What is the evidence base for using DIY manikins?

Thursday, 13.10.2022

Reading time 5 mins

In this post, we will present all studies that have specifically tested how well CPR skills can be learned by using DIY manikins. We will summarize what this means for practice, and where we need more research.

October 16, 2022 is World Restart a Heart Day, an international awareness campaign that aims to highlight the importance of learning CPR. To increase access to CPR training worldwide at very low costs, do-it-yourself manikins (i.e., made by hand of materials available in the home) may be a suitable tool.  

CPR is one of the most important skills by which bystanders may save a person’s life. However, only 46.1% of cardiac arrest victims initially receive CPR from a bystander (1,2). Teaching CPR in courses is expensive and time-consuming, and during the COVID-19 pandemic has become difficult to realise in person. While instructor-led training is recommended, European guidelines suggest that self-instruction with hands-on practice appears to be an effective alternative (3). To increase the scope of such methods, a wide range of homemade manikin models have been developed by independent, motivated instructors and learners, which render the method practically no-cost. 

Only a handful of studies have specifically tested how well CPR skills can be learned by using DIY manikins. We will present the main studies below and summarize what this means for practice, and where we need more research.  

Figure 1. The first documented ventilation trainer dates back to the 1960's

The oldest publications on DIY mannikins date back to the early 1960s – for example, Hainfeld (4) describes a tool for practicing rescue breaths that uses an empty one-gallon bleach bottle, a plastic bag, a book and some tape (see picture on the left).   

The book provides visual and tactile feedback of the achieved ventilation volume.

Studies that tested learning effects of DIY manikins

A few studies exist that have assessed skill learning via pre-post comparisons or control conditions (i.e., practice on a commercial manikin). For example, Wanner et al. (5) evaluated the effectiveness of teaching compression-only CPR to untrained and trained individuals using an online CPR training video with practice on a homemade manikin (towel, toilet paper roll, t-shirt). Beginners showed significant improvements in compression rate, hand position and compression release. However, compression depth remained problematic. With the thought of adding a simple feedback mechanism, Ohle and colleagues (6) designed a similar, homemade trainer made of two toilet paper rolls with a jar lid underneath, which clicks when the correct compression depth is reached. The team found that the homemade trainer was non-inferior to a commercial manikin in enabling learning of CPR (compression depth, rate, full release, hand position, no flow time). 

Figure 2: The homemade CPR trainers tested by Wanner et al. (left and middle) and Ohle et al. (right). 

The softness of toilet rolls may explain some of the difficulties pertaining to compression depth and recoil skills. Apart from toilet paper, PET bottles seem to be a universal material that is available, easy to cut and form into different shapes, and that also provides the necessary stiffness for compressions. Two randomised studies compared the effect of training with a PET- bottle manikin against a commercially available CPR manikin (7,8) . The authors found that there were no significant between-group differences in compression performance. An even more elaborate manikin was recently developed by David Szpilman: a PET bottle-model with a plastic bag used for practicing rescue breaths (9). Nakagawa and her team (10) compared 1’630 children who practiced with Szpilman’s manikin against 347 children who underwent a longer, standard program with a regular manikin. The handmade version seemed adequate to develop overall CPR and first response skills. 

Figure 3: A slightly more elaborate manikin that allows practice of compressions and rescue breaths, developed by David Szpilman.

 Some skills, such as checking local safety, assessing victim’s responsiveness, calling for help, and assessing victim’s breathing were further improved in the standard program, however, this is likely due to the thoroughness and duration of the longer standard course (and not due to the manikin). Interestingly, the completion rate for all skills components in the shorter, low-cost program was higher than 89% throughout: this suggests that  shorter, simpler courses may lead to better participation by young learners. 

Very recently, Barcala and colleagues conducted a multidisciplinary educational project in which primary school students built a low-cost manikin (abbr. “LOCOMAN”) during science class, while learning about the heart and blood circulation (R. Barcala, personal communication, May 25, 2022). Students completed the manikin’s build at home, with the help of parents or caregivers. This had the added benefit that per child, an additional 1.6 people came into contact with the CPR manikin idea. The students then trained CPR with their manikin during PE class. 

Students’ skills were assessed using instrumented manikins. Preliminary data show that in 10- and 11-year-olds who practiced with LOCOMAN, recoil, compression rate, and depth as well as overall CPR quality ratings were comparable to children who practice with regular manikins (e.g., as reported by Onan et al., 11). 

Figure 4. the LOCOMAN model developed and tested by Barcala and colleagues.

Summary

Overall, we can say that the skill of providing compressions at the correct rate (100-120 bpm) was learnt consistently in all studies (even by children), whereas depth, recoil and compression location varied with different manikin models.  This was probably due to the wide variety of physical characteristics of manikins. In some studies, other measures of first aid performance were assessed, such as hands-off time (i.e., time until CPR was initiated), calling for help, and assessing the victim’s responsiveness. These factors were impacted differently by the different programs, but this is highly likely not to be related to the physical form of the manikin: in these studies, the practice sessions differed between control and intervention conditions, so there were many other factors that might explain these outcomes.  

