1. Manikin Use and Cleaning During CPR Class
Slide 1: Reducing Risk Through Effective Classroom Practice
Safety during CPR training has gained increased attention. The following recommendations should minimize risk of infectious complications to instructors and students during CPR training and actual CPR performance. The recommendations for manikin decontamination and rescuer safety originally established in 1978 by the Centers for Disease Control have been updated twice by the AHA, the American Red Cross, and the Centers for Disease Control and Prevention.
American Heart Association

2. Low Risk of Disease Transmission
Risk of disease transmission during CPR training is extremely low
CPR manikins have never been shown to cause an outbreak of infection
No reports of infection are associated with CPR training
However, there is public concern about use of manikins
Slide 2: Risk of Disease Transmission
The risk of disease transmission during CPR training is very low. Use of CPR manikins has never been shown to be responsible for an outbreak of infection, and a search of the literature through March 2000 found no reports of infection associated with CPR training.
To date, an estimated 70 million people in the United States have had direct contact with manikins during CPR training courses without reported infectious complications.
The 1980s, however, saw a dramatic increase in inquiries about the possible role of CPR training manikins in transmitting infectious diseases such as HIV, hepatitis B virus (HBV), herpes viruses, and various upper and lower respiratory infections, such as influenza, infectious mononucleosis, and tuberculosis.

3. Prevention of Infection During Manikin Practice
Manikin surfaces can present a very small potential risk of disease transmission
Manikin surfaces should be cleaned and disinfected in a consistent way
After each rescuer use
After each class
Rescuers should avoid mouth or body contact with a manikin if saliva or body fluids are present on the manikin
Slide 3: Prevention
Under certain circumstances manikin surfaces can present a very small risk of disease transmission. Therefore, manikin surfaces should be cleaned and disinfected in a consistent manner after each use by rescuers and after each class.

4. Potential Participant-Manikin Cross-Contamination
Students’ hands and mouths can become contaminated if they touch a manikin that has not been cleaned
Contamination can occur when a student’s hands or mouth touch a manikin mouth (ie, finger sweep) before it is cleaned
Contamination can be prevented by
Adequate cleaning of manikins between uses
Avoiding finger sweeps
Slide 4: Prevention—Manikin Exterior
To minimize risk of transmission of infectious agents during CPR training, rescuers should avoid any contact with any saliva or body fluids present on manikins.
The hands and oral mucosa can become contaminated if the rescuer touches a manikin that has not been properly cleaned between uses. This type of contamination can occur when students touch manikins around the mouth before the manikins are properly cleaned, if rescuers practice mouth-to-mouth ventilation on a manikin that has not been properly cleaned, or if rescuers place their fingers inside the manikin mouth during practice sessions.
Most contamination will be prevented with adequate cleaning of the manikin between practice uses. However, student rescuers often forget that the inside of the manikin mouth is contaminated with saliva unless the manikin is cleaned after every use.
If students touch the inside of the manikin mouth, they should wash their hands thoroughly before continuing practice. Otherwise bacteria can be transmitted from the hands of those students to their own oral, nasal, or ocular mucosa or to other students.

5. Manikin Cleaning and Decontamination
The manikin airway becomes contaminated during use
Both the manikin interior and exterior must be thoroughly cleaned between classes
HIV is comparatively delicate and is inactivated in less than 10 minutes at room temperature by several disinfectants
Follow manufacturers’ instructions for cleaning manikins
Slide 5: Prevention—Manikin Interior
There is no evidence to date that HIV can be transmitted by casual personal contact, indirect contact with inanimate surfaces, or the airborne route.
It is now clear that HBV and HIV are more susceptible to disinfectant chemicals than previously thought.
HIV, the primary retroviral agent that causes acquired immunodeficiency syndrome (AIDS), is comparatively delicate and is inactivated in less than 10 minutes at room temperature by a number of disinfectants, including agents (bleach) recommended for manikin cleaning.
If current recommendations published by the AHA and manikin manufacturers for manikin cleaning and decontamination are carefully followed, risk of transmission of HIV and HBV, as well as bacterial and fungal infections, should be minimized.
The recommendations that follow describe decontamination of manikins and face masks and provide practical recommendations on how to minimize risk of disease transmission during CPR classes.

