CPR Blog

The CPR Blog is dedicated to providing content focused on all aspects of CPR.

RQI and CPR Training

Before coming to the CPR Training Company, I was an AHA Training Center Coordinator at a mid-sized hospital. During my six year tour, three years were tasked with moving the hospital's traditional AHA Instructor Led training model over to the integration and exclusive use of an RQI based model. The facility's AHA Training Center certified about 1,200 staff every year in BLS and another 100 in ACLS. What follows is my personal observation and experiences in a highly condensed blog entry. First some definitions for those reading along...

RQI Definitions 


Voice Assisted Manikins (VAM) measure the learner's real time application of CPR's psychomotor skills through several sensors. These sensors measure compression depth, rate, recoil, and hand placement. VAMs also measure a learner's application of ventilation skills including force of breath, tidal volume, allowing for full exhalation, and two breaths in 10 (or less) seconds.


RQI stands for Resuscitation Quality Improvement (RQI®). The RQI Program is a subscription-based American Heart Association (AHA) solution designed to address the well documented problem of rapid CPR skills decay after initial training.

RQI is Not a Turnkey Training Solution

What I found out is RQI (which uses VAMs) is not a turnkey learning and training service. I spent at least two eight hour days a week helping staff learn how to complete just the hands segment with a manikin (VAM) based skill session. Side note...many staff wait until the last second to complete this training which makes for even more stress. I felt pleased if I could have a single staff member complete their BLS skill session within 45 minutes. I nearly went crazy doing this day in and day out. But that's what it took to help our staff shift from an instructor led model to the RQI model. This time consuming aspect is something the AHA vendors will not openly share. Remember staff are used to attending class and getting spoon fed content. With RQI, staff will own the entire CPR/ACLS training process from start to finish. While this is a good thing it also will lead to significant learner dissatisfaction.  

Drawbacks to VAMs and RQI

Because I was part of the early integration of VAMs and RQI, I get a lot of questions on VAMs and RQI. RQI is based on sound research and I agree with the underlying RQI approach. Interacting with resuscitation content every six months is a best practice confirmed by research.

However I am critical of VAMs and (more importantly) the replacement of instructors with VAMs. VAMs have a really poor learner satisfaction score. My own instructor practice strongly suggests VAMs ought to augment the instructor's role, not remove the instructor. My general response to VAMs...they are great…at measuring specific aspects of CPR but they really are very limited and do not reinforce other and equally important content. VAMs, I cannot say these enough, VAMs:

RQI Will Shift Your CPR Training Paradigm

When I took on the AHA Training Center Director role, the facility only offered instructor led BLS and ACLS training. The transition to online HeartCode learning was hard and caused a significant amount of distress in the organization (relational and financial). I literally had staff swearing in my face because they didn't like playing video games. They hated the VAMs and hated me, it was not a good situation. Fast forward two years and everyone widely agreed the HeartCode training was the better approach but now they were faced with having to learn yet another new platform RQI. The bottom line is learner satisfaction was in the toilet.

Once the HeartCode training approach became the standard at my facility, RQI started. It is important for those looking at RQI to understand it took me two long and hard years to get staff weaned off instructor led classes. The move to RQI, while also painful, at least had the hard work of moving staff to HeartCode finished. In other words I had a solid foundation to work from. I cannot imagine what the move would be like if we would have moved directly from instructor led classes to RQI. This is one reason why I say the RQI Program is a training paradigm shifter. Expect the shift to be a long, hard road that we found needed a dedicated FTE (staff member) to support. Yes another FTE. This is yet another reason why I say the RQI program is not a turnkey program.

RQI Research Findings to Consider

The findings of this study not only confirmed the importance of practicing CPR psychomotor skills to retain them but also revealed that short monthly practices could improve skills over baseline. Students who practiced their psychomotor skills on VAMs for only 6 min monthly either maintained or improved their skills over the 12-month period

Oermann, M. H., Kardong-Edgren, S. E., & Odom-Maryon, T. (2011). Effects of monthly practice on nursing students' CPR psychomotor skill performance. Resuscitation,82(4), 447-453. doi:10.1016/j.resuscitation.2010.11.022

Better skill retention was obtained in cardiopulmonary resuscitation using a bag-valve-mask with an instructor than an automated voice advisory manikin.

Isbye, D. L., Høiby, P., Rasmussen, M. B., Sommer, J., Lippert, F. K., Ringsted, C., & Rasmussen, L. S. (2008). Voice advisory manikin versus instructor facilitated training in cardiopulmonary resuscitation. Resuscitation,79(1), 73-81. doi:10.1016/j.resuscitation.2008.06.012

The VAM system does not eliminate the need for other teaching techniques as at present it covers only the psychomotor skills of ventilation and CPR. In conclusion, 20 min of training with an automated VAM system without instructor involvement produced virtually no retention of basic CPR skills 6 months later. Adding 30 min of similar training divided into 10 3 min sessions the next month improved retention.

Wik, L., Myklebust, H., Auestad, B. H., & Steen, P. A. (2002). Retention of basic life support skills 6 months after training with an automated voice advisory manikin system without instructor involvement. Resuscitation,52(3), 273-279. doi:10.1016/s0300-9572(01)00476-2


Short, increased, topic specific refreshers yield better response and skills in CPR (think RQI) but VAMs are not the best tool to use for every aspect of CPR Training. Of course the challenge is how can a healthcare facility justify increasing training time and resources on a relatively high risk, low volume (al be it life threatening) topic. And one more parting idea…. research suggests that certain skills are better left to be taught by an instructor instead of a VAM and the RQI model. Over 20 years ago instructors used feedback manikins only to ditch them....let's see what changes happen this time. 

About the author - ​Joe Love is the owner of the CPR Training Company and works full time as a Pediatric Critical Care Transport Nurse and dedicated Code Team Nurse. Although he has enjoyed great success as a flight nurse, critical care pediatric transport nurse, owner of the CPR Training Company, and medical simulation center coordinator, his true passion is in helping others.

CPR Manikin Feedback
Case Study on Heatstroke