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Resuscitation

j o ur na l h o me p a g e:ww w . e l s e v i er . c o m / l o c a t e / r e s u s c i t a t i o n

European

Resuscitation

Council

Guidelines

for

Resuscitation

2015

Section

10.

Education

and

implementation

of

resuscitation

Robert

Greif

a,∗

,

Andrew

S.

Lockey

b

,

Patricia

Conaghan

c

,

Anne

Lippert

d

,

Wiebe

De

Vries

e

,

Koenraad

G.

Monsieurs

f,g

,

on

behalf

of

the

Education

and

implementation

of

resuscitation

section

Collaborators

1

aDepartmentofAnaesthesiologyandPainMedicine,UniversityHospitalBernandUniversityofBern,Bern,Switzerland

bEmergencyDepartment,CalderdaleRoyalHospital,Halifax,SalterhebbleHX30PW,UK

cSchoolofNursing,Midwifery&SocialWork,TheUniversityofManchester,Manchester,UK

dDanishInstituteforMedicalSimulation,CenterforHR,CapitalRegionofDenmark,Copenhagen,Denmark

eKnowledgeCentre,ACMTrainingCentre,Elburg,TheNetherlands

fEmergencyMedicine,FacultyofMedicineandHealthSciences,UniversityofAntwerp,Antwerp,Belgium

gFacultyofMedicineandHealthSciences,UniversityofGhent,Ghent,Belgium

Introduction

Thechainofsurvival1wasextendedtotheformulaofsurvival2

becauseit wasrealisedthatthegoalofsavingmore livesrelies notonlyonsolidandhighqualitysciencebutalsotheeffective educationoflaypeopleandhealthcareprofessionals.3Ultimately,

thosewhoareengagedinthecareofcardiacarrestvictimsshould beabletoimplementresourceefficientsystemsthatcanimprove survivalaftercardiacarrest.

This chapter incorporates the 17 key educational PICO-questions (Population–Intervention–Control–Outcome) that wherereviewedbytheEducation,ImplementationandTeams(EIT) TaskForceoftheInternationalLiaisonCommitteeonResuscitation (ILCOR)from2011to2015.Thisevidencereviewandevaluation processfollowedtheGradingofRecommendations,Assessment, Developmentand Evaluation(GRADE)process described in the Consensus on Science and Training Recommendations 2015 (CoSTR).4Itsummarisesthenewtreatmentrecommendationsfor

training and implementation. Thischapter alsocovers the ERC basicprinciplesoftraining andteachingofbasiclifesupportas wellas advanced level life support.There is a strongfocus on non-technicalskillsteaching(e.g.communicationskills,teamand leadershiptraining).TheERCportfolioofcoursesisalsoincluded in this chapter,which ends withan outlook abouteducational resuscitationresearchandfuturecoursedevelopments.

Delaysinprovidingtrainingmaterialsandfreeingstafffor train-ingwerecitedasreasonsfordelaysintheimplementationofthe last guidelines.5–7 Therefore the ERC hascarefully plannedthe

∗ Correspondingauthor.

E-mailaddress:robert.greif@insel.ch(R.Greif).

1 ThemembersoftheEducationandimplementationofresuscitationsection

CollaboratorsarelistedintheCollaboratorssection.

translationanddisseminationprocessfortheseguidelinesandthe teachingmaterialforallcoursestofacilitatetheimplementation ofthe2015guidelinesonresuscitationinatimelymanner.This chapterprovidesthebasisofasuccessfuleducationalstrategyfor improvedCPReducation.

Summaryofchangessincethe2010ERCguidelines

Thefollowingisasummaryofthemostimportantnewreviews orchangesinrecommendationsforeducation,implementationand teamssincetheERC2010Guidelines:

Training

• High fidelitytraining manikinsprovide greater physical real-ismandtheiruseispopularwithlearners.Theyare,however, moreexpensivethanstandardlowerfidelitymanikins.Incentres thathavetheresourcestopurchaseandmaintainhighfidelity manikins,we recommendtheiruse. The useof lower fidelity manikinshoweverisappropriateforalllevelsoftrainingonERC courses.

• DirectiveCPRfeedbackdevices areusefulforimproving com-pressionrate,depth, release,andhandposition.Tonaldevices improve compression rates only and may have a detrimen-tal effect oncompression depthwhile rescuersfocus onthe rate.Thereisnocurrentevidencetolinktonaldeviceusewith improvedoutcomesfollowinganERCcourse.

• Theintervalsforretrainingwilldifferaccordingtothe character-isticsoftheparticipants(e.g.layorhealthcare).Itisknownthat CPRskillsdeterioratewithinmonthsoftrainingandtherefore annualretrainingstrategiesmaynotbefrequentenough.Whilst optimalintervalsarenotknown,frequent‘lowdose’retraining maybebeneficial.

http://dx.doi.org/10.1016/j.resuscitation.2015.07.032

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• Traininginnon-technicalskills(e.g.communicationskills,team leadershipandteam memberroles)is anessentialadjunctto thetraining oftechnicalskills.Thistypeof trainingshouldbe incorporatedintolifesupportcourses.

• Ambulanceservicedispatchershaveaninfluentialroletoplayin guidinglayrescuershowtodeliverCPR.Thisroleneedsspecific traininginordertodeliverclearandeffectiveinstructionsina stressfulsituation.

Implementation

• Data-drivenperformance-focuseddebriefinghasbeenshownto improveperformanceofresuscitationteams.Wehighly recom-mendtheiruseforteamsmanagingpatientsincardiacarrest, • Regional systems including cardiac arrest centres are to be

encouraged,asthereisanassociationwithincreasedsurvival andimprovedneurologicaloutcomeinvictimsofout-of-hospital cardiacarrest.

• The use of innovative technologies and social media can be beneficialforthedeploymentofrapidresponderstovictimsof out-of-hospitalcardiacarrest.Novelsystemsarealsobeing devel-opedtoalertbystanderstothelocationofthenearestAED.Any technologythat improvesthedeliveryof swiftbystanderCPR withrapidaccesstoanAEDistobeencouraged.

• “It takes a system to save a life”. [http://www. resuscitationacademy.com/]Healthcaresystemswitha respon-sibilityfor themanagement of patientsin cardiac arrest(e.g. EMSorganisations,cardiacarrestcentres)shouldevaluatetheir processestoensurethattheyareabletodelivercarethatensures thebestachievablesurvivalrates.

Basicleveltraining

Whototrain

BasicLifeSupport(BLS)isthecornerstoneofresuscitationand it is well established that bystander CPR is critical to survival inout-of-hospitalcardiacarrests.Chestcompressionsand early defibrillationarethemaindeterminantsofsurvivalfroman out-of-hospital cardiac arrest and there is some evidence that the introductionoftrainingforlaypeoplehasimprovedsurvivalat30 daysand1year.8,9

For this reason a primary educational goal in resuscitation shouldbethetrainingoflaypeopleinCPR.Thereisevidencethat traininglaypeopleinBLSiseffectiveinimprovingthenumberof peoplewillingtoundertakeBLSinarealsituation.10–12Theterm

‘laypeople’includesawiderangeofcapabilitiesfromthose with-outanyformalhealthcaretrainingtothosewitharolewhereit maybeexpectedthattheywouldprovideCPR(e.g.lifeguards,first aiders).Despitetheincreaseinaccesstotrainingforlaypeople, thereisstillanunwillingnessofsometoperformCPR.Thereasons identifiedforthisincludefearofinfection,fearofgettingitwrong, andfearoflegalimplications.13

Trainingoffamily membersofhighriskpatientscanreduce anxietyofthosefamilymembersandthepatient,improve emo-tionaladjustment,andempowerindividualstofeelthattheywould beabletostartCPR.Forhigh-riskpopulations(e.g.areaswhere thereishighriskofcardiacarrestandlow bystanderresponse), recentevidenceshowsthatspecificfactorscanbeidentifiedwhich willenabletargeted training basedonthecommunity’sunique characteristics.14,15Thereisevidencethatlikelyrescuersinthese

populationsareunlikelytoseektrainingontheirownbutthatthey gaincompetencyinBLSskillsand/orknowledgeaftertraining.16–18

Theyarewillingtobetrainedandarelikelytosharetrainingwith others.16,17,19–21

Mostresearchintheteachingofresuscitationhasbeenbased ontrainingadultrescuersinadultresuscitationskills.However teaching children and youngadults arguablyrequires different approaches,butmoreresearchisrequiredintothebestmethodsto teachthesegroupsbasiclifesupport.22