6. General Recommendations for CPR Classes
Students should be told that CPR training will involve physical contact with manikins
Students and instructors should postpone CPR training if they are
1. Known to be in the active stages of an infectious disease
2. Believe they have been exposed to an infectious disease
3. Have sores or skin lesions on the hands or mouth or around the mouth
Slide 6: General Recommendations for CPR Classes
Students should be told before the course that training sessions will involve close physical contact with manikins used by their fellow students.
Students or instructors should postpone CPR training if they are known to be in the active stages of an infectious disease, have reason to believe they have been exposed to an infectious disease, or have skin lesions on their hands, mouth, or circumoral areas.

7. General Recommendations for CPR Classes
Options to train someone with a known chronic infection or lesions:
Provide infected student with a separate manikin
Honor requests for individual manikin, within reason
Slide 7: General Recommendations for CPR Classes
Chronic infections such as HBV and HIV persist over an extended period and can be transmitted even when the carrier is asymptomatic.
If an instructor wishes to train someone with a known chronic infection or if the instructor has a known chronic infection, precautions should be taken to protect other participants from exposure. This is best accomplished by providing the infected person with a separate manikin not used by anyone else until it has been cleaned according to recommended end-of-class decontamination procedures. In such instances the infected person’s personal physician should review the circumstances of the class carefully and indicate whether participation is appropriate.
Requests for individual manikins should be honored, within reason. Equitable accommodations for all participants are encouraged.

8. General Consideration for Manikin Use and Hygiene
When using multiple manikins
Students should be assigned in pairs
Each pair has contact with only 1 manikin
Instructors/students should practice good hygiene by
Washing hands before handling manikins
Avoiding eating during class
Slide 8: General Considerations
If more than one CPR manikin is used in a training class, students should preferably be assigned in pairs, each pair of students having contact with only one manikin. This lessens the risk of possible contamination of several manikins by one person, thus limiting possible exposure of other class members.
CPR instructors should practice good hygiene by washing their hands before handling manikins and by avoiding eating during class.

9. Manikin Maintenance
Follow procedures for cleaning/maintaining manikins during class
Routinely inspect manikins for signs of deterioration
Wash manikin clothing periodically
Slide 9: Manikin Maintenance
Follow procedures for cleaning and maintaining manikins and accessories (eg, face shields and resuscitation masks) during class.
Routinely inspect manikins for signs of physical deterioration, such as cracks or tears in plastic surfaces, which make careful cleaning difficult or impossible.
Periodically wash manikin hair or clothing (perhaps monthly or if obviously soiled).

10. Minimizing Contamination During Skill Practice
During 2-rescuer CPR practice, the second student should simulate ventilation
Slide 10: Skills Recommendations
During 2-rescuer CPR training there is no opportunity to disinfect manikins between uses when the switching procedure is practiced. To limit the potential for disease transmission during this exercise, the second student taking over ventilation on the manikin should simulate ventilation instead of blowing into the manikin.
During training in the obstructed airway procedure, the student uses a finger to sweep foreign matter out of the manikin mouth. This action could contaminate the student's finger with exhaled moisture and saliva from previous students or contaminate the manikin with material from the student's finger. When practicing this procedure, the finger sweep should either be simulated or performed on a manikin whose airway was decontaminated before the procedure and will be decontaminated after the procedure.

