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On the future of Basic Life Support training
Trends in Anaesthesia and Critical Care xxx (2017) 1e4
Contents lists available at ScienceDirect
Trends in Anaesthesia and Critical Care journal homepage: www.elsevier.com/locate/tacc
On the future of Basic Life Support training Nicolas Mpotos a, b, c, *, Robert Greif d, e a
Emergency Department, St. Lucas General Hospital, Groenebriel 1, B-9000 Ghent, Belgium Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium c Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium d Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, 3010 Bern, Switzerland e University of Bern, Bern 3010, Switzerland b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 August 2017 Accepted 3 October 2017
Most but not all of the steps of cardiopulmonary resuscitation (CPR) were known by 1900. They were however not implemented because established opinion leaders feared change at that time; researchers in laboratories, clinicians, and rescuers did not communicate their findings resulting in no one putting together effective steps for a lifesaving approach to the sudden cardiac arrest [1]. By discussing the training strategies and contents, the present opinion paper aims to highlight the parallels with basic life support (BLS) training and future potentials for the 21st century. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Basic Life Support Cardiopulmonary resuscitation Education Training Standards
The title of this article is adapted from a presentation entitled “on the future of reanimatology” given at the 1999 Society for Academic Emergency Medicine annual meeting by Dr. Peter Safar [2]. He presented a brief history of past accomplishments, recent findings, and future potentials for resuscitation research. Dr. Safar recalled that by 1900, most but not all of the steps of cardiopulmonary resuscitation (CPR) were known. They were however not implemented because, in his words “dictatorial professors” feared change; researchers in laboratories, clinicians, and rescuers did not communicate their experiences with the result that no one was able to put together an effective system of lifesaving steps [1]. In this present opinion paper we aim to discuss parallels with CPR training and future potentials for the 21st century. Nearly 55 years have passed since cardiologist Leonard Scherlis started the American Heart Association's CPR Committee in 1963, and in the same year, the American Heart Association (AHA) formally endorsed CPR. Since then not only the AHA but also other international and national organizations have set up educational systems to teach lifesaving techniques effectively. However, over many decades the survival of patients after cardiac arrest did not change that much despite the introduction of new drugs, resuscitation techniques, and better organized rescue systems.
* Corresponding author. St. Lucas General Hospital, Emergency Department, Groenebriel 1, B-9000 Ghent, Belgium. E-mail address: [email protected] (N. Mpotos).
On the other hand we observed that over more then 20 years several alternatives to instructor-led Basic Life Support (BLS) training, such as self-instruction using videos or digital versatile discs (DVDs) with or without a manikin [3,4], the use of automated voice feedback [5,6], computers [7], electronic flashcards [8], peer learning with apps [9], micro-simulation [10], micro-trainings [11], repetitive automated testing [12] were investigated in an attempt to improve CPR quality. Several of these educational interventions are superior or equal to traditional BLS courses which in general last a couple of hours (including didactic lectures and some hands-on training). Despite those diverse training alternatives, BSL skills are still poorly acquired and retention deteriorates in as little as three to 6 months [13]. Perhaps the answer to better skill acquisition and retention lies in the training strategy rather then the training method. Already in 2010, the Consensus of Science and Treatment Recommendation Statement (CoSTR) of the International Liaison Committee on Resuscitation which inspired the publication of the European Resucitation Council's (ERC) guidelines, mentioned that training should be tailored to the needs of different types of learners and learning styles to ensure acquisition and retention of skills [14,15]. Despite this knowledge, initial BLS training continues to be a “once and done or single learning” strategy, often without measurable educational objectives to attain beyond the level 1 in the Kirkpatrick Model (Fig. 1). Some students learn very fast and need only a bit of guidance, while others learn slowly and need hard work, regular attention
https://doi.org/10.1016/j.tacc.2017.10.061 2210-8440/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Mpotos, R. Greif, On the future of Basic Life Support training, Trends in Anaesthesia and Critical Care (2017), https://doi.org/10.1016/j.tacc.2017.10.061
2
N. Mpotos, R. Greif / Trends in Anaesthesia and Critical Care xxx (2017) 1e4
Fig. 1. Kirkpatrick Model. (http://www.kirkpatrickpartners.com/Our-Philosophy/The-New-World-KirkpatrickModel).