One of the most important steps in increasing the rate of bystanderresuscitation andimprovingsurvival worldwideis to educateallschoolchildren.TheAmericanHeartAssociation advo-cated compulsoryresuscitation training inAmerican schools in 2011.23 Prior tothis, the experienceof teaching CPR to school

childreninSeattleoverthelastthreedecadeshasresultedin sig-nificantlyhigherbystanderCPRratesandsurvivalrate.Similarly, Scandinavianeducationalresuscitationschoolprogramsreport sig-nificantlyhigherresuscitationrates.24Thiscanbeeasilyachieved

byteaching children forjust 2hper year,beginningat theage oftwelve.22Atthatage,schoolchildrenhaveapositiveattitude

towardlearningresuscitationandbothmedicalprofessionalsand teachersrequiretrainingtoenablethemtomaximisethepotential ofthesechildren.25Schoolchildrenandtheirteachersare

resusci-tationmultipliersinbothprivateandpublicsettingsasthechildren havebeenshowntopassontheirlearningtofamilymembers.The proportionoftrainedindividualsinsocietywillmarkedlyincrease inthelongerterm,leadingtoanincreaseintheoverallrateoflay resuscitation.26

Healthcareprofessionalsworkinginavarietyofsettings includ-ingthecommunity, emergencymedical systems(EMS), general hospitalwards,andcritical careareasshouldallbetaughtCPR. Whilst lowquality compressionsarecommonboth in termsof incorrectdepthandrate,interruptionsalsocontributeto ineffec-tiveCPR.27Giventhatpoorperformanceisassociatedwithlower

survivalrates,trainingonthesecomponentsshouldbeacoreaspect ofanyresuscitationtraining.

IthasbeenshownthatwelltrainedEMSdispatchersareable toimprovebystanderCPRandpatientoutcomes.28Howeverthere

areconcernswiththeirabilitytorecognisecardiacarrest partic-ularlyinrelationtoagonalbreathing.29Consequentlytrainingof

EMSdispatchersshouldincludeafocusonidentificationandthe significanceofagonalbreathing,30andtheimportanceofseizures

asaspectsofcardiacarrest.InadditionEMSdispatchersneedtobe taughtsimplifiedscriptsforinstructingbystandersinCPR.30

Howtotrain

BLS/AEDcurriculashouldbetailoredtothetargetaudienceand keptassimpleaspossible.Increasingaccesstodifferent modali-tiesoftraining(e.g.theuseofdigitalmedia,online,instructor-led teaching) and self-directed learning, offer alternative meansof teachingbothlayandprofessionalproviders.Theeffectivenessof thesedifferentblendedlearningapproachesremainsunclearand furtherresearchisrequirednotonlytolinktheimmediate out-comesofcoursestotheteachingapproachbutalsoultimatelyto identifytheimpactontheoutcomeofreallifecardiacarrest situ-ations.Trainingshouldbetailoredtotheneedsofdifferenttypes oflearnersandavarietyofdifferentteachingmethodsshouldbe usedtoensureacquisitionandretentionofresuscitation knowl-edgeandskills.Self-instructionprogrammeswithsynchronousor asynchronoushandsonpractice(e.g.video,DVD,on-linetraining, computergivingfeedbackduringtraining)appeartobeaneffective alternativetoinstructor-ledcoursesforlaypeopleandhealthcare providerslearningBLSskills.31–35

ThosewhoareexpectedtoperformCPRregularlyneedtohave knowledgeofcurrentguidelinesandbeabletousethemeffectively aspartofamulti-professionalteam.Theseindividualsrequiremore complextrainingincludingbothtechnicalandnon-technicalskills (e.g.teamwork,leadership,structuredcommunicationskills).36,37

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BasiclifesupportandAEDcurriculum

Lay peopleare not only capable ofeffectively learning CPR, but evidence shows that they can be taught to use AEDs.38

The introduction of Public Access Defibrillator (PAD) schemes has demonstrated the effectiveness of lay people in perform-ingdefibrillation,39butthequestionremainswhetherlaypeople

requiretrainingtouseAEDsorcanusethemwithoutanyprior input.40 The curriculum forbasic lifesupportand AED training

shouldbetailoredtothetargetaudienceandkeptassimple as possible.Whichevermodalityischosenfortheteaching,the fol-lowingshouldbeconsideredascoreelementsoftheBLSandAED curriculum:

• WillingnesstostartCPR,includinganunderstandingofpersonal andenvironmentalrisk

• Recognitionofunconsciousness,gaspingoragonalbreathingin unresponsiveindividualsbyassessmentofresponsiveness, open-ingoftheairwayandassessmentofbreathingtoconfirmcardiac arrest.41,42

• Goodqualitychestcompressions(adherencetorate,depth,full recoilandminimisinghands-offtime)andrescuebreathing (ven-tilationtimeandvolume)

• Feedback/prompts(humanfeedbackwithintheCPR-teamand/or fromdevices)duringCPRtrainingtoimproveskillacquisitionand retentionduringbasiclifesupporttraining.43

StandardCPRversuschestcompression-onlyCPRteaching

TheroleofstandardCPRversuschestcompression-onlyCPRis discussedintheBLSChapteroftheseERCguidelines.42Asimplified,

education-basedapproachissuggestedtoallowcommunitiesto trainallcitizensinCPR:

• Allcitizensshouldbetaughthowtoperformchestcompressions asaminimumrequirement.

• Ideally,fullCPRskills(compressionsandventilationusinga30:2 ratio)shouldalsobetaughttoallcitizens.

• Whentrainingis time-limitedoropportunistic (e.g.EMS tele-phoneinstructionstoabystander,massevents,publiccampaigns, internet-basedviralvideos),itshouldfocusoncompression-only CPR.Localcommunities maywanttoconsidertheirapproach basedontheirlocalpopulationepidemiology,culturalnormsand bystanderresponserates.

• Forthoseinitiallytrainedincompression-onlyCPR,ventilation maybecoveredin subsequenttraining. Ideallythese individ-ualsshouldbetrainedincompression-onlyCPRandthenoffered traininginchestcompressionswithventilationatthesame train-ingsession.

• Thoselaypersonswithadutyofcare,suchasfirstaidworkers, lifeguards,andcarers,shouldbetaughtstandardCPRi.e.chest compressionsandventilation.

• Fortheresuscitationofchildren,rescuersshouldbeencouraged toattemptresuscitationusingwhicheveradultsequencethey havebeentaught,astheoutcomeisworseifnothingisdone. Non-specialistswhowish tolearnpaediatric resuscitationbecause theyhavea responsibility for children (e.g.parents, teachers, schoolnurses,lifeguards),shouldbetaughtthatitispreferable tomodifyadultbasiclifesupportandgivefiveinitialbreaths fol-lowedbyapproximately1minofCPRbeforetheygoforhelp,if thereisno-onetogoforthem.44

BasiclifesupportandAEDtrainingmethods

Therearenumerousmethodstodeliverbasiclifesupportand AEDtraining.Traditionally,instructor-ledtrainingcoursesremain

themostfrequentlyusedmethodforbasiclifesupportandAED training.45Whencomparedwithtraditionalinstructor-led

train-ing,welldesignedself-instructionprogrammes(e.g.video,DVD, computersupportedfeedback)withshortenedinstructor coach-ing may be effective alternativesfor laypeople and healthcare providerslearningbasiclifesupportand,inparticular,forthe train-ingoflaypeopleinAEDskills.18,33,34,46–49

If instructor-led training is not available then self-directed trainingisanacceptablepragmaticoptiontouseanAED.Short video/computerself-instruction (with minimal or noinstructor coaching)that includes synchronous hands-on practice in AED use(practice-while-you-watch)maybeconsideredasaneffective alternativetoinstructor-ledAEDcourses.48,50,51

Ultimately,itisknownthatrescuerscanuseAEDswithoutany formaltraining.Ithasbeenshownthatthepresenceofanearby AEDisnoguaranteeoftheirusage.52Theadvantageofdelivering

training,therefore,isthatitincreasesgeneralawarenessoftheir useandbenefit,whilstalsoprovidingaforumtodispelcommon mythsabouttheiruse(e.g.thebeliefthattheymaydoharm).

