Beyond the Two-Year Card: Reimagining Cardiac Arrest Education
As healthcare professionals, we commit ourselves to lifelong learning. Yet while sitting through another certification course and watching the same familiar videos, it is reasonable to ask:
Are we truly doing what is best for our learners?
Traditional courses require clinicians to step away from their jobs—or give up a day off—to revisit material they may have encountered many times before. Were you on vacation when your organization offered its only Basic Life Support class? Could you trade shifts to attend an eight-hour Advanced Cardiovascular Life Support refresher? Did the course reflect your organization’s protocols, equipment, and patient population?
The classroom experience presents challenges of its own. An experienced clinician may become frustrated when the course moves too slowly, while a new provider may feel uncomfortable asking questions in front of more experienced colleagues. At its worst, certification can become little more than a transaction: attend the class, complete the requirements, and receive a card.
All of these experiences affect whether people arrive ready to learn or simply ready to leave.
From course completion to clinical competence
Instructor-led education remains valuable. A skilled instructor can answer questions, identify uncertainty, and help learners connect national guidelines with clinical practice. But a course is not automatically effective because it takes place in a classroom.
Those of us who taught CPR before feedback devices may remember estimating whether someone’s compressions were too fast, too shallow, or deep enough. We coached learners based largely on what we could see and hear.
Feedback technology changed that. Today, learners can receive objective information about compression rate, depth, recoil, hand placement, and ventilation performance. What looks or feels correct does not always meet the recommended target.
Ventilation is one example. During adult CPR with an advanced airway in place, the American Heart Association recommends one breath every six seconds. In a stressful situation, that interval can easily become one breath every two or three seconds. Without objective feedback or careful observation, excessive ventilation may go unrecognized.
Experience matters. But experience without measurement does not always reveal small—and potentially important—changes in performance.
The weakness of the two-year model
Resuscitation education has traditionally treated competence as something demonstrated during a course and renewed approximately two years later. Psychomotor skills, however, do not necessarily follow a two-year schedule.
Research suggests that shorter, repeated learning experiences can improve retention. In one randomized study of hospital-based pediatric providers, participants receiving brief booster training were 2.3 times more likely to retain their CPR skills after two sessions and 2.9 times more likely after three sessions. The study also found that instructor-led coaching produced better retention than automated feedback alone—an important reminder that technology should support educators rather than make their expertise irrelevant. Sutton et al., Pediatrics
The American Heart Association’s 2025 Guidelines recommend feedback devices during CPR training for healthcare professionals. They also recommend booster sessions when traditional massed training is used and identify spaced learning as a reasonable alternative to completing all training in one extended event. AHA 2025 Resuscitation Education Science
This leads to a different question:
Why should our education be organized primarily around the expiration date of a card rather than the continued maintenance of a lifesaving skill?
A different approach
After watching healthcare professionals struggle to recall CPR steps, cardiac-arrest algorithms, and the management of pediatric emergencies, Justin and I began looking for a better approach.
We explored the American Heart Association’s Resuscitation Quality Improvement program, or RQI. We saw an opportunity to better serve clinicians with different professions, experience levels, and scheduling needs.
RQI addresses a fundamental weakness in traditional education: we have treated competence as something demonstrated periodically instead of something maintained continuously.
The program uses shorter, more frequent educational activities and quarterly hands-on skills sessions. Instrumented manikins provide immediate feedback on compression and ventilation performance. Instead of relying only on an instructor’s visual estimate, the learner receives objective data. Instead of waiting approximately two years to practice again, the learner regularly returns to demonstrate the skill.
A 2025 systematic review examined 20 randomized trials involving 4,579 participants. Training with feedback devices improved compression depth, depth compliance, rate compliance, and chest recoil. Although results varied among the studies, the evidence supporting these performance improvements was rated as moderate to high certainty. Lin et al., Resuscitation Plus
Buying back time without lowering the standard
We began describing this model with a simple phrase: Buy Back Your Time.
I completed my first BLS course through RQI in about an hour. A new provider could take more time where needed, while an experienced provider could move more quickly through familiar material. I later completed BLS, ACLS, and PALS in a fraction of the time traditional courses would have required.
This is not about making education easier or lowering expectations. It is about using time more intelligently.
An experienced clinician should be able to demonstrate competence without spending hours reviewing material already mastered. A less experienced learner should have the repetition, feedback, and time needed to improve.
That is the promise of competency-based education: the time may vary, but the performance standard does not.
“I perform CPR all the time”
Experienced clinicians may reasonably ask why they need quarterly practice when they participate in cardiac arrests regularly.
Clinical experience is valuable, but participating in a code and receiving objective skills verification are not the same. A clinician may attend numerous arrests as the team leader, medication nurse, recorder, airway clinician, or defibrillator operator. Even when performing compressions, that person may not receive individual feedback on rate, depth, recoil, or ventilation.
A real cardiac arrest is also a performance environment—not a practice environment. The team cannot pause patient care so someone can adjust technique, repeat a skill, or deliberately work on a weakness.
RQI does not discount clinical experience. It adds a brief, standardized checkpoint:
Experience builds fluency. Objective feedback protects accuracy.
For an experienced clinician, a quarterly session may simply confirm continued mastery. If the system identifies a gap, the clinician can correct it without placing a patient at risk.
What RQI does not replace
RQI offers meaningful advantages, but it does not reproduce every part of a traditional ACLS or PALS course.
Standard RQI ALS and PALS education assesses advanced knowledge through cognitive activities rather than a live, instructor-led team megacode. RQI’s own guidance recommends internal team-based simulations to support quality resuscitation outcomes. RQI program FAQ
That limitation matters. Successful resuscitation requires more than technically correct compressions. It requires leadership, closed-loop communication, rhythm recognition, timely defibrillation, airway and medication coordination, situational awareness, and familiarity with local protocols.
The strongest model should not force us to choose between RQI and team-based simulation. They address different needs.
RQI can help maintain measurable individual knowledge and CPR skills. Customized mock codes can help clinicians apply those abilities as a coordinated team.
A foundation—not the entire solution
We must also be honest about the evidence. The strongest research supporting RQI concerns skill acquisition and retention, not patient survival.
A 2026 study examined 49,870 in-hospital cardiac arrests at RQI and matched non-RQI hospitals. RQI adoption alone was not associated with improved survival to discharge or return of spontaneous circulation during the two years after implementation. The authors concluded that focusing primarily on CPR delivery may not be sufficient by itself to improve survival. Chan et al., JAMA Cardiology
That finding does not eliminate RQI’s value. It helps define its proper role.
High-quality CPR is essential, but survival also depends on early recognition, rapid activation, defibrillation, clinical decision-making, teamwork, post-arrest care, and the performance of the entire resuscitation system.
RQI should not be presented as the complete solution. It can be the foundation of a more complete one.
Our vision combines shorter, more frequent learning with objective skills verification and realistic team practice designed around local needs. It means less unnecessary time away from patients, more opportunities for meaningful feedback, and education that adapts to both the learner and the organization.
This is not education designed merely to satisfy an expiration date. It is education designed to keep people ready.
More practice. Less disruption. Better feedback. Education built around the learner, the team, and the realities of patient care.
That is how we reimagine education.