11. Manikin Cleaning After Class
Manikins should be cleaned as soon as possible at the end of each class
Wash with warm soapy water and brushes
Rinse with fresh water
Moisten with a mixture of ¼ cup bleach per gallon of water for 10 minutes
Make a fresh solution for each class
Rinse with fresh water and dry immediately
Rinse with alcohol to aid drying of internal surfaces
Slide 11: External/Internal Surfaces
Manikins should be cleaned as soon as possible at the end of each class to avoid drying of contaminants on manikin surfaces. Personnel disassembling and decontaminating the manikins should wear protective latex gloves and wash their hands when finished.
Manikins should be disassembled as directed by the manufacturer. As indicated, all external and internal surfaces, as well as reusable protective face shields, should be washed thoroughly with warm soapy water and brushes. All surfaces should be rinsed with fresh water.
All surfaces should be moistened with a solution of sodium hypochlorite with at least 500 ppm free available chlorine (¼ cup liquid household bleach per gallon of tap water) for 10 minutes. This solution must be made fresh for each class and discarded after each use.
All external and internal surfaces are rinsed with fresh water and immediately dried. Rinsing with alcohol will aid drying of internal surfaces, which will prevent the survival and growth of bacterial or fungal pathogens if manikins are stored for periods longer than the day of cleaning.

12. Manikin Cleaning During Class
Discuss cleaning and use of manikins before practice
Individual protective face shields can be used
Wipe manikin face and mouth with alcohol between each use:
Leave the surface wet for at least 30 seconds before wiping
Emphasize scrubbing and wiping
Slide 12: Use of Manikins During Class
The individual protective face shield should be changed each time a different student uses the manikin during training. Between student uses and after instructor demonstrations, the manikin face and inside of the manikin mouth should be wiped vigorously with a clean, absorbent material (eg, a 44-inch gauze pad) wet with either hypochlorite solution or 70% alcohol (isopropanol or ethanol). The surface should remain wet for at least 30 seconds before it is wiped dry with a second piece of clean, absorbent material.
The use of alcohols is recommended in this instance as an alternative because some people object to the odor of sodium hypochlorite. Although highly bactericidal, alcohols are not considered broad-spectrum agents, and their use here is recommended primarily as an aid in mechanical cleaning. In a short contact period, alcohols may not be as effective against pathogens, but in the context of vigorous cleaning with alcohol and absorbent material, little viable microbial contamination of any kind is likely after cleaning.
Instructors should be encouraged not to rely solely on the use of a disinfectant to protect themselves and their students from cross-infection during training. Thorough physical cleaning (scrubbing and wiping) should be emphasized as the first step in effective decontamination. Microbial contamination is easily removed from smooth, nonporous surfaces with disposable cleaning cloths moistened with a detergent solution. There is no evidence that soaking alone is as effective as soaking accompanied by vigorous scrubbing.

13. Summary Risk of infection is very low
Instructors should carefully follow all manufacturers’ recommendations
Practice and implement other recommendations discussed in the text
Minimize the risk of disease transmission by carefully following guidelines
Slide 13: Summary
The risk of transmission of any infectious disease by manikin practice appears to be very low. Although millions of people worldwide have used training manikins in the last 30 years, no documented case of transmission of bacterial, fungal, or viral disease by a CPR training manikin was found in a recent review article or an extensive literature search through March In the absence of evidence of infectious disease transmission, the lifesaving potential of CPR should continue to be vigorously emphasized, and broad-scale CPR training should be continued.
The following recommendations summarize steps to minimize risk of infectious disease transmission during CPR training courses:
Manikin surfaces should be cleaned and disinfected in a consistent manner
After each rescuer use
After each class
Instructors should carefully follow all the manufacturers’ recommendations
Practice and implement other recommendations discussed in the text
Minimize risk of disease transmission by carefully following guidelines
If these recommendations are followed consistently, students in each class should be able to use manikins with cleanliness that equals or exceeds that of properly cleaned eating utensils. A higher level of surface disinfection is not warranted, and the recommended disinfectants (household bleach or alcohol) are safe, effective, inexpensive, easily obtained, and well tolerated by students, instructors, and manikin surfaces when used properly.