan05Final.doc


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WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS

Worksheet Author:


Taskforce/Subcommittee:

__
BLS
__
ACLS
__
PEDS
X

ID
__
PROAD
__
Other:
Authors Home Resuscitation Council:
X AHA
__
ANZCOR
__
CLAR
__
ERC
__
HSFC
__
HSFC
__
RCSA

___IAHF ___Other:

Date Submitted to Subcommittee:

March 15, 2004 (Resubmitted Sept. 25, 2004, Jan. 12, 2005)

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.
Existing guideline, practice or training activity, or new guideline:

Audio prompts that guide action sequences and the timing of chest compressions and ventilations increase learning and retention of CPR skills and improve CPR
performance (Class IIb). Page I-22, Part 3: Adult Basic Life Support Major Guideline Changes

Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific,
positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific
outcomes (ROSC vs. hospital discharge).


NOTE: The 2000 Guideline attempted to answer two questions with one guideline. Evidence indicates that there are separate answers to the original question
posed. Therefore, the revised guideline is separated into two parts.

Hypothesis 1: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations may aid in the early
learning of CPR skills when used as a model for performance; however, overuse of audio prompts may have a detrimental effect on retention and ample practice
time without audio prompting devices must be supplied.

Hypothesis 2: Audio prompts or other forms of feedback that guide action sequences and timing of chest compressions and ventilations during cardiac arrest events
will aid rescuers in performing CPR skills.


Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.

Initially, medical literature was searched. However, there were very few applicable returns to address Hypothesis 1. Search was expanded into education and
psychology literature to obtain articles that included experimental studies, literature reviews, meta-analysis, or theory building. Search concentrated on the motor
skill acquisition and retention literature. While not directly related to the provision of CPR, all relevant articles that focused on motor skill learning, particularly those
that dealt specifically with timing tasks, were reviewed. The premise was created that CPR is a motor skill and information, studies, and theories relevant to motor
skill learning were applicable to CPR. Note: All articles outside the medical literature are highlighted by Italics.

Utilizing combinations of the text search word CPR with the text words learning, skill, retention, feedback, education, training, KR (Knowledge of Results), KP
(Knowledge of Perfromance), audio, prompts, or timing, relevant libraries and databases were searched. Additional searches of the non-medical literature on the
text words learning, skill, retention, feedback, KR (Knowledge of Results), KP (Knowledge of Perfromance), audio, prompts, and timing in various combinations
produced additional articles for review. Abstracts and/or articles were reviewed to determine relevance and match inclusion/exclusion criteria.

List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register
of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles,
and books.

Searches completed February 2004 (updated Sept. 2004) . Databases searched: Literature search results of Guidelines 2000 worksheet; MEDLINE
(PubMed); AHA EndNote 7 Master Library (April 2004 Edition); Cochrane Database for Systematic Reviews; Central Register of Controlled Trials; EMBASE;
CINAHL; Academic Search Premier; ERIC; and hand searches of key articles. A late-breaking publication was included in January, 2005
Total combined unique potentially relevant returns - 245
State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects
> minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)

- Exclusion criteria No abstract only studies. No editorials or letters to editor. No non-peer-reviewed articles.
- Inclusion criteria Peer-reviewed manuscripts only. Study subject had to have been CPR skills or other forms of psychomotor skills.

Number of articles/sources meeting criteria for further review:.

Regarding Hypothesis 1 36 Selected for inclusion
Regarding Hypothesis 2 14 Selected for inclusion

i.CPRPrompts.DLR.10Jan05Final.doc


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STEP 2: ASSESS THE QUALITY OF EACH STUDY
Step 2A: Determine the Level of Evidence.
For each article/source from step 1, assign a level of evidencebased on
study design and methodology.

Level of
Evidence
Definitions
(See manuscript for full details)
Level 1
Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Level 2
Randomized clinical trials with smaller or less significant treatment effects
Level 3
Prospective, controlled, non-randomized, cohort studies
Level 4
Historic, non-randomized, cohort or case-control studies
Level 5
Case series: patients compiled in serial fashion, lacking a control group
Level 6
Animal studies or mechanical model studies
Level 7
Extrapolations from existing data collected for other purposes, theoretical analyses
Level 8
Rational conjecture (common sense); common practices accepted before evidence-based guidelines


Step 2B: Critically assess each article/source in terms of research design and methods.
Was the study well executed?

Suggested criteria appear in the table below. Assess design and methods and provide an overall
rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be
excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary
endpoint of each study. For more detailed explanations please see attached assessment form.

Component of
Study and Rating

Excellent

Good

Fair

Poor

Unsatisfactory
Design &



Methods
Highly appropriate
sample or model,
randomized, proper
controls
AND
Outstanding
accuracy,
precision, and data
collection in its
class
Highly appropriate
sample or model,
randomized, proper
controls
OR
Outstanding accuracy,
precision, and data
collection in its class
Adequate,
design, but
possibly biased

OR
Adequate under
the
circumstances
Small or clearly
biased population or
model

OR
Weakly defensible in
its class, limited
data or measures
Anecdotal, no
controls, off
target end-points

OR
Not defensible in
its class,
insufficient data
or measures

A = Return of spontaneous circulation
C = Survival to hospital discharge
E = Other endpoint
B = Survival of event


D = Intact neurological survival

Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

DIRECTION of study
by results & statistics:

SUPPORT the proposal

NEUTRAL

OPPOSE the proposal

Results
Outcome of proposed guideline
superior, to a clinically important
degree, to current approaches
Outcome of proposed guideline
no different from current
approach
Outcome of proposed guideline
inferior to current approach
Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction
(ie, supporting or neutral/
opposing)
; combine and summarize.
Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality
studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/
date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies.
Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.
i.CPRPrompts.DLR.10Jan05Final.doc


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