- Email: [email protected]
The immediate life support (ILS) course – The Italian experience
Resuscitation (2007) 72, 451—457
TRAINING AND EDUCATIONAL PAPER
The immediate life support (ILS) course — The Italian experience夽 Andrea Scapigliati a,∗, Tommaso Sanna a, Roberto Zamparelli a, Claudio Sandroni b, Christian Colizzi a, Peter Fenici b, Gabriella Arlotta a, Carmen Nuzzo a, Carmela Bonarrigo b, Fulvio Bellocci a, Rocco Schiavello a, Gianfederico Possati a a
Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy b Department of Emergency Medicine, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy Received 25 May 2006 ; received in revised form 20 July 2006; accepted 27 July 2006 KEYWORDS Cardiopulmonary resuscitation (CPR); Education; In-hospital CPR; Immediate life support (ILS); Training; Resuscitation
Summary Aim of the study: The 1-day immediate life support course (ILS) was started in the United Kingdom and adopted by the ERC to train healthcare professionals who attend cardiac arrests only occasionally. Currently, there are no reports about the ILS course from outside the UK. In this paper we describe our initial Italian experience of teaching ILS to nurses. We have also measured the impact that ILS has on the resuscitation knowledge of nurses. Methods: The ILS course materials were translated by Italian ALS instructors who had observed the ILS course previously in the UK. From March to November 2005 nurses from a single hospital department attended the Italian ILS course. Candidate feedback was collected using an evaluation form. The change in knowledge of candidates was measured using a pre- and post-course test. Variables associated with candidate performance on course papers were investigated using multivariate linear regression analysis. Results: A total of 119 nurses attended nine ILS courses. All candidates completed the course successfully and gave high evaluation scores. ILS produced a significant increase from pre- to post-course score (10.15 ± 2.75 to 13.19 ± 2.53, p < 0.001). The pre-course score was higher for nurses working in ICU compared with those coming from non-intensive wards, but this difference disappeared in the post-course evaluation (13.89 ± 2.18 versus 12.79 ± 2.65, p = ns).
夽 A Spanish translated version of the summary of this article appears as appendix in the final online version at 10.1016/j.resuscitation.2006.07.024 ∗ Corresponding author at: Institute of Anaesthesiology and Intensive Care, Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, L.go A. Gemelli 8, 00168 Rome, Italy. Tel.: +39 0630154507. E-mail address: [email protected] (A. Scapigliati).
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.07.024
452
A. Scapigliati et al. Conclusions: We have reproduced the ILS course in Italy successfully. ILS teaching resulted in an improvement in resuscitation knowledge of the first group of nurses trained. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction
Emergency response organization
Survival after in-hospital cardiac arrest (IHCA) is poor.1,2 Education in resuscitation for healthcare professionals (HCP) is one among several strategies suggested to improve survival rates after IHCA. In particular, improving the quality and efficacy of interventions performed by HCPs who may be called to attend IHCA as ‘‘first responders’’3,4 is expected to reinforce the ‘‘in-hospital chain of survival’’.5,6 However, current restrictions on resources for training and evidence encouraging an appropriate tailoring of educational contents to the real needs of candidates suggest a ‘‘fit for purpose’’ training format.7 The immediate life support (ILS) course was developed and implemented in the United Kingdom (UK) to improve and standardise knowledge and skills in HCPs who attend cardiac arrests only occasionally. The ILS course teaches candidates the initial treatment of cardiac arrest (CA) patients until the resuscitation team arrives and also how to be active members of the team.8 The ILS course has been adopted by the European Resuscitation Council (ERC).9 At the time of this study there are no reports about ILS from outside the UK. This study was designed to replicate the ILS format in Italy and to evaluate the effect of ILS on the resuscitation knowledge of candidates.
As opposed to all other areas of the hospital that rely on a hospital cardiac arrest team,10 the DCVM area has no cardiac arrest team. For emergencies requiring life support that occur in the DCVM, the ward nurse or other healthcare bystanders call the physician on duty and the anaesthesiologist who is present constantly in the CSICU using a digital enhanced cordless telephone (DECT). If necessary, cardiopulmonary resuscitation (CPR) is started by the first healthcare bystanders and, after the arrival of the anaesthesiologist, a resuscitation team is formed at the victim’s bed using participating ward staff. During cardiac arrest management, the anaesthesiologist acts as team leader while physicians and nurses on duty in the ward usually play as ALS team members. All areas of the DCVM have full standardised resuscitation equipment including manual defibrillators. There were no automated external defibrillators (AED) at the time of the study. No retraining in CPR was required for nurses before implementation of the ILS course. Nurses were not trained in rhythm recognition. In the critical areas nurses were allowed to use manual defibrillators under medical supervision.
Methods Setting From March to November 2005, nurses working in the Department of Cardiovascular Medicine (DCVM) of ‘‘Agostino Gemelli’’ Hospital, Catholic University of the Sacred Heart, Rome, Italy, participated in the ILS course. At this time, 125 nurses were employed in the DCVM. The DCVM has 89 adult patient beds on the same floor including cardiology, cardiac surgery, and vascular surgery wards, a coronary care unit (CCU), a post-operative cardiac surgery intensive care unit (CSICU), invasive and non-invasive cardiology diagnostic laboratories, and cardiac and vascular surgery operating rooms.
