Training interval, feedback, and retention in cardiopulmonary resuscitation education: a systematic review

High-quality cardiopulmonary resuscitation (CPR) is a key determinant of survival after cardiac arrest; however, CPR skills deteriorate rapidly after training. Increasing attention has therefore been directed toward optimizing training design, including training intervals, feedback mechanisms, and educational delivery models, to improve skill retention. This systematic review aimed to synthesize evidence on the effectiveness of CPR education strategies, with particular emphasis on retention-oriented approaches.

This systematic review was conducted in accordance with the PRISMA 2020 guidelines. A comprehensive literature search was performed in PubMed/MEDLINE, Embase, and the Cochrane Library for studies published from January 2015 to June 30, 2024. Interventional studies evaluating CPR education-including randomized controlled trials and quasi-experimental designs-were included. Due to substantial heterogeneity in study designs, interventions, and outcome measures, a meta-analysis was not feasible; therefore, a narrative synthesis was conducted.

A total of 20 studies were included. Across the included studies, spaced training was generally associated with improved skill retention compared with single-session training. Interventions incorporating feedback mechanisms were associated with improved compression performance, while reflective and cognitively oriented approaches showed potential for enhancing long-term skill retention, particularly at follow-up assessments. In addition, school- and community-based CPR education-including peer-led training-demonstrated outcomes comparable to traditional instructor-led models.

These findings suggest that the effectiveness of CPR education is associated less with total training duration and more with how training is structured and reinforced. Retention-focused approaches-such as spaced training, feedback integration, and cognitively informed strategies-may support improved skill maintenance. However, given the heterogeneity of included studies and the presence of moderate to high risk of bias in several studies, these findings should be interpreted with caution.