A bystander’s willingness to perform CPR on a stranger is probably an important predictor of victim survival. When designing DIY manikins, the most important outcome is that people feel confident that they can attempt CPR: their performance is a secondary goal here. Two studies assessed willingness to perform CPR on strangers after training with a homemade manikin, via self-report. An increase in comfort performing CPR, and in the willingness to perform CPR (5) and greater likelihood to perform CPR on stranger post training (6) were found.  

Aside from properly handmade manikins, there are other forms of low-cost manikins (e.g. inflatable manikins such as Laerdal mini anne, cardboard kitsets such as CANNE) that have been developed and proven to be effective (3,17–20). 

My manikins -inventory

Over the last months, we have been collecting all the different prototypes of DIY and low-cost manikins that people have already invented. Some are scientifically tested, some are not. We have compiled an inventory of all these manikin models for anyone to use. If you are looking for a manikin that suits your specific needs or purposes, this here is your best starting point: Have a look at the required materials, the estimated costs, and the purported benefits of each manikin, and you might just find your ideal one.   

Go to inventory

We would like to acknowledge that aside from real handmade manikins, there are other forms of low-cost manikins (e.g. inflatable manikins such as Laerdal mini anne, cardboard kitsets such as CANNE) that have been developed and proven to be effective (3,17–20). 

References

  1. Hansen CM, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010-2013. JAMA – J Am Med Assoc. 2015;314(3):255–64.
  2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38–360.
  3. Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG, et al. European resuscitation council guidelines for resuscitation 2015: section 10. Education and implementation of resuscitation. Resuscitation. 2015;95:288–301.
  4. Hainfeld H. Home-Made Mannequin for First Aid Classes. J Heal Phys Educ Recreat. 1966;37(2):65–65.
  5. Wanner GK, Osborne A, Greene CH. Brief compression-only cardiopulmonary resuscitation training video and simulation with homemade mannequin improves CPR skills. BMC Emerg Med. 2016;16(1):4–9.
  6. Ohle R, Moskalyk M, Boissonneault E, Bilgasem A, Tissot E, McIsaac S. Is a homemade cardiopulmonary resuscitation (CPR) trainer non-inferior to a commercially available CPR mannequin in teaching high-quality CPR? A non-inferiority randomized control trial. Resusc Plus. 2021;6(February 2021):100134.
  7. Piscopo A, Piscopo IC, Fonseca FA, Pinto IM, Saraiva FK, Avezum A. PO378 Cardiopulmonary Resuscitation (CPR) Mass Training for High School Children in Public Schools in São Paulo – Brazil – Using PET Bottle Mannequins and Recycled Material. Glob Heart. 2018;13(4):458–9.
  8. Piscopo A, Piscopo ICC, Avezum A, I.M. P, Saraiva FKK. New mannequin made by recyclable plastic bottles for training thoracic compressions at schools. Circulation. 2018;138(2018 PG-2021–2021):2021.
  9. Szpilman D. How to do your own CPR mannequin for drowning training. 2021.
  10. Nakagawa NK, Oliveira KMGG, Lockey A, Semeraro F, Aikawa P, Macchione M, et al. Effectiveness of the 40-Minute Handmade Manikin Program to Teach Hands-on Cardiopulmonary Resuscitation at School Communities. Am J Cardiol. 2021;139(PG-126-130):126–30.
  11. Onan A, Turan S, Elcin M, Erbil B, Bulut ŞÇ. The effectiveness of traditional Basic Life Support training and alternative technology-enhanced methods in high schools. Hong Kong J Emerg Med. 2019;26(1):44–52.
  12. Magill RA. The influence of augmented feedback on skill learning depends on characteristics of the skill and the learner. Quest. 1994;46(3):314–27.
  13. Salmoni AW, Schmidt RA, Walter CB. Knowledge of results and motor learning: a review and critical reappraisal. Psychol Bull. 1984;95(3):355–86.
  14. Sá-Couto C, AM F, Almeida D, Nicolau A, Vieira-Marques P. Evaluation of skills acquisition using a new low-cost tool for CPR self-training. Porto Biomed J. 2018;3(1 PG-e8):e8.
  15. Schmidt RA, Wulf G. Continuous Concurrent Feedback Degrades Skill Learning: Implications for Training and Simulation. Hum Factors. 1997;39(4):509–25.
  16. Ohle R, Moskalyk M, Boissonneault E, Simmons K, McIsaac S. A homemade CPR trainer can enable real time practice during online hands only CPR training. Resuscitation. 2021;158(PG-71-72):71–2.
  17. Beskind DL, Stolz U, Thiede R, Hoyer R, Burns W, Brown J, et al. Viewing a brief chest-compression-only CPR video improves bystander CPR performance and responsiveness in high school students: A cluster randomized trial. Resuscitation. 2016;104:28–33.
  18. Jones I, Handley AJ, Whitfield R, Newcombe R, Chamberlain D. A preliminary feasibility study of a short DVD-based distance-learning package for basic life support. Resuscitation. 2007;75(2):350–6.
  19. Reder S, Cummings P, Quan L. Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students. Resuscitation. 2006;69(3):443–53.
  20. Roppolo LP, Pepe PE, Campbell L, Ohman K, Kulkarni H, Miller R, et al. Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Airlines Study. Resuscitation. 2007;74(2):276–85.

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