The Italian ILS course The ILS course has been described previously.8 Briefly, ILS is a 1-day course delivered by ERC certified ALS instructors. ILS includes lectures, skill stations and scenario teaching tailored to the clinical roles of the candidates. A continual assessment process is used to test candidates knowledge and skills. With the support of the ERC and Italian Resuscitation Council (IRC), three experienced ALS instructors (A.S., T.S. and P.F.) attended an ILS course as observers in London (UK). Course material was translated into Italian with the approval of the ERC. The ILS courses were conducted according to the ERC ILS course regulations. The laryngeal mask airway (LMA) was only mentioned in our courses as it is not currently used for resuscitation in the study setting. A discussion about tracheal intubation and resuscitation drugs and delivery was included. The aim was to train all the nurses of the DCVM (125 candidates). Nine courses were planned from
The immediate life support (ILS) course — The Italian experience Table 1 naire
Contents evaluated through the question-
Contents Demographics and professional backgrounds Signs of clinical deterioration Chain of survival In-hospital BLS Cardiac arrest main drugs Equipment for endotracheal intubation Cardiac arrest rhythms
March to November 2005. Each course included nurses from every area of the DCVM. A mean of 13 candidates attended each course with an instructor/candidate ratio of 1 to 4—5. A multidisciplinary group including educational officers, physicians (anaesthesiologists and cardiologists) involved in resuscitation training and the nurse managers of the DCVM planned the training schedules. An initial pilot phase of five courses was planned to gain experience in conducting the ILS course. This was followed by a study phase of four courses. Provided a proportional representation of nurses from each division of the DCVM, candidates were assigned to the pilot phase (66/119) or to the study phase (53/119) by chance. In the study phase demographics and professional backgrounds and the knowledge improvement associated with ILS were evaluated by a preand post-course assessment form with 10 questions not provided in the original course format. The assessment form was designed to verify knowledge on the critical aspects of prevention, recognition and treatment of cardiac arrest and included multiple choice questions and open answer questions (Table 1). The highest possible score was 16. Course evaluation by all the attending candidates was tested by feedback forms provided with teaching material. The influence on pre- and post-course score of the following covariates was explored with linear multiple regression analysis: serving time as HCP, sex, high perceived frequency of attended cardiac arrests attended (defined as a perceived frequency of attended cardiac arrests of at least 1/month), previous BLS certification and current occupation in ICU.
Statistical analysis Normal distribution of explored variables was assessed with Shapiro—Wilk test. Variables showing normal distribution are presented as mean ± S.D. Variables not showing normal distribution are pre-
453
sented as median (range). Categorical variables are presented as proportions or percentages. An unpaired mean comparison of variables with normal distribution was performed with t-test for independent samples. A paired mean comparison of variables with normal distribution was performed with t-test for paired samples. Level of significance for all comparisons was set a p < 0.05. Multiple linear regression was performed with a backward elimination strategy with a significance cut-off for removal set at p < 0.05. Dummy coding was operated in the case of nominal variables with multiple levels. Assumptions of multiple linear regression on covariates, on residuals, on specification error and measurements were verified.
Results A total of 119 candidates attended the course. Six candidates did not participate due to personal reasons. Age, sex and place of work of the candidates are presented in Table 2. All the participants completed the ILS course successfully, meeting the required standards. Feedback form results are summarised in Table 3. All candidates who answered the form expressed high evaluation scores on course format and contents; in particular they would recommend the course to their colleagues. In the study group (53/119 candidates), the median service time as a nurse was 11 years (range 1—35), 19/53 worked in an intensive care unit (10 in coronary care unit, nine in cardiac surgery intensive care unit) and 34/53 in ordinary wards or cardiology diagnostic labs (21 in cardiology, cardiac surgery and vascular surgery wards, two in non-invasive cardiology labs, five in invasive cardiology labs and six in the cardiac and vascular surgery operating room). Only 20 of 53 NMHCP who underwent the ILS
Table 2 Baseline characteristics of candidates (n = 119) attending the ILS course Characteristic of candidates Age (years) Mean ± S.D.
40 ± 9
Sex Male Female
30 (25.21%) 89 (74.79%)
Place of work Intensive care unit Wards Operating rooms Diagnostic cardiology laboratories
40 48 13 18
(33.61%) (40.34%) (10.92%) (15.13%)
454 Table 3
A. Scapigliati et al. Selected items from feedback forms
Items
Scores
Was the ILS course useful to you? Was the manual useful to attend the course? Would you recommend this course to your colleagues?
Missing
1/5
2/5
3/5
4/5
5/5
— — —
— 1.7 —
— 3.4 —
2.6 6.8 —
84.6 71.8 83.8
12.8 16.3 16.2
Results are presented as percentages.
course had received a formal BLS certification previously (median 2.5 years before [range 1—10]). The perceived frequency of attended cardiac arrests was 1/week for 13/53 candidates, 1/month for 7/53, more than 2/year for 26/53, 1—2/year for 5/53 and less than 2/year for 2/53 (Table 4). In the study group, the ILS course produced a significant improvement in cardiac resuscitation knowledge, as documented by an increase from pre- to post-course score from 10.15 ± 2.75 to 13.19 ± 2.53 (p < 0.001) (Figure 1). While a significant difference of baseline cardiac resuscitation knowledge had been observed between nurses who worked in an intensive care unit as compared to those who did not (pre-course score 11.74 ± 2.08 versus 9.26 ± 2.71, p = 0.001), this difference disappeared after ILS course (post-course score 13.89 ± 2.18 versus 12.79 ± 2.65, p = ns) (Figure 2). Pre-course score was positively correlated with the current occupation in ICU of candidates (standardised beta 0.39, p = 0.002; model R = 0.52, R2 = 0.27) and negatively correlated with serving time (standardised beta −0.29, p = 0.022; model R = 0.52, R2 = 0.27) but not with sex, perceived frequency
Table 4
Figure 1 Questionnaire score in the study group before and after the course.