Durationandfrequencyofinstructor-ledbasiclifesupportand AEDtrainingcourses

Theoptimalduration ofinstructor-ledBLS andAED training courseshasnotbeendeterminedandislikelytovaryaccordingto thecharacteristicsoftheparticipants(e.g.layorhealthcare; previ-oustraining),thecurriculum,theratioofinstructorstoparticipants, theamount of hands-on training and theuse of end-of-course assessments.MoststudiesshowthatCPRskillsdecaywithinthree tosixmonthsafterinitialtraining.33,46,53–55AEDskillsareretained

forlongerthanBLSskillsalone.56,57

Althoughthereissomeevidencethathigherfrequency,short bursttrainingcouldpotentiallyenhanceBLStrainingandreduce skilldecay,morestudiesareneededtoconfirmthis.53,55–57

Current evidence shows that performance in the use of an AED (e.g. speed of use, correct pad placement) can be fur-ther improved with brief training of laypeople and healthcare professionals.49,58–60 BriefbedsideboosterCPRtrainingof2min

hasalsobeenshowntoimproveCPRqualityirrespectiveoftraining content(instructor,orautomatedfeedbackorboth)inPaediatric BasicLifeSupportprovidersduringsimulatedcardiacarrest61and

improvedwithfurthertraining.62

Peer-ledresuscitationtraining hasalsobeenshowntobean effectivemeansofdeliveringBLStraining.Peer-tutorsand asses-sorsare competent,moreavailableand lesscostlythanclinical staff.Student instructors develop skillsin teaching, assessment andappraisal,organisationandresearch.Sustainabilityis possi-blegivensuccession-planningandconsistentleadership.A15year review of peerled BLS teaching in a major University medical schooldemonstrated thatsuchprogrammescandelivergreater participantsatisfactionwithlearningoutcomesequaltoprevious lecture-basedsessions.63

AsthereisevidencethatfrequenttrainingimprovesCPRskills, responderconfidence andwillingnesstoperformCPR, itis rec-ommendedthatorganisationsandindividualsreviewtheneedfor morefrequentretrainingbasedonthelikelihoodofcardiacarrestin theirarea.Retrainingshouldtakeplaceatleastevery12–24months forstudentswhoaretakingBLScourses.Additionalhighfrequency, lowdoseupdateorretrainingincertainsettingsmaybeconsidered. Itisrecommendedthatindividualsmorelikelytoencountercardiac arrestconsidermorefrequentretraining,duetotheevidencethat skillsdecaywithin3–12monthsafterBLStraining33,46,53,54,56,64

and evidencethat frequent training improvesCPRskills,34,65–69

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UseofCPRprompt/feedbackdevicesduringtraining

Theuseof CPRprompt/feedbackdevices maybeconsidered duringCPRtrainingfor laypeopleandhealthcare professionals. Devices canbe prompting(i.e. signalto performan action e.g. metronome for compressionrateor voicefeedback),give feed-back (i.e. after-event information based on effect of an action suchasvisualdisplayofcompressiondepth),oracombinationof promptsandfeedback.Trainingusingaprompt/feedbackdevice can improve CPR skill performance.70 Instructors and rescuers

shouldbemadeawarethata compressiblesupportsurface(e.g. mattress)maycausesomeprompt/feedbackdevicesto overesti-matedepthofcompression.71,72

A systematic appraisal of the literature determined in both manikinandhumanstudiesthataudiovisualfeedbackdevices dur-ingresuscitationresultedinrescuersprovidingchestcompression parametersclosertorecommendationsbutnoevidencewasfound thatthistranslatesintoimprovedpatientoutcomes.73Substantial

variationintheabilityofCPRfeedbackdevicestoimprove perfor-mancewasfound.74–76

Advancedleveltraining

Advancedlevelcoursesaremainlydirectedathealthcare per-sonnel.Ingeneral,theycovertheknowledge,skillsandattitudes neededtofunctionaspartof(andultimatelylead)aresuscitation team.

Pre-coursetrainingandpossiblealternativesstrategiestoimprove CPRtraining

Avarietyofmethodscanbeusedtopreparecandidatesbefore attending a life support course.These include theprovision of pre-coursereading,intheformofmanualsand/ore-learning. Incor-poratingapre-testintothepreparatoryworkmayfurtherenhance thesematerials.77–82OnesuchexamplewasaCD-basedpre-course

e-learningprogramforALSthatwaswellreceivedbythe partici-pants.It wasratedasimprovingtheirunderstandingofthekey learningdomainsoftheALScoursebutfailedtoshowsuperiority forcognitiveorpsychomotorskillsduringastandardcardiacarrest simulation.83

Evidence has emerged regarding blended learning models (independent electroniclearning coupledwith a reduced dura-tioninstructor-ledcourse).Apilotblendedlearningapproachto ALStraining includinge-learning ledtoa 5.7% lower passrate incardiacarrestscenariotesting,butsimilarscoresona knowl-edge and skills assessments, and reduced costs by more than half.Therewasnosignificantdifferencein overallpassrates.84

This UK-based e-learning-ALS course was subsequently imple-mentedand afurtherstudyof27,170candidatesdemonstrated equivalencetotraditionalinstructor-ledlearning.85Theonline

e-learning program of 6–8h wasto be completed by candidates priortoattendingaone-daymodifiedinstructor-ledALS-course. e-ALS scores were significantly higher on the pre- and post-courseMCQandfirstattemptCAS-testpassratewashigherthan compared tostandard ALS courses (overallpass ratesimilar in both). Considering benefits suchas increased candidate auton-omy,improvedcost-effectiveness,decreasedinstructorburdenand improvedstandardisationofcoursematerialthesereports encour-agefurtherdisseminationofthee-learningcoursesforCPRtraining. Principlesofteachingskills

CPRskillscanbetaughtinastepwiseprocess:dissectingthe components of a skill into a real-time demonstration, explain-ingthefacts,demonstration bytheparticipants,and practicing

to facilitate visualisation, understanding, cognitive processing and execution of a skill. No studies have showed any advan-tage for differentstepwise approaches despitetheir theoretical framework.86,87

Basicsofsimulationtoteachonadvancedlevelcourses

Simulationtrainingisanintegralpartofresuscitationtraining. Asystematic reviewandmeta-analysisof182studiesinvolving 16,636participantsonsimulation-basedtrainingforresuscitation showedimprovementinknowledgeandskillperformance com-paredtotrainingwithoutsimulation.88

Simulationtrainingcanbeusedtotrainarangeofrolesfromthe firstrespondertotheresuscitationteammemberandultimately theresuscitationteamleader.Itcanbeutilisedtotrainboth indi-vidualandteambehaviour.Acriticaladjuncttothislearningisthe debriefingthatoccursattheconclusionofthescenario.

Withtheexceptionofsimulationtrainingusingliveactors,the majorityoftraining involvestheuseofpurposebuiltmanikins. High-fidelitymanikinscanprovidephysicalfindings,displayvital signs,physiologicallyrespondtointerventions(viacomputer inter-face)andenableprocedures tobeperformedonthem(e.g.bag mask ventilation, intubation, intravenous or intra-osseous vas-cular access).89 Simulation training using high-fidelity versus

low-fidelitymanikins seemstodeliveraslight improvementin trainingoutcomeonskillperformanceattheendofthecourse.90

When considering physical realism, these high-fidelity manikins are more popular with candidates and faculty but theyare alsomuch more expensive. Evidence that participants in ERC courseslearn more or betterCPR by usinghigh-fidelity manikins is lacking. With this in mind, high-fidelity manikins canbeusedbutiftheyarenotavailable,theuseoflow-fidelity manikinsisacceptableforstandardadvancedlifesupporttraining. Adherencetoreal-time2-mincyclesduringadvancedlife sup-port simulations is an important part of realistic fidelity. It is important that the duration of CPR cycles is not deliberately decreasedinordertoincreasethenumberofscenarios.91

Newteachingmethodsholdpromisefor thefuturebutneed moreresearchbeforebeingadoptedonalargerscale.Examples includespecificallyteaching“action-linkedphrases”like“There’s no pulse,I willstart chest compressions”which willgenerally promptaction(e.g.chestcompressions)whentaughtoncourses.92

Anotherexampleis“Rapidcycledeliberatepractice”(RPSD) train-ing, which has been shown to increase resuscitation skills in paediatricresidents.93Afteraninitialuninterruptedscenarioand

debriefing,thenextscenariosareshort,andinterruptedat pre-determinedpointstogivedirectfeedbackonspecificprocedures oractions.