Characteristics of the study group
Male Median age (years) Median service time (years) Place of work ICU General ward Diagnostic laboratories Invasive laboratories Operating theatre Former BLS/AED training Years before ILS course (median) (years) Perceived CA frequency 1/week 1/month >1—2/year 1—2/year <1—2/year
16/53 (30%) 36 (24—63) 11 (1—35) 19 (36%) 21 (40%) 2 (4%) 5 (9%) 6 (11%)
Figure 2 Score related to the place of work of the study group candidates before and after the course.
of attended cardiac arrests and previous BLS certification. Post-course score was negatively correlated with serving time (standardised beta −0.44, p = 0.001; model R = 0.44, R2 = 0.19) but not with sex, frequency of attended cardiac arrests, previous BLS certification and current occupation in ICU.
20 (38%) 2.5 (1—10)
Discussion 13 (24.5%) 7 (13.2%) 26 (49.1%) 5 (9.4%) 2 (3.8%)
Prevention, recognition and immediate treatment of CA by ward HCP are critical aspects in improving IHCA prognosis.10—12 An Italian study which investigated several hospitals in Rome has shown how ward staff BLS skills and attitudes to cooperate with car-
The immediate life support (ILS) course — The Italian experience diac arrest team (CAT) during the ALS phase were perceived as unsatisfactory by CAT members.13 In general wards, nurses are likely to be the most common bystanders of patients suffering CA since they are usually closer to patients in terms of space and time. However, the lesser frequency of medical emergencies in this setting is likely to lead to a lower level of experience and skills just in those who should recognize clinical deterioration, summon the appropriate help and initiate effective CPR. Furthermore, resource restrictions or local policies limit availability of emergency-dedicated staff in many hospitals. For example, in our department, which can be considered as a ‘‘micro-system’’ within the hospital system, there is no dedicated CAT, and the cardiac arrest team is built up at the patient’s bed after arrival of the anaesthesiologist, who acts as team leader. Therefore, healthcare providers who initially performed BLS are requested to become active team members and should have appropriate knowledge and skills to participate effectively in the ALS team.14 Therefore, educational programmes for HCP aiming at increasing knowledge and skills to prevent, recognise and treat IHCA effectively are expected to reinforce the in-hospital ‘‘chain of survival’’ and ultimately to improve outcomes. According to the ILCOR Symposium on Education in Resuscitation, training strategy should be tailored to the settings, specific roles and educational background of the learners.15 To be as closefitting to the authentic learners practice, training in mock scenarios should reach a good compromise of professional-based skills stations (e.g., nurses learn to do what nurses are expected to really do) followed by multidisciplinary teamwork that offers different useful perspectives. In this way learners are enabled to do what is suitable with their own role but at the same time they become aware of what other professionals have to do as well. While planning on this basis a ‘‘fit for purpose’’ resuscitation training programme intended for HCP of our Department, we considered the educational content of the current BLS course as inadequate for our needs. Prevention of cardiac arrest, airway management with adjuncts and bag-valve ventilation, ALS universal algorithm, drug preparation and their delivery are not covered by this training course. On the other hand, the ALS course is intended for training of ALS team leaders and provides an excessive load of learning input; far from real life roles, the course seemed to have a little impact on daily practice in terms of skills deployment,7 especially for nurses.16 Moreover, ALS is a 2—3-
455
day course requiring large availability of human resources and impact on duty time: in our experience it was not suitable for an extensive training programme according to the requests of our institution’s managers. To fill the ‘‘no course land’’ between BLS and ALS formats, the ILS course has been recently proposed8,9 as a new educational tool to provide training in resuscitation to HCPs who occasionally attend cardiac arrest and who are not expected to be leader or usual members of a cardiac arrest team but who can start CPR as first responders and then participate in ALS as team members. The ILS format offers the advantage of expanding the core issues of BLS courses in a 1-day course with clear advantages in terms of human and economic resource allocation compared to a full 3-day ALS course. At the time of the study, we could not find published reports of ILS courses run outside UK. Replication of the ILS course in our institution required participation of three instructors as observers of a course in the UK and translation of the course material. The total time required for the entire process was about 5 weeks. Adaptation of the course programme to our candidate profile was an option already included in the course format and did not require special modifications. The 1-day format and the presence of a small number of nurses (two to four) from each area of the DCVM limited the impact of the course on service delivery. All candidates gave high evaluation scores and would recommend the course to colleagues. This suggests that the course meets candidates’ expectations and their perceived educational needs. Both course results (in terms of skills performance) and the course questionnaire showed that the ILS course was successful in achieving a satisfactory and homogeneous level of skills and knowledge in our candidates’ population. This aspect seems to be confirmed by a recent study in a community setting in the UK in which a quantitative and qualitative course evaluation was undertaken at the start of the course, and at the end and at 6 months; a significant knowledge improvement was observed in a candidate sample between the preand post-course test and no significant knowledge decline was found by 6 months while skills were worsened.17 In our experience, the study questionnaire shows a significant increase in knowledge about prevention, recognition and treatment of cardiac arrest in candidates who attend the ILS course. Of interest, a significant gap was observed at baseline between candidates currently working in ICUs and those who did not, while that difference was rectified
456 by the course, thus producing a homogeneous cultural background and shared protocols. Both these results are highly desirable in our clinical setting. Older candidates and those with a longer period of service scored significantly worse than younger candidates, both before and after the course. This is not entirely surprising, and may be explained by lack of professional update and motivation, prevalent assignment to settings where there was a low incidence of medical emergencies or a combination of the two. However, as older candidates may still be called to attend medical emergencies, alternative strategies should be developed to overcome this critical point. Questionnaires could be perceived as uncomfortable in this group of candidates and other assessment tools should be investigated; however, they improved their scores as well. In our study population, perceived frequency of attended cardiac arrests did not significantly influence the performance of candidates. This could generate the hypothesis that cardiac arrests were attended rather passively by our nurse population and that self-perceived experience is not enough to increase knowledge in absence of an educational program. However, better scores of candidates working in ICU showed how practice and confidence with critically ill patients rather than passive attendance to medical emergencies can make a difference even in knowledge. A systematic audit of attended cardiac arrests and team debriefing after interventions could help in using clinical experience as a more effective learning tool. Different attitude and increased awareness during emergencies after ILS course attendance should be verified prospectively. The absence of a significant influence of previous BLS certification on the performance of candidates may be the result of poor adherence to the recommended retraining frequency, educational content of the previous BLS course or both. Importance of ILS retraining is crucial and must be part of continuous training programmes. In our DCVM we are planning retraining sessions at 1-year intervals. The very low rate of failure in passing the course could be related to the lack of a formal testing station for practical skills in the course format.17 This aspect should be further investigated. In perspective, whether the knowledge improvement observed after ILS course implementation is associated with an improvement of skill deployment in real practice remains to be established and should be investigated prospectively.18,19 Recent evidence suggests that the implementation of the ILS course including automated external defibrillation training as part of a hospital wide resuscitation strategy can improve IHCA survival rates.20
A. Scapigliati et al.
Study limitations This was a single-centre study which included only nurses from a single clinical department. Therefore, it is possible that our results may not be similar when applied to other Italian contexts. A second pilot course for 300 practitioners of the Italian National Health Service is currently under way to test the applicability of ILS in a wider and different context.
Conclusion This first Italian experience shows that the ILS course format can be exported successfully outside the UK, translated and adapted to local needs. Our study supports the ILS course as a possible ‘‘fit-forpurpose’’ training format for those settings where nurses are expected to take part in prevention and recognition of cardiac arrest, summon help, give early treatment and actively join the ALS team that builds up at the patient’s bed. The course improves knowledge scores and abolishes knowledge differences due to different working backgrounds of candidates.
Acknowledgements Thanks to Peter Baskett, Jerry Nolan and Jasmeet Soar for prompting this experience; Leo Bossaert, Ralph Cosyn and Chantal Schoeters (ERC Secretariat, Antwerp, Belgium) for supporting our centre; Paul White, David Bushby and Dan Purnell (resuscitation officers of Chelsea and Westminster Hospital, London, United Kingdom) for welcoming us as observers; Concetta De Angelis (Head nurse, Policlinico A. Gemelli, Rome, Italy) and Maria Rosaria Ripa (education officer, Policlinico A. Gemelli, Rome, Italy) for helping in organisation; Jennifer Wykes (Italian Resuscitation Council) for language supervision.
References 1. Gwinnutt CL, Columb M, Harris R. Outcome after cardiac arrest in adults in UK hospital: effect of the 1997 guidelines. Resuscitation 2000;47:125—35. 2. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297—308. 3. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305—10.
The immediate life support (ILS) course — The Italian experience 4. Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal. Circulation 2005;111:428—34. 5. Kaye W, Mancini ME, Giuliano KK, et al. Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med 1995;25: 163—8. 6. Perkins GD, Soar J. In hospital cardiac arrest: missing links in the chain of survival editorial. Resuscitation 2005;66: 253—5. 7. Hulme J, Perkins GD, Baldock C, MacNamara A. Use of advanced life support skills. Resuscitation 2003;58:59—63. 8. Soar J, Perkins GD, Harris S, Nolan JP. The immediate life support course. Resuscitation 2003;57:21—6. 9. Baskett PJF, Nolan JP, Handley A, Soar J, Biarent D, Richmond S. European Resuscitation Council guidelines for resuscitation 2005. Section 9. Principles of training in resuscitation. Resuscitation 2005;67S1:S181—9. 10. Sandroni C, Ferro G, Santangelo S, et al. In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response. Resuscitation 2004;62:291—7. 11. Spearpoint KG, Mc Lean P, Zideman DA. Early defibrillation and the chain of survival in ‘in-hospital’ adult cardiac arrest: minutes count. Resuscitation 2000;44:165—9.