Trainingofnon-technicalskills(NTS)includingleadershipand teamtrainingtoimproveCPRoutcome

Accomplishingsuccessfulresuscitationisateamperformancein mostinstancesandaswithanyotherskill,effectiveteamworkand leadershipskillsneedtobetrained.94,95Forexample,the

imple-mentationofteamtrainingprogrammesresultedinanincreasein hospitalsurvivalfrompaediatric cardiacarrest96andinsurgical

patients.97

Training in non-technical skills, such as effective communi-cation,situationalawareness,leadershipandfollowership,using crisisresourcemanagementprinciplespurposefullyinsimulations, hasbeenshowntotransferlearningfromsimulationintoclinical practise.98,99Resuscitationteamperformancehasbeenshownto

improveinactualcardiacarrestorsimulatedin-hospitaladvanced lifesupportscenarios,whenspecificteamorleadershiptrainingis addedtoadvancedlevelcourses.100–104Bydeliveringtrainingin

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anenvironmentasclosetoreal-lifeexperienceaspossible, con-ceptsregardingteamworkingcanbeaddressedatthelevelofthe individual.105,106

Specificteamtrainingcanincreaseteamperformance, leader-shipskills,andtaskmanagementperformanceandtheeffectcan lastforuptooneyear.94,95,100,101,107–111Ontheotherhand,

lead-ershiptrainingin additiontoCPRskills hasbeenshown notto improveactualCPRskills.112

Assessmentinstruments(mainlychecklists)havebeen devel-oped,validated,andrecommendedforindividualteammembers. Rating scales exist for the assessment of team performance, which can subsequently be used to deliver feedback on team performance.113–116

Trainingintervalsandassessmentofcompetences

Littleevidenceexistsabouttheretention ofknowledgeafter ALScourses.117Itisbelievedthatlearnerswithincreasedclinical

experiencehaveimprovedlong-termretentionofknowledgeand skills.118,119WrittentestsinALScoursesdo notreliablypredict

practicalskillperformanceandshouldnotbeusedasasubstitute fordemonstrationofclinicalskillperformance.120,121Assessment

attheendoftrainingseemstohaveabeneficialeffecton subse-quentperformanceandretention.122,123

There is emerging evidence that frequent manikin-based refreshertraining in theform oflow-dose in-situtraining may savecosts,reducethetotaltime forretraining,and itseemsto bepreferredbythelearners.124,125Refreshertrainingisinvariably

requiredtomaintainknowledgeandskills;however,theoptimal frequencyforrefreshertrainingisunclear.124,126–128

A simulation-enhanced booster session nine months after a neonatal resuscitation training program demonstrated better procedural skilland teamworkbehaviour at fifteen months.129

Teamworkbehaviourswerefurtherenhancedwhenresidentswere engaged in clinical resuscitation or by exposure to deliberate practicewithsimulation.

Useofchecklists,feedbackdevices,andin-situtraining

Cognitiveaids suchaschecklists mayimproveadherenceto guidelinesas long as theydo not cause delays in starting CPR andthecorrectchecklistisusedduringsimulation 130 andreal

patientcardiacarrest.131Forexample,theimplementationofan

AdvancedTraumaLifeSupportchecklistimprovedadherenceto protocoldriven taskperformance, frequency and speed oftask completion.132

Feedbackdevicesthatprovidedirectivefeedbackin compres-sionrate,depth,release,andhandpositionduringtrainingmaybe consideredtoimprovethelevelofskillacquisitionbytheendof course.61,74,76,133–137Intheirabsence,tonalguidance(e.g.music

ormetronome)duringtraining mayimprove compressionrates only.Thereisevidencethattonalguidancecanreducecompression depthasthecandidatefocusesontherate.137–139CPRpromptor

feedbackdevicesimproveCPRskillacquisitionandretentioninBLS andmightalsobeusedtoimproveproperapplicationofthesebasic CPRskillsduringadvancedleveltraining.However,theuseofCPR feedbackorpromptdevicesduringCPRshouldonlybeconsidered aspartofabroadersystemofcarethatshouldinclude compre-hensiveCPRqualityimprovementinitiatives,140ratherthanasan

isolatedintervention.

In-situsimulationscanofferopportunitiestotrainthefullteam

141aswellasprovideinsightintotheworkflowonthe

organisa-tionallevel.142Furthermoreitmightbeeasiertoincludetraining

of a full team of care providers across disciplines in-situ and this canimprove advanced lifesupportprovider knowledge,143

skillperformance,144confidenceandpreparedness,141familiarity

withtheenvironment145 andidentifycommonsystemand user

errors.142,146,147

Briefinganddebriefingaftercardiacarrestsimulation

Debriefingaftercardiacarrestsimulationisanessentialpartof thelearningprocess.Ifthesimulatedscenariotrainingisfollowed bydebriefingthenlearningwilloccur,asopposedtoscenario train-ingwithoutdebriefing.148Theidealformatofdebriefinghasyetto

bedetermined.Studieshavefailedtoshowadifferencewithand withouttheuseofvideoclipsfordebriefing.149,150

Implementationandchangemanagement

The formula for survival concludes with ‘Local Implementation’.2 The combination of medical science and

educationalefficiencyisnotsufficienttoimprovesurvivalifthere ispoororabsentimplementation.Frequently,thisimplementation willalsorequiresomeformofchangemanagementtoembednew visionsintoalocalculture.Quiteoften,the‘easyfix’willnotbe thesustainablesolutionandprolongednegotiationanddiplomacy maybeneeded.Aprimeexampleofthis istheimplementation of CPR training on the school curriculum–countries that have achievedthisgoalhavesometimesspentyearscampaigningand persuadinggovernments forthis changetobeadopted.Change canbedrivenfrombelow,buttobesustainableitusuallyneeds topdownbuy-inaswell.

Thissectionwasnotpresentinthe2010ERCGuidelinesandhas beenaddedinrecognitionofitsimportanceinthequesttoimprove survival.

Impactofguidelines

Ineachcountry,implementationislargelybasedonthe inter-nationally agreed guidelines for cardiac resuscitation. National strategiesforeducationaredependentuponevidence-based solu-tionstothemanagement ofcardiac arrest.Themostimportant question,therefore,shouldbewhethertheseguidelinesactually result in anymeaningful and improvedoutcomes. Theauthors freelyacknowledgeaconflictofinteresthere—ifweprovethatour guidelineshavenotangiblebenefitthenwecallintoquestionthe resourcesthathavebeeninvestedtogeneratethem.Theevidence suggestsapositivebenefitwhenconsideringsurvivaltohospital discharge,8,151–156returnofspontaneouscirculation,8,151–155 and

CPRperformance.8,153Irrespective,thelikelihoodofbenefitishigh

relativetopossibleharm.

Cardiacarrestcentres

Inthelastfewyears,regionalhealthcaresystemshaveemerged forthemanagementofconditionslikestroke,majortrauma,and myocardialinfarction.Thesehavemainlybeendrivenby centrali-sationoflimitedresourcesasopposedtoevidenceofbenefitfrom randomisedtrials.Thereisemergingevidencethatthetransport ofpatientswithout-of-hospitalcardiacarresttoaspecialised car-diacarrestcentremaybeassociatedwithimprovedneurologically intactsurvival.157–170Thestudiescurrentlyavailablehad

inconsis-tenciesintermsofthespecificfactorsthatallegedlycontributedto betteroutcomes.Moreresearchneedstobeperformedtoidentify thespecificaspectsofacardiacarrestcentrethatimproveoutcome, aswellastheinfluenceofjourneytimesandwhethersecondary transferstosuchcentrescouldalsoobtainthesamebenefit.

Scenario-based simulation training and re-training, regular practiceandateamapproachtodeviceplacementarenecessaryfor coronarycatheterisationlaboratorypersonnel.Whenintroducing

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mechanical chest compression devices into clinical practice a significant learning curve was observed.171 During prolonged

resuscitationeffortsinthecoronarycatheterisationlaboratory,the implementationofastructuredresuscitationapproachimproved teamwork.172

Useoftechnologyandsocialmedia

Theprevalenceofsmartphonesandtabletdeviceshasledtothe generationofnumerousapproaches toimplementationthrough theuseof‘apps’andalsosocialmedia.Thesefallintoseveral cate-gories:

(1)Simpledeliveryofinformation–appsthatdisplayresuscitation algorithms.

(2)Interactive delivery of information–apps that use the geo-locationoftheusertodisplaythelocationofthenearestAED. (3)Interactivedeliveryofeducation–appsthat engagewiththe

userandcreateanimmersiveandinteractivemeansof edu-catingtheuser(e.g.Lifesaver)[www.life-saver.org.uk]. (4)Blended learning packages for life support courses–an

e-learningprogrammewithabbreviatedinstructor-ledtraining has been shown to be equivalent to standard training for advancedlifesupportcourses.85

(5)Feedback devices—real time use of the accelerometer to improverate,depthofcompressionsaswellasrecordingdata fordebriefing.173

(6)Notificationandactivationofbystanderschemes—ifindividuals arewillingandabletoprovidebasiclifesupportina commu-nity,theuseofthesesystemsmayleadtofasterresponsetimes whencomparedwithemergencyserviceattendance.174,175

(7)Useofsocialmediatodisseminateinformationtoawider audi-enceandassistwithcampaignstoeffectchange.