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12. Peberdy MA, Ornato JP. Post-resuscitation care: is it the missing link in the chain of survival? Resuscitation 2005;64: 135—7. 13. Sandroni C, Cavallaro F, Ferro G, et al. A survey of the inhospital response to cardiac arrest on general wards in the hospitals of Rome. Resuscitation 2003;56:41—7. 14. Nolan JP, Deakin CD, Soar J, B¨ ottiger BW, Smith G. Resuscitation Council guidelines for resuscitation. Section 4. Adult advanced life support. Resuscitation 2005;67S1:S39—86. 15. Chamberlain DA, Hazinski MF. Education in resuscitation an ILCOR symposium. Resuscitation 2003;59(1):11—43. 16. O’Higgins F, Ward M, Nolan J. Advanced life support skills undertaken by nurses—–UK survey. Resuscitation 2001;50: 45—9. 17. Cooper S. Immediate life support in a community setting: an evaluation. Resuscitation 2006;69(39) (Abstracts O-9). 18. Murphy M, Fitzsimons D. Does attendance at an immediate life support course influence nurses’ skill deployment during cardiac arrest? Resuscitation 2004;62:49—54. 19. Perkins GD, Soar J. Skill deployment and the ILS course. Letter to the Editor. Resuscitation 2005;64:245—6. 20. Spearpoint K, Root S, Treanor G, Zideman DA. Influence upon survival from in-hospital cardiac arrest; automated external defibrillators and the immediate life support course. Resuscitation 2006;69(66) (Abstracts O-70).
TRAINING AND EDUCATIONAL PAPER
The immediate life support (ILS) course — The Italian experience夽 Andrea Scapigliati a,∗, Tommaso Sanna a, Roberto Zamparelli a, Claudio Sandroni b, Christian Colizzi a, Peter Fenici b, Gabriella Arlotta a, Carmen Nuzzo a, Carmela Bonarrigo b, Fulvio Bellocci a, Rocco Schiavello a, Gianfederico Possati a a
Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy b Department of Emergency Medicine, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy Received 25 May 2006 ; received in revised form 20 July 2006; accepted 27 July 2006 KEYWORDS Cardiopulmonary resuscitation (CPR); Education; In-hospital CPR; Immediate life support (ILS); Training; Resuscitation
Summary Aim of the study: The 1-day immediate life support course (ILS) was started in the United Kingdom and adopted by the ERC to train healthcare professionals who attend cardiac arrests only occasionally. Currently, there are no reports about the ILS course from outside the UK. In this paper we describe our initial Italian experience of teaching ILS to nurses. We have also measured the impact that ILS has on the resuscitation knowledge of nurses. Methods: The ILS course materials were translated by Italian ALS instructors who had observed the ILS course previously in the UK. From March to November 2005 nurses from a single hospital department attended the Italian ILS course. Candidate feedback was collected using an evaluation form. The change in knowledge of candidates was measured using a pre- and post-course test. Variables associated with candidate performance on course papers were investigated using multivariate linear regression analysis. Results: A total of 119 nurses attended nine ILS courses. All candidates completed the course successfully and gave high evaluation scores. ILS produced a significant increase from pre- to post-course score (10.15 ± 2.75 to 13.19 ± 2.53, p < 0.001). The pre-course score was higher for nurses working in ICU compared with those coming from non-intensive wards, but this difference disappeared in the post-course evaluation (13.89 ± 2.18 versus 12.79 ± 2.65, p = ns).
夽 A Spanish translated version of the summary of this article appears as appendix in the final online version at 10.1016/j.resuscitation.2006.07.024 ∗ Corresponding author at: Institute of Anaesthesiology and Intensive Care, Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, L.go A. Gemelli 8, 00168 Rome, Italy. Tel.: +39 0630154507. E-mail address: [email protected] (A. Scapigliati).
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.07.024
452
A. Scapigliati et al. Conclusions: We have reproduced the ILS course in Italy successfully. ILS teaching resulted in an improvement in resuscitation knowledge of the first group of nurses trained. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction
Emergency response organization
Survival after in-hospital cardiac arrest (IHCA) is poor.1,2 Education in resuscitation for healthcare professionals (HCP) is one among several strategies suggested to improve survival rates after IHCA. In particular, improving the quality and efficacy of interventions performed by HCPs who may be called to attend IHCA as ‘‘first responders’’3,4 is expected to reinforce the ‘‘in-hospital chain of survival’’.5,6 However, current restrictions on resources for training and evidence encouraging an appropriate tailoring of educational contents to the real needs of candidates suggest a ‘‘fit for purpose’’ training format.7 The immediate life support (ILS) course was developed and implemented in the United Kingdom (UK) to improve and standardise knowledge and skills in HCPs who attend cardiac arrests only occasionally. The ILS course teaches candidates the initial treatment of cardiac arrest (CA) patients until the resuscitation team arrives and also how to be active members of the team.8 The ILS course has been adopted by the European Resuscitation Council (ERC).9 At the time of this study there are no reports about ILS from outside the UK. This study was designed to replicate the ILS format in Italy and to evaluate the effect of ILS on the resuscitation knowledge of candidates.
As opposed to all other areas of the hospital that rely on a hospital cardiac arrest team,10 the DCVM area has no cardiac arrest team. For emergencies requiring life support that occur in the DCVM, the ward nurse or other healthcare bystanders call the physician on duty and the anaesthesiologist who is present constantly in the CSICU using a digital enhanced cordless telephone (DECT). If necessary, cardiopulmonary resuscitation (CPR) is started by the first healthcare bystanders and, after the arrival of the anaesthesiologist, a resuscitation team is formed at the victim’s bed using participating ward staff. During cardiac arrest management, the anaesthesiologist acts as team leader while physicians and nurses on duty in the ward usually play as ALS team members. All areas of the DCVM have full standardised resuscitation equipment including manual defibrillators. There were no automated external defibrillators (AED) at the time of the study. No retraining in CPR was required for nurses before implementation of the ILS course. Nurses were not trained in rhythm recognition. In the critical areas nurses were allowed to use manual defibrillators under medical supervision.
Methods Setting From March to November 2005, nurses working in the Department of Cardiovascular Medicine (DCVM) of ‘‘Agostino Gemelli’’ Hospital, Catholic University of the Sacred Heart, Rome, Italy, participated in the ILS course. At this time, 125 nurses were employed in the DCVM. The DCVM has 89 adult patient beds on the same floor including cardiology, cardiac surgery, and vascular surgery wards, a coronary care unit (CCU), a post-operative cardiac surgery intensive care unit (CSICU), invasive and non-invasive cardiology diagnostic laboratories, and cardiac and vascular surgery operating rooms.
The Italian ILS course The ILS course has been described previously.8 Briefly, ILS is a 1-day course delivered by ERC certified ALS instructors. ILS includes lectures, skill stations and scenario teaching tailored to the clinical roles of the candidates. A continual assessment process is used to test candidates knowledge and skills. With the support of the ERC and Italian Resuscitation Council (IRC), three experienced ALS instructors (A.S., T.S. and P.F.) attended an ILS course as observers in London (UK). Course material was translated into Italian with the approval of the ERC. The ILS courses were conducted according to the ERC ILS course regulations. The laryngeal mask airway (LMA) was only mentioned in our courses as it is not currently used for resuscitation in the study setting. A discussion about tracheal intubation and resuscitation drugs and delivery was included. The aim was to train all the nurses of the DCVM (125 candidates). Nine courses were planned from
The immediate life support (ILS) course — The Italian experience Table 1 naire
Contents evaluated through the question-
Contents Demographics and professional backgrounds Signs of clinical deterioration Chain of survival In-hospital BLS Cardiac arrest main drugs Equipment for endotracheal intubation Cardiac arrest rhythms
March to November 2005. Each course included nurses from every area of the DCVM. A mean of 13 candidates attended each course with an instructor/candidate ratio of 1 to 4—5. A multidisciplinary group including educational officers, physicians (anaesthesiologists and cardiologists) involved in resuscitation training and the nurse managers of the DCVM planned the training schedules. An initial pilot phase of five courses was planned to gain experience in conducting the ILS course. This was followed by a study phase of four courses. Provided a proportional representation of nurses from each division of the DCVM, candidates were assigned to the pilot phase (66/119) or to the study phase (53/119) by chance. In the study phase demographics and professional backgrounds and the knowledge improvement associated with ILS were evaluated by a preand post-course assessment form with 10 questions not provided in the original course format. The assessment form was designed to verify knowledge on the critical aspects of prevention, recognition and treatment of cardiac arrest and included multiple choice questions and open answer questions (Table 1). The highest possible score was 16. Course evaluation by all the attending candidates was tested by feedback forms provided with teaching material. The influence on pre- and post-course score of the following covariates was explored with linear multiple regression analysis: serving time as HCP, sex, high perceived frequency of attended cardiac arrests attended (defined as a perceived frequency of attended cardiac arrests of at least 1/month), previous BLS certification and current occupation in ICU.
Statistical analysis Normal distribution of explored variables was assessed with Shapiro—Wilk test. Variables showing normal distribution are presented as mean ± S.D. Variables not showing normal distribution are pre-
453
sented as median (range). Categorical variables are presented as proportions or percentages. An unpaired mean comparison of variables with normal distribution was performed with t-test for independent samples. A paired mean comparison of variables with normal distribution was performed with t-test for paired samples. Level of significance for all comparisons was set a p < 0.05. Multiple linear regression was performed with a backward elimination strategy with a significance cut-off for removal set at p < 0.05. Dummy coding was operated in the case of nominal variables with multiple levels. Assumptions of multiple linear regression on covariates, on residuals, on specification error and measurements were verified.
Results A total of 119 candidates attended the course. Six candidates did not participate due to personal reasons. Age, sex and place of work of the candidates are presented in Table 2. All the participants completed the ILS course successfully, meeting the required standards. Feedback form results are summarised in Table 3. All candidates who answered the form expressed high evaluation scores on course format and contents; in particular they would recommend the course to their colleagues. In the study group (53/119 candidates), the median service time as a nurse was 11 years (range 1—35), 19/53 worked in an intensive care unit (10 in coronary care unit, nine in cardiac surgery intensive care unit) and 34/53 in ordinary wards or cardiology diagnostic labs (21 in cardiology, cardiac surgery and vascular surgery wards, two in non-invasive cardiology labs, five in invasive cardiology labs and six in the cardiac and vascular surgery operating room). Only 20 of 53 NMHCP who underwent the ILS
Table 2 Baseline characteristics of candidates (n = 119) attending the ILS course Characteristic of candidates Age (years) Mean ± S.D.