Ultimately,technologyandsocialmediaarepowerfulvectors forimplementationandchangemanagement.Theirdevelopment anduseshouldbeencouragedandanalysedtoassesstheactual impactonsurvival.

Measuringperformanceofresuscitationsystems

Assystemsevolvetoimprovetheoutcomesfromcardiacarrest, we need to accurately assess their impact. This is particularly importantforlargersystemswithmulti-factorialcomponentsany ofwhichmaybebeneficialeitherinisolationorcombination.For example,ithasalreadybeenshownthatfurtherworkneedstobe donetoevaluatetheimpactofcardiacarrestcentres.

Measuringperformance and implementing quality improve-mentinitiativeswillfurtherenhancesystemstodeliveroptimal results.102,176–181

Debriefingafterresuscitationintheclinicalsetting

Feedbacktomembersofanin-hospitalcardiacarrestteamabout theirperformanceinanactualcardiacarrest(asopposedtothe trainingenvironment)canleadtoimprovedoutcomes.Thiscan eitherbereal-timeanddata-driven(e.g.useoffeedbackdevices oncardiaccompressionmetrics)orinastructuredpostevent per-formancefocuseddebrief.102,182Theidealapproachtodebriefing

isyettobedetermined,includingtheintervalbetweenactual per-formanceandthedebriefingevent.Althoughitseemsintuitiveto providethislevelofdebriefingforout-of-hospitalcardiacarrest performance,noevidenceexiststosupportorrefuteitsbenefit.

Medicalemergencyteamsforadults

Whenconsideringthechainofsurvivalforcardiacarrest,1the

firstlinkistheearlyrecognitionofthedeterioratingpatientand preventionofcardiacarrest.Aconsiderableamountofworkhas beendonetoevaluatetheroleoftheMedicalEmergencyTeam (MET)inthisrespect.Werecommendtheiruseand,inparticular, theuseofhigherintensitysystems(e.g.higherMETcallingrates, seniormedicalstaffontheteam)astheirusehasbeenassociated withareducedincidenceofcardiac/respiratoryarrest183–189and

improvedsurvivalrates.184,186–189,183,190

Itisrecommendedthatthesesystemsinclude: (1)staffeducationaboutthesignsofpatientdeterioration (2)appropriateandregularvitalsignsmonitoringofpatients (3)clearguidance(e.g.viacallingcriteriaorearlywarningscores)

toassiststaffintheearlydetectionofpatientdeterioration (4)aclearuniformsystemofcallingforassistance

(5)aclinicalresponsetocallsforassistance.

Traininginresourcelimitedsettings

There are many different techniques for teaching ALS and BLSinresourcelimitedsettings.Theseincludesimulation, multi-media learning, self-directed learning, limited instruction, and self-directedcomputer-basedlearning.Someofthesetechniques are less expensiveand require less instructorresources than a traditionalteachingformat.Sometechniquesalsoenablewider dis-seminationofALSandBLStraining.Itisreasonabletosuggestthe useofthesestrategiesinresourcelimitedsettings,althoughthe optimalstrategyisyettobedeterminedandwilldifferfromone countrytoanother.191–197

Traininginethicsandfirstaid

Insights into training health care professionals about DNAR issues and approaches to practicing procedures on the newly deceasedareprovidedintheEthicschapteroftheERCguidelines 2015.198TheFirstAidchapterofthe2015ERCGuidelinesprovides

guidelinesaboutfirstaideducationandtrainingprogramsaswell aspublichealthcampaigns.199

TheERCresuscitationcourseprogram

TheERChasdevelopedawiderangeofcoursestargetingall lev-elsofproviders,frombasiclifesupportforlayrescuerstoadvanced lifesupportforhealthcareproviders.ERCcoursesteachthe com-petencestoundertakeresuscitationintheclinicalsettingatthe levelthattheywouldbeexpectedtoperform.Besides resuscita-tionskills,emphasisisgiventonon-technicalskillsandleadership training,applicationofethicalprinciplesandadvancededucational strategiesaswellasorganisationalimprovementsonasystemlevel toimprovesurvivalaftercardiacarrest.Specificcoursesteachthese competenceswhilstotherstrainhowcompetencesaretobetaught. ERC courses focus onteaching in smallgroups witha high instructor to candidate ratio using blended learning strategies, includinginteractivediscussion,workshopsandhands-onpractice forskillsandsimulationsusingresuscitationmanikins.200,201

Up-to-dateinformation aboutERCcoursesis availableinthe “ERCcourserules”ontheERCwebsite[https://www.erc.edu/index. php/doclibrary/en/]. Thecourserules describeindetail theERC terminologyanddefinitions;specificsoftheorganisationand man-agementofdifferentERCcourseformatsandqualitycontrol;the instructordevelopmentuptocoursedirector,instructortrainerand ERCeducator;theERCassessmentandcertification/recertification

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process;and theERCprofessional behaviouralguides including complaintsprocedures.

Ethos

InstructorsonERCcoursesaretrainedinteachingand assess-ment. The ethos is to create a supportive, learner-centred environmentthatpromoteslearning,enhancingunderstandingof knowledge and retention of skills. First names are encouraged amongbothfacultyandcandidatestoreduceapprehension. Inter-actionsbetweenfacultyandcandidatesaredriventolearnfrom eachother’sexperiences.Aimedchangesinbehaviourare elabo-ratedbyencouragementwithconstructiveandcorrectivefeedback aswellasdebriefingonperformance.Amentor/menteesystem isusedtoenhancefeedbackandsupportforthecandidate.Some stressisinevitable,202particularlyduringassessment,but

instruc-torsaimtoenablethecandidatestodotheirbest.ERCcoursesare drivenbytheultimategoaltoimproveresuscitationperformance toincreasesurvivalofcardiacarrestvictims.

Coursemanagement

ERCcoursesareoverseenbytheJointInternationalCourse Com-mittee(JICC) consistingofthechairpersonsoftheInternational CourseCommittees(ICC)forallERC-coursetypes(BLS/AED, Imme-diateLifeSupport(ILS),ALS,NeonatalLifeSupport(NLS),European PaediatricImmediateLifeSupport/EuropeanPaediatricAdvanced LiveSupport(EPILS/EPALS),GenericInstructorCourse(GIC))andis ledbytheBoardDirectorforTrainingandEducation(DTE).Onthe nationallevel,eachNationalResuscitationCouncil(NRC)assigns NationalCourseDirectors(NCD)foreachcoursetype.

TheERChasdevelopedaweb-basedcoursemanagementsystem [http://courses.erc.edu] for theadministration of these courses. Candidatesmaysignuponline toacourse,or maycontactthe courseorganisertoregistertheirinterestinaspecificcourse.At theendofthecoursethesystemwillgenerateuniquenumbered coursecertificatesforsuccessfulcandidatesandalsoeachfaculty member.Forqualitycontrolanevaluationtoolisavailableforeach courseand resultsareaccessibleforNRCs,NCDsandICC mem-bers.Participantswhosuccessfullycompleteprovidercoursesare referredtoas‘providers’.

Language

Initially,theERCcoursesweretaughtinEnglishbyan interna-tionalfaculty.Aslocalinstructorshavebeentrained,andmanuals andcoursematerialshavebeentranslatedintodifferentlanguages, manyNRCsarenowabletodelivertheircourseslocallyintheir nativelanguage.Itisimportantthatthisdoesnotcompromisethe qualitycontrolofcoursesandinstructordevelopmentandthe pro-cessoftranslationofnewguidelinesandcoursematerialsshould notdelaytheimplementationofnewguidelines.5

Instructordevelopment

Individualswhohave passedand demonstrated a highlevel ofperformanceduringaprovidercourseand,importantly,have shownqualitiesofleadershipand teamworking,shownclinical credibility,withskillsthatincludebeingarticulate,supportive,and motivatedmaybeidentified bythecoursefacultyasInstructor Potential(IP).IndividualswithIPinanyadvancedcoursewillbe invitedtotaketheERCGenericInstructorCourse(GIC).IPsafter BLS/AEDcourseswill beinvited totaketheBLS/AEDinstructor Course.

AttheGIC,anERCeducatorwhohasundertakenspecifictraining inmedicaleducationandintheprinciplesofadultlearning(ERC

EducatorMasterClass),isresponsiblefordeliveringtheeducational principlesofERCcourses.