40 ± 9
Sex Male Female
30 (25.21%) 89 (74.79%)
Place of work Intensive care unit Wards Operating rooms Diagnostic cardiology laboratories
40 48 13 18
(33.61%) (40.34%) (10.92%) (15.13%)
454 Table 3
A. Scapigliati et al. Selected items from feedback forms
Items
Scores
Was the ILS course useful to you? Was the manual useful to attend the course? Would you recommend this course to your colleagues?
Missing
1/5
2/5
3/5
4/5
5/5
— — —
— 1.7 —
— 3.4 —
2.6 6.8 —
84.6 71.8 83.8
12.8 16.3 16.2
Results are presented as percentages.
course had received a formal BLS certification previously (median 2.5 years before [range 1—10]). The perceived frequency of attended cardiac arrests was 1/week for 13/53 candidates, 1/month for 7/53, more than 2/year for 26/53, 1—2/year for 5/53 and less than 2/year for 2/53 (Table 4). In the study group, the ILS course produced a significant improvement in cardiac resuscitation knowledge, as documented by an increase from pre- to post-course score from 10.15 ± 2.75 to 13.19 ± 2.53 (p < 0.001) (Figure 1). While a significant difference of baseline cardiac resuscitation knowledge had been observed between nurses who worked in an intensive care unit as compared to those who did not (pre-course score 11.74 ± 2.08 versus 9.26 ± 2.71, p = 0.001), this difference disappeared after ILS course (post-course score 13.89 ± 2.18 versus 12.79 ± 2.65, p = ns) (Figure 2). Pre-course score was positively correlated with the current occupation in ICU of candidates (standardised beta 0.39, p = 0.002; model R = 0.52, R2 = 0.27) and negatively correlated with serving time (standardised beta −0.29, p = 0.022; model R = 0.52, R2 = 0.27) but not with sex, perceived frequency
Table 4
Figure 1 Questionnaire score in the study group before and after the course.
Characteristics of the study group
Male Median age (years) Median service time (years) Place of work ICU General ward Diagnostic laboratories Invasive laboratories Operating theatre Former BLS/AED training Years before ILS course (median) (years) Perceived CA frequency 1/week 1/month >1—2/year 1—2/year <1—2/year
16/53 (30%) 36 (24—63) 11 (1—35) 19 (36%) 21 (40%) 2 (4%) 5 (9%) 6 (11%)
Figure 2 Score related to the place of work of the study group candidates before and after the course.
of attended cardiac arrests and previous BLS certification. Post-course score was negatively correlated with serving time (standardised beta −0.44, p = 0.001; model R = 0.44, R2 = 0.19) but not with sex, frequency of attended cardiac arrests, previous BLS certification and current occupation in ICU.
20 (38%) 2.5 (1—10)
Discussion 13 (24.5%) 7 (13.2%) 26 (49.1%) 5 (9.4%) 2 (3.8%)
Prevention, recognition and immediate treatment of CA by ward HCP are critical aspects in improving IHCA prognosis.10—12 An Italian study which investigated several hospitals in Rome has shown how ward staff BLS skills and attitudes to cooperate with car-
The immediate life support (ILS) course — The Italian experience diac arrest team (CAT) during the ALS phase were perceived as unsatisfactory by CAT members.13 In general wards, nurses are likely to be the most common bystanders of patients suffering CA since they are usually closer to patients in terms of space and time. However, the lesser frequency of medical emergencies in this setting is likely to lead to a lower level of experience and skills just in those who should recognize clinical deterioration, summon the appropriate help and initiate effective CPR. Furthermore, resource restrictions or local policies limit availability of emergency-dedicated staff in many hospitals. For example, in our department, which can be considered as a ‘‘micro-system’’ within the hospital system, there is no dedicated CAT, and the cardiac arrest team is built up at the patient’s bed after arrival of the anaesthesiologist, who acts as team leader. Therefore, healthcare providers who initially performed BLS are requested to become active team members and should have appropriate knowledge and skills to participate effectively in the ALS team.14 Therefore, educational programmes for HCP aiming at increasing knowledge and skills to prevent, recognise and treat IHCA effectively are expected to reinforce the in-hospital ‘‘chain of survival’’ and ultimately to improve outcomes. According to the ILCOR Symposium on Education in Resuscitation, training strategy should be tailored to the settings, specific roles and educational background of the learners.15 To be as closefitting to the authentic learners practice, training in mock scenarios should reach a good compromise of professional-based skills stations (e.g., nurses learn to do what nurses are expected to really do) followed by multidisciplinary teamwork that offers different useful perspectives. In this way learners are enabled to do what is suitable with their own role but at the same time they become aware of what other professionals have to do as well. While planning on this basis a ‘‘fit for purpose’’ resuscitation training programme intended for HCP of our Department, we considered the educational content of the current BLS course as inadequate for our needs. Prevention of cardiac arrest, airway management with adjuncts and bag-valve ventilation, ALS universal algorithm, drug preparation and their delivery are not covered by this training course. On the other hand, the ALS course is intended for training of ALS team leaders and provides an excessive load of learning input; far from real life roles, the course seemed to have a little impact on daily practice in terms of skills deployment,7 especially for nurses.16 Moreover, ALS is a 2—3-