Fromtheinstructorcandidate(IC)stagetofullinstructor(FI) Followingsuccessfulcompletion ofa GIC, IPs aregranted IC status and normallywill teachon two providercourses, under supervisionofthecoursefaculty,receivingconstructiveand cor-rectivefeedbackonhisorherperformancewiththeaimofbeing promotedtoFIstatus.Thisfeedbackenhancesteachingpractice duringtheGICandasanICinthefirstprovidercoursesby formu-latinglearninggoalsforsubsequentcourses.

Coursedirector(CD)status

AnapprovedCourseDirectorleadseachERCcourse.CDsare pro-posedbyNCDsandapprovedbytheirNRCortherespectiveICC. CDsareseniorinstructorswhoareclinicallycredible,have demon-stratedexcellentqualitiesasateacher,mentor,andassessor,and possesstheskillstoleadafacultyofinstructors.

GeneralERCcourseprinciples[ERCcourserulesonwww.erc.edu] ContentofERCcourses

All ERC courses follow contemporary ERC guidelines. Each coursehasitsspecificcoursemanualorteachingbookletproviding therequiredpre-courseknowledge.Candidatesreceivethemanual inadvancetoprepareforeachcoursewithamandatorypre-course MCQ(exceptforBLS/AED,ILSandEPILS)thataimstoensurethat candidatesreadthematerialsbeforeattendingthecourse.

AllERCcoursescompriseinteractivelectureandgroup discuss-ions, smallgroup workshops, hands-on skills teaching and, for advancedleveltraining,clinicallyorientatedCardiacArrest Sim-ulation(CAS)andemergencycasescenarios.Mostcourseformats includeoptionsenablinginstructorstotailortheirteachingtothe candidates’localneeds.

Immediateandadvancedlifesupportcourses

Immediateandadvancedlifesupportcoursestargetthetraining ofhealthcareproviders.Curriculahavecorecontentandcanbe tail-oredtomatchindividuallearningneeds,patientcasemixandthe individual’srolewithinthehealthcaresystemsresponsetocardiac arrest.Coremodulesforthesecoursesinclude:

• Cardiacarrestprevention.203,204

• Highqualitychestcompressions(adherencetorate,depth,full recoilandminimizinghands-offtime)andventilationusingbasic skills(e.g.pocketmask,bagmask).

• Defibrillation,withchargingduringcompressionsforhands-free defibrillation.

• Advancedlifesupportalgorithmsandcardiacarrestdrugs. • Non-technicalskills(e.g.leadershipandteamtraining,

commu-nication).

Immediatelife support courses. ILS courses for adults and EPILS coursesforchildrenareone-daycoursesfocusingonthecauses andpreventionofcardiacarrest,theABCDEapproachtothe crit-icallyillpatient,startingeffectiveBLS/AED,initiatingthechainof survival,andbasicCPRskills(e.g.effectivechestcompressionand safedeliveryofadefibrillationshock,basicairwaymanagement, choking,intravenousorintra-osseousaccess,anddrugsduring car-diacarrest).205Thesecoursesaredesignedtobesimpletorunwith

smallgroupsofcandidates.Theaimistotraincandidatesintheuse oftheequipment(e.g.defibrillatortype)thatisavailableintheir clinicalsettingandthemanagementofthefirstminutesofcardiac arrestuntilprofessionalrescuersarrive.

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Advanced lifesupport courses. ALS courses for adults, EPALS for neonatesandchildren,andNLScoursesfornewbornsbuildupon theknowledgeandskillsfromtherespectiveBasicand/or Imme-diateLifeSupportcourses.Thisprovidesthefoundationforthese 2-dayadvancedcoursesplacingemphasisonsafedefibrillationand ECGinterpretation,themanagementoftheairway,ventilationand vascularaccess,themanagementofperi-arrestrhythms,and spe-cialcircumstancesrelating tosevere illness, injury,and cardiac arrest.Post-resuscitationcare,ethicalaspectsrelatedto resusci-tationandcareofthebereavedarealsoincluded.Thesecourses shouldenableproviderstocoverthefirsthourofcriticalillnessor injuryandcardiacarrest.Theyarenotdesignedtoprovide instruc-tioninadvancedintensivecareorcardiology.

Thefacultymeeting

Thefacultymeetingusuallytakesplaceatthestartandatthe endofeachcoursedayandisledbythecoursedirector.Theaim istobrieftheteachingfacultyandtoassesstheperformanceand progressofeachcandidate.Duringthefinalfacultymeetingeach candidate’sperformance is reviewed tomake a decision about successfulcourseparticipationandwhethercandidateswhohave mettherequired criteriaareofferedinstructorpotentialstatus. Instructorcandidatesonthecoursesarealsoassessedontheir per-formance.Facultymeetingsalsoprovideanopportunitytodebrief thefacultyattheendofthecourse.

Assessmentandfeedback

Throughoutthecourse,thefacultyassesseseachcandidate for-mativelyandindividually.Candidates’performancesandattitudes arediscussedatthedailyfacultymeetings,withmentoringand feedbackgivenasrequired.Instructorsaretaughttousea frame-work aimed at providing timely, constructive, goal orientated, studentcentredandactionplannedfeedbacktoenablethelearner toachievethedesiredoutcome.

ThestandardERC feedbackformatistheLearning Conversa-tion.Thelearningconversationstartswithaninvitationtoreflect anditisprimarilycentredonanyissuethatthecandidatewishes todiscuss.Thisisfollowedbyadiscussionofanykeyareasthat theinstructorwishestodiscuss,alongwithcontributionsfromthe groupandotherinstructors.Anyimportantperformanceissuesare thensummarisedwithspecificactionpointsforthecandidateto improvetheirfurtherperformance.

Candidates’performancesarecontinuouslyassessed through-outBLS,ILS,andGICcourses,measuringtheircompetencesagainst pre-determinedcriteria;nosummativetests arerequiredtobe certified.

TowardstheendofNLSandALScoursesaCardiacArrest Simu-lationTest(CAST)assessesthecandidates’appliedknowledgeand skillsduringasimulatedcardiacarrestincludingleadingacardiac arrestteam.ThereliabilityandmeasurementpropertiesofCAST havebeenestablished.121,206,207Theircoreknowledgeisassessed

withanMCQ. Mentoring

MentoringisanessentialpartofallERCcoursesandenables candidatestohaveanominatedrolemodel.Groupor1:1mentoring happensduringERCcoursesonaregularbasis.

SpecificformatsofERCresuscitationcourses

Basic lifesupport andautomated external defibrillation (BLS/AED) providercoursesandBLS/AEDinstructorcourse. BLS/AEDcoursesare appropriateforallcitizensincludinglaypersonsandtrainedfirst responders(first-aidworkers,lifeguards),thosewithadutyofcare forothers(e.g.schoolteachers,careworkers,securitypersonnel) andultimatelyallclinicalandnon-clinicalhealthcareprofessionals (includingEMSsystemsdispatchers,generalpractitioners,dentists,

medicalandnursingstudents,andthosewhoarelesslikelyto man-ageacardiacarrest).CombinedBLS/AEDcoursesareencouraged.

BLS/AEDcourses aimtoenableeach candidatetogain com-petencyinrecognisingacardiacarrest,immediateinstigationof effectivechestcompression,callingappropriatehelptothescene andsafeuseofanAED.Thesecoursesteachchildrenandadultsin CPRcompetencesforchildrenandadultsincardiacarrest.

TheERCBLS/AEDinstructorcourseofferscandidateswhohold a validBLS/AEDcertificate and whoare identifiedas instructor potentialtheopportunitytotraintobeBLS/AEDinstructors. Immediate life support (ILS) course. The ILS course teaches the majorityofhealthcareprofessionalsfromalldisciplinesand pro-fessionswhofaceadultcardiacarrestsrarelybutarepotentialfirst respondersorresuscitationteammembers.208 AppliedILS

com-petencesshouldresultinsuccessfulresuscitationwhilstawaiting thearrival of theresuscitation team coveringthe firstminutes of CPR.209 In a cohort study after implementation of an

ILS-programme the number ofcardiac arrest calls and truearrests decreasedwhilepre-arrestcallsincreasedaswellasinitialsurvival andsurvivaltodischarge.210

Advancedlifesupport(ALS)course. ThetargetcandidatesfortheALS coursearephysicians,nurses,EMSpersonnel,andselectedhospital technicianswhomayberesuscitationteamleadersandmembers foradultCPR.211,212

BeyondtheexpectedBLSandILScompetencestobemastered bythecandidates,thiscourseformatteachesthemanagementof cardiacarrestfromadiversityofcausesandthemanagementof peri-arrestproblemsandconcentratesontheapplicationof non-technicalskills withemphasis onteam-cooperationunder clear teamleadership.

Newbornlifesupport(NLS)course. Thisone-dayinter-professional course aims togive healthcare workers likely to bepresent at the birth of babies (e.g. midwives,213 nurses, EMS personnel,

physicians)thebackgroundknowledgeandskillstoapproachthe managementandresuscitationofthenewlybornduringthefirst 10-20min.NLSplacesappropriateemphasisonairway manage-ment,chestcompression,umbilicalvenousaccessanddrugsfor newbornCPR.214

Europeanpaediatricimmediatelifesupport(EPILS)course. EPILSisa one-daycourse(5to8h)thattrainsnurses,EMSpersonnel,and doctors who are not partof a paediatric resuscitation team to recogniseandtreat critically-illinfantsand children,toprevent cardiorespiratoryarrestandtotreatchildrenincardiorespiratory arrestduringthefirstfewminuteswhilstawaitingthearrivalof a resuscitationteam.Shortpracticalsimulationsadapted tothe workplaceandtotheactualclinicalroleofcandidatesareusedto teachthecorecompetencies.

Europeanpaediatricadvancedlifesupport(EPALS)course. EPALSis designedfor healthcareworkerswhoareinvolvedinthe resus-citation of newborns, infants or children providing sufficient competencestomanagecriticallyillorinjuredchildrenduringthe firsthourofillness.215–218Refreshertraininginpaediatricbasiclife

supportandreliefofforeignbodyairwayobstructionisincluded. EPALSputsgreatemphasisontherecognitionandcontinuous assessmentandtimelytreatmentofthesickchild(e.g.cardiacand respiratoryfailure,arrestandtraumasimulations).Aspectsofteam workingandteamleadershipareintegratedinthetraining, includ-ingproblemanticipationandsituationalawareness.Dependingon localneedsandcircumstancesEPALSmayfurtherincludemodules onnewbornresuscitation,post-arrestcareandhandover,and/or

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modulesonmoreadvancedknowledgeortechnicalskills.These lattermodulesarebeingcontinuouslydeveloped.

Genericinstructorcourse(GIC). TheGICisforcandidateswhohave beenrecommendedasinstructorpotential(IP)emanatingfromany ERCprovidercourses(excepttheBLS/AEDcoursethathasa sepa-rateinstructorcourse)orwithIPstatusfromcertainotherprovider courses(e.g. EuropeanTraumaCourse). TheGIC puts emphasis ondevelopingteachingandconstructiveandcorrectivefeedback andmentoring.Coreknowledgeoftheoriginalprovidercourseis assumed.

AnERCeducatorleadstheeducationalprocess,thediscussions andprovidescriticalfeedback.TheEducatordeliversinteractive sessionscoveringthetheoryofadultlearning,effectiveteachingof skillsandsimulatedscenarios,assessmentandeffectivefeedback, andleadershipandnon-technicalskillsthroughaseriesof interac-tivesessions.Thefacultydemonstrateseachofthesecompetencies, followedbyopportunitiesforthecandidatestopractise.

Abbreviatedmaterialfromtheoriginalprovidercourseisused forthesimulatedteachingsessions.TheGICemphasisesthe con-ceptof constructive and corrective feedback to develop future learningstrategiesthusprovidinganopportunityforeach candi-datetoadopttheinstructorrole.

Educatormasterclass(EMC). ERCeducatorsareanessential manda-torycomponentoftheGICfaculty.Atwo-dayeducatormasterclass teachesexperiencedprovidercourseinstructorswitha demonstra-bleinterestineducationtobecomeERCeducators.NRCspropose suitablecandidateswhoarethenshortlistedbytheERCWorking Groupon Education based on specificcriteria (including moti-vation, qualification in medical education or documentation of demonstratedspecialcommitmenttoeducationalpracticeovera numberofyearswithintheERC).

EMC instructors are experienced educators assigned by the WorkingGroup onEducation and theDirector of Training and Education.TheEMCcoversthetheoreticalframeworkforERC edu-cators,assessmentand qualitycontrol, teachingmethodologies, critical appraisal,the mentor role, multi-professionaleducation strategiesandcontinuousdevelopmentoftheERCteaching fac-ulty.TheformatoftheEMCisaseriesofcloseddiscussions,small breakoutgroupsandproblemsolvingsessions.Candidatesare for-mativelyassessedthroughouttheEMC.

Europeanresuscitationacademy(ERA)—“Ittakesasystem

tosavealife”

TheERAaimstoimprovesurvivalfromcardiacarrestthrough afocusonhealthcaresystemimprovementsthatbringthe indi-viduallinksintheChainofSurvivalandtheFormulaforSurvival together.EntireEMSstaff(managers,administrativeandmedical directors,physicians,EMTsanddispatchers)fromdifferenthealth caresystemsandcountriesareinvitedtolearnfromtheERA Pro-gram(derivedfromtheSeattle(US)basedResuscitationAcademy [http://www.resuscitationacademy.com/]tenstepsforimproving cardiacarrestsurvival)togetherwiththelocalhosthealth institu-tions.TheERAputsemphasisondefiningthelocalcardiacarrest survivalratebyunderstandingtheimportanceofreportingdata inastandardisedUtsteintemplate.ParticipatingEMSsystemsare encouragedtodevelopconcretemeasurestoimprovecardiacarrest survival followedby appropriatemeasurements ofthese action plans.

Futuredirectionforresearchandcoursedevelopment

Theproductionofinternationalguidelinesforresuscitationis aconstantlyevolvingexercise.Highqualityresearchcontinuesto bepublishedwithevidencethatmayormaynotsuggestthatthe guidelinesoftodayareacceptable.

Inparallelwiththis,thescienceofeducationalsocontinuesto evolve.Ourmethodsforteachingtheseguidelineshavechanged substantiallyovertheyearsfromtheearlydaysofdidactic theo-reticaldeliveryofteachingtocontemporaryinteractive,hands-on methodsthatalsoutilisetechnologyandsocialmedia.

Thereisstillapaucityofhighqualityevidenceaboutthebest methodsofteaching,primarilybecausethenumbersofcandidates neededtoproducestatisticalsignificanceformeaningfuloutcomes (e.g.increaseinpatientsurvival)wouldneedtobemassive.There isarolethereforeforinternationalcollaborationtoachievesuch numbersinasimilarstyletothecollaborationsusedtoassesssome oftheclinicalcontenttotheguidelines.Untilthetimethat sta-tistical significance is achieved,it is essentialthat we continue toevaluateoureducationalmethodsand assesstheeducational importanceorrelevanceofthefindings.

Newinsightsabouteducationalprocess,neuro-scienceimpact ontraining andrapid developmentsin socialmediaand online applicationsmeanthatourapproach toeducationisconstantly changing.Thischapterhighlightscurrentchangesandwhatmay changeinthenearfuture.

Recommendationsforeducationalresearchinresuscitation

Everyeducationalinterventionshouldbeevaluatedtoensure that it reliably achieves thelearning objectives and at its best improvespatientoutcomein acardiacarrestsituation.Theaim istoensurethatlearnersnotonlyacquireskillsandknowledgebut alsoretainthemtobeabletoprovideadequateactionsdepending onthe level of training. Evaluationat thelevel of patient out-comeisdifficulttoachieve,asseveralotherparametersinfluence patientoutcome,suchaschangesinguidelines,changesin case-mix, andorganisational changes. Thelevel of outcome studied, shouldbedeterminedduringtheplanningphaseoftheeducational event.219Itisdifficulttoassessbehaviourintheclinicalsettingso

thisattributeismorecommonlyassessedwithsimulationusing manikins.Generalisabilityfrommanikin studiesis questionable, though,andthatisthereasonwhysolittlehigh-levelevidenceis foundintheliterature.

Educationinresuscitationisstillarelativelynewfieldlacking highqualityresearch.Studiesareheterogenousindesignandprone toriskofbiasandthereforedifficulttocompare.Aresearchcompass toguidefuturestudiesineducationhasbeendevisedataresearch summit.220

Futurecoursedevelopment

TheeducationalstrategyoftheERCisbasedonuniform instruc-torcoursesandstandardisedprovidercoursecurricula.Thiswill evolveasmoreblendedlearningmethodsbecomeavailable. Flexi-bilityisneededinteachingCPRonalllevelsasdifferentmedialike DVD,Internetandon-linetrainingincreasethelearningbenefit.