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day course requiring large availability of human resources and impact on duty time: in our experience it was not suitable for an extensive training programme according to the requests of our institution’s managers. To fill the ‘‘no course land’’ between BLS and ALS formats, the ILS course has been recently proposed8,9 as a new educational tool to provide training in resuscitation to HCPs who occasionally attend cardiac arrest and who are not expected to be leader or usual members of a cardiac arrest team but who can start CPR as first responders and then participate in ALS as team members. The ILS format offers the advantage of expanding the core issues of BLS courses in a 1-day course with clear advantages in terms of human and economic resource allocation compared to a full 3-day ALS course. At the time of the study, we could not find published reports of ILS courses run outside UK. Replication of the ILS course in our institution required participation of three instructors as observers of a course in the UK and translation of the course material. The total time required for the entire process was about 5 weeks. Adaptation of the course programme to our candidate profile was an option already included in the course format and did not require special modifications. The 1-day format and the presence of a small number of nurses (two to four) from each area of the DCVM limited the impact of the course on service delivery. All candidates gave high evaluation scores and would recommend the course to colleagues. This suggests that the course meets candidates’ expectations and their perceived educational needs. Both course results (in terms of skills performance) and the course questionnaire showed that the ILS course was successful in achieving a satisfactory and homogeneous level of skills and knowledge in our candidates’ population. This aspect seems to be confirmed by a recent study in a community setting in the UK in which a quantitative and qualitative course evaluation was undertaken at the start of the course, and at the end and at 6 months; a significant knowledge improvement was observed in a candidate sample between the preand post-course test and no significant knowledge decline was found by 6 months while skills were worsened.17 In our experience, the study questionnaire shows a significant increase in knowledge about prevention, recognition and treatment of cardiac arrest in candidates who attend the ILS course. Of interest, a significant gap was observed at baseline between candidates currently working in ICUs and those who did not, while that difference was rectified
456 by the course, thus producing a homogeneous cultural background and shared protocols. Both these results are highly desirable in our clinical setting. Older candidates and those with a longer period of service scored significantly worse than younger candidates, both before and after the course. This is not entirely surprising, and may be explained by lack of professional update and motivation, prevalent assignment to settings where there was a low incidence of medical emergencies or a combination of the two. However, as older candidates may still be called to attend medical emergencies, alternative strategies should be developed to overcome this critical point. Questionnaires could be perceived as uncomfortable in this group of candidates and other assessment tools should be investigated; however, they improved their scores as well. In our study population, perceived frequency of attended cardiac arrests did not significantly influence the performance of candidates. This could generate the hypothesis that cardiac arrests were attended rather passively by our nurse population and that self-perceived experience is not enough to increase knowledge in absence of an educational program. However, better scores of candidates working in ICU showed how practice and confidence with critically ill patients rather than passive attendance to medical emergencies can make a difference even in knowledge. A systematic audit of attended cardiac arrests and team debriefing after interventions could help in using clinical experience as a more effective learning tool. Different attitude and increased awareness during emergencies after ILS course attendance should be verified prospectively. The absence of a significant influence of previous BLS certification on the performance of candidates may be the result of poor adherence to the recommended retraining frequency, educational content of the previous BLS course or both. Importance of ILS retraining is crucial and must be part of continuous training programmes. In our DCVM we are planning retraining sessions at 1-year intervals. The very low rate of failure in passing the course could be related to the lack of a formal testing station for practical skills in the course format.17 This aspect should be further investigated. In perspective, whether the knowledge improvement observed after ILS course implementation is associated with an improvement of skill deployment in real practice remains to be established and should be investigated prospectively.18,19 Recent evidence suggests that the implementation of the ILS course including automated external defibrillation training as part of a hospital wide resuscitation strategy can improve IHCA survival rates.20
A. Scapigliati et al.
Study limitations This was a single-centre study which included only nurses from a single clinical department. Therefore, it is possible that our results may not be similar when applied to other Italian contexts. A second pilot course for 300 practitioners of the Italian National Health Service is currently under way to test the applicability of ILS in a wider and different context.
Conclusion This first Italian experience shows that the ILS course format can be exported successfully outside the UK, translated and adapted to local needs. Our study supports the ILS course as a possible ‘‘fit-forpurpose’’ training format for those settings where nurses are expected to take part in prevention and recognition of cardiac arrest, summon help, give early treatment and actively join the ALS team that builds up at the patient’s bed. The course improves knowledge scores and abolishes knowledge differences due to different working backgrounds of candidates.
Acknowledgements Thanks to Peter Baskett, Jerry Nolan and Jasmeet Soar for prompting this experience; Leo Bossaert, Ralph Cosyn and Chantal Schoeters (ERC Secretariat, Antwerp, Belgium) for supporting our centre; Paul White, David Bushby and Dan Purnell (resuscitation officers of Chelsea and Westminster Hospital, London, United Kingdom) for welcoming us as observers; Concetta De Angelis (Head nurse, Policlinico A. Gemelli, Rome, Italy) and Maria Rosaria Ripa (education officer, Policlinico A. Gemelli, Rome, Italy) for helping in organisation; Jennifer Wykes (Italian Resuscitation Council) for language supervision.
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