Newcurriculashouldallowthisflexibility.Somecore-content moduleswillbethe‘heart’ofanyERC-coursewhichwillallowthe customisationofeachcourseformatwithadditionaloptional con-tent(medicalaswellasnon-technicalaspects)tosupportandtrain learnersaccordingtolocalneeds.Someinstitutionswill,forsome learners,haveveryspecialisedmodules(e.g.cardiacarrestafter cardiacsurgery, advancedneonatal supportatanICU, obstetric resuscitation,resuscitationduringsurgeryintheoperationroom) thatcanbeaddedtothestandardcore-contentofthecourse.

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Newteachingtechnology(IT-basedlearninglikewebinars, e-learningmodulesontheERCvirtuallearningenvironment)willbe adoptedandthisneedstobeaddressedintheGICaswellasinthe supervisionandmentoringofallinstructors,coursedirectorsand educators.

Learnersusingvideo-oronlinetrainingmaynolongerneeda printedmanual,astheywillhaveimmediateaccesstothecontent ontheInternet.Thiswillprovidesubstantiallymoreopportunity tointegratepictures,demonstrationvideosofskillsandteam per-formance,self-assessmenttestswithguidanceofhowtoimprove, andlinkedliteraturetodeepeninterests.Avirtuallearning envi-ronment(VLE)willfurthermoremonitorandsupporttheongoing learningtrajectoryofeachindividualintermsofknowledge,skills, attitudesandglobalperformancefromproviderstoinstructorsas wellascourseorganisers.

Readingandlearningknowledge-basedfacts,thinkingthrough proceduresandactionstrategies,anddiscussingopenquestions canallbedonebeforecandidatescometothecoursevenue.Highly motivatedcourseparticipantswillcometothecoursecentrewith ahighlevelofknowledge,aclearvisionwhentoapplywhich pro-ceduresandhowtointeractwithateamtoperformqualityCPR. Duetoincreasingconstraintsonstudyandteachingleave,thetime spentatthecoursecentreneedstobefocusedonthetranslation ofthelearnedconceptsinthesimulatedscenarios.Thiswillenable candidatestotryout,rehearseandexecutelife-savingtechniques, usingbestmedicalpracticeandteamleadershipandmanagement. Thisshouldultimatelyenableproviderstoincreasesurvivalafter cardiacarrestintheclinicalsetting.

Highfrequencytrainingwillbeveryshortandmightnot nec-essarilyneedpersonalcoachingbyaninstructorormentor.The trainingenvironmentshouldbebroughttothelearners,sothat theycanexperience it duringdaily activitiestoreachthe high frequencyobjective.AbriefannualCPRcompetencetestmaybe usedtofilteroutthosewhodonotachieveinstitutionallydefined levelsofcompetence.Somemightneedbrieftrainingunder super-visiontoreachcompetence,whereasothers mayneedalonger formal refresher process. Course organisers have to plan their coursesina flexibleway,allowingashorterduration fortarget groupswithextrabackground,and morehands-ontime forlay rescuers.

Theuseofhighfidelitymanikinsandadvancedfeedbackdevices willbeavailableforcountriesandorganisationswiththe finan-cialcapacity, but notfor allcountriesand organisations. When using low fidelity manikins, instructors need to be trained to delivertimelyandvalidfeedbacktothelearnertoincreasetheir learning.

Ultimately,thegoaloftheERCistostrengtheneachcomponent oftheChainofSurvival througheffectiveeducationand imple-mentation.Theaimshouldbetodevelopteachingstrategiesfor lay peopleand healthcare professionals to deliver highquality BLS,swiftdefibrillation,effectiveadvancedresuscitation,andhigh qualitypostresuscitationcare. Thesestrategies shouldbeeasy, accessible,wellvalidated,andappealing.Thiswillensurethatthe scientificguidelinescaneffectivelytranslateintoimprovedsurvival rates.

Collaborators

JohnH.W.Ballance,Woolhope,Herefordshire,UK

AlessandroBarelli,TeachingHospitalAgostinoGemelli,Rome,Italy Dominique Biarent, Paediatric Intensive Care and Emergency Department,HôpitalUniversitairedesEnfants,UniversitéLibrede Bruxelles,Brussels,Belgium

LeoBossaert,UniversityofAntwerp,Antwerp,Belgium

MaaretCastrén,DepartmentofEmergencyMedicineandServices, Helsinki University Hospital and Helsinki University, Helsinki, Finland

AnthonyJ.Handley,HillcrestCottage,Hadstock,Cambridge,UK Carsten Lott, Department of Anesthesiology, University Medical Center,JohannesGutenberg-University,Mainz,Germany

IanMaconochie,PaediatricEmergencyMedicine,ImperialCollege HealthcareNHSTrustandBRCImperialNIHRGrantHolder, Impe-rialCollegeLondon,London,UK

Jerry P. Nolan, Department of Anaesthesia and Intensive Care Medicine,RoyalUnitedHospital,Bath,Bristol,UK;Bristol Univer-sity,Bristol,UK

Gavin Perkins,Warwick Medical School,University of Warwick, Coventry,UK;CriticalCareUnit,HeartofEnglandNHSFoundation Trust,Birmingham,UK

ViolettaRaffay,MunicipalInstituteforEmergencyMedicineNovi Sad,NoviSad,Serbia

CharlotteRingsted,Faculty ofHealth, Aarhus University,Aarhus, Denmark

JasmeetSoar,AnaesthesiaandIntensiveCareMedicine,Southmead Hospital,Bristol,UK

JoachimSchlieber,TraumaHospitalSalzburg,Salzburg,Austria PatrickVandeVoorde,UniversityHospitaland UniversityGhent, FederalDepartmentHealth,Ghent,Belgium

JonathanWyllie,JamesCookUniversityHospital,Middlesbrough, UK

DavidZideman,ImperialCollegeHealthcareNHSTrust,London,UK

Conflictsofinterest

RobertGreif EditorforTrendsinAnesthesiaandCriticalCare.

AndrewS.Lockey MedicalAdvisor“FirstonSceneFirstAidCompany”.

AnneLippert Noconflictofinterestreported.

KoenraadG.Monsieurs Noconflictofinterestreported.

PatriciaConoghan Noconflictofinterestreported.

WiebeDeVries TrainingOrganisationACMemployee.

Acknowledgement

TheWritingGroupacknowledgesthesignificantcontributions tothischapterbythelateSamRichmond.

References

1.NolanJ,SoarJ,EikelandH.Thechainofsurvival.Resuscitation2006;71:270–1.

2.SoreideE,MorrisonL,HillmanK,etal.Theformulaforsurvivalinresuscitation. Resuscitation2013;84:1487–93.

3.Chamberlain DA, Hazinski MF. Education in resuscitation. Resuscitation 2003;59:11–43.

4.MorleyPT,LangE,AickinR,etal.Part2:evidenceevaluationandmanagement ofconflictofinterestfortheILCOR2015consensusonscienceandtreatment recommendations.Resuscitation2015;95:e33–41.

5.BerdowskiJ,SchmohlA,TijssenJG,KosterRW.Timeneededforaregional emergencymedicalsystemtoimplementresuscitationguidelines2005—The Netherlandsexperience.Resuscitation2009;80:1336–41.

6.Bigham BL, Aufderheide TP, Davis DP, et al. Knowledge translation in emergencymedicalservices:aqualitativesurveyofbarrierstoguideline imple-mentation.Resuscitation2010;81:836–40.

7.BighamBL,KoprowiczK,AufderheideTP,etal.Delayedprehospital implemen-tationofthe2005AmericanHeartAssociationguidelinesforcardiopulmonary resuscitation and emergency cardiac care. Prehospital Emergency Care 2010;14:355–60(OfficialjournaloftheNationalAssociationofEMSPhysicians andtheNationalAssociationofStateEMSDirectors).

8.Kudenchuk PJ, Redshaw JD, Stubbs BA, et al. Impact of changes in resuscitationpracticeonsurvivaland neurologicaloutcomeafter out-of-hospitalcardiacarrestresultingfromnonshockablearrhythmias.Circulation 2012;125:1787–94.

9.SteinbergMT,OlsenJA,BrunborgC,etal.Minimizingpre-shockchest compres-sionpausesinacardiopulmonaryresuscitationcyclebyperforminganearlier rhythmanalysis.Resuscitation2015;87:33–7.

10.SworR,KhanI,DomeierR,HoneycuttL,ChuK,ComptonS.CPRtraining andCPRperformance:doCPR-trainedbystandersperformCPR?AcadEmerg

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