and lot of supervision and input from a dedicated teacher. Different students have different learning attitudes and learning habits, but it's obvious that a “one size fits all” strategy or a “once and done single learning” strategy will only suit the fast and maybe only the bright learners. However, if international CPR organizations really want to increase survival, educational strategies need to address all citizens including a large group of “slower” learners. If their learning needs are not addressed properly, all the efforts will result in poor skill acquisition and in term even less retention. By adopting 21st century educational strategies with straight forward learning and evaluation objectives, strategies such as selfinstruction allowing multiple training opportunities, organising shorter but more frequent BLS training refreshers aiming at the mastery of BLS skills, the quality of resuscitation performance in real life could be increased. It has been shown that low level short BLS training sessions for a very broad population was likely to improve the BLS performance and resulting in better survival rates [16e18]. In addition to the training strategy and despite the international recommendations to retrain BLS skills at least once a year, retraining intervals are often much longer [19]. In fact many official instances, such as accreditation organisms or training organizations, are satisfied with 2 year or even longer retraining intervals. Most of the time logistic impairments, the large amount of personnel to train in BLS, finding time in a busy work schedule or financial matters are the barriers to prevent more frequent training. The use of more frequent (automated) assessments could identify those individuals who require refresher training to help maintain their knowledge and skills [5,11,12,20e22]. An equally important shortcoming of most training strategies is the fact that they generally focus on the “visible outcome of learning”, knowledge and skills, which is the part being certified and known to others. The “invisible outcomes” like attitude towards helping others, first aid and BLS is rarely approached. Especially when targeting larger populations like school children, first responders, security and rescue personnel, building a strong base for these “invisible” attitudes form the backbone for the effective acquisition of knowledge and skills. Adopting these “positive” attitudes is broader then performing BLS skills alone, but also need to focus on prevention of cardiac arrest, such as healthy life style and early recognition of pre-arrest situations. Ideally this education starts at school and should be perceived as a social responsibility [23]. Breckwoldt and colleagues, reviewing 20 BLS courses in Berlin found that on the one hand teachers did not always comply to the current guidelines and on the other hand that there was insufficient emphasis on reducing fear to act in a real time situation [24]. The open question is how to overcome that? Several attempts to hold world records in mass BLS training are examples of disseminating knowledge and/or skills on a very large scale. By mediatising the topic they contribute to facilitate and increase awareness and shape the right attitudes to immediately help persons needing help without prejudice. The Danish experiment of
mass distribution of manikins among schoolchildren is another example of getting beyond “simple” skills training. In this experiment a substantial observed multiplier effect demonstrated the potential of mass education and dissemination of knowledge [25]. Furthermore, a targeted media campaign together with widespread education can significantly increase the willingness to use an AED, and increase the confidence in providing chest compressions and mouth-to-mouth ventilations [26]. In this trial Nielsen and colleagues reported that almost all participants with a BLS course in the past 5 years had a significantly greater willingness to perform BLS including the use of an AED. In a 3-year follow-up period after that intervention, the authors observed a persistent significant increase in the bystander BLS rate, however without significant difference in 30-day survival [27]. After discussing the strategy to teach knowledge and skills and shaping the right attitudes towards CPR, we also need to look into the BLS course content. Despite the recommendation for 30:2 CPR, compression-only CPR has been advocated as a preferable approach for bystanders since the elimination of mouth-to-mouth ventilation addresses some of the barriers to performing CPR [28]. A recent review on chest-compression-only CPR confirms it is faster to initiate CPR and delivers more compressions, however compressions are often shallower due to fatigue and the long term skill retention is unclear [29]. Since the confidence in the equivalence between chest compression-only and standard CPR is not sufficient to change current practice to compression only CPR, the ERC recommend the teaching of 30:2 CPR [13]. Only when a bystander has not been trained in adult CPR, the emergency medical dispatcher should instruct him or her to give chest-compressiononly CPR while awaiting the arrival of professional help [30]. Proper compression depth of at least 5 cm is the major determinant of survival after cardiac arrest [31,32]. However, most teaching strategies do not measure the achieved depth in an objective way and more important, no predefined bench of “good quality” is defined (e.g. proportion of compressions with adequate depth or effective compression ratio) [33e36]. Multiple repetitive formative tests were able to train people to a predefined success level and even although there was a small decay in skills after 5 months, compression depth was still adequate in 80% of the participants [12,37]. Other authors also described the efficiency of rapid cycle deliberate practice or training based on mastery learning principles [38,39]. Combining such strategies of multiple short sessions, together with objective measurements and straight forward learning outcomes might ultimately result in better acquisition and retention of BLS skills for every type of learner. Furthermore, by translating the principles of mastery learning into a CPR game with multiple short gaming levels which gradually train people to a good level of CPR quality, new technologies might offer a perspective to overcome the deficits of traditional approaches. In the 1950's Don Kirkpatrick proposed to rank the result of education in a model which is in the meantime used worldwide as the standard evaluation of training effectiveness. At the lowest level 1 it rates the reaction of participants response to the training. Level 2 “Learning” measures if they actually learned the material. Level 3 “Behaviour” considers if they are using what they learned on the job, and Level 4 “Results” evaluates if the training positively impacted the organization. The model is applied before, during and after training to both maximize and demonstrate training's value to the organization. All of our work is based on the sound principles of the updated Kirkpatrick Model e the “New World Kirkpatrick Model” (Fig. 1): Level 1 or reaction: measures the degree to which participants find the training favourable and relevant for their job. How they
Please cite this article in press as: N. Mpotos, R. Greif, On the future of Basic Life Support training, Trends in Anaesthesia and Critical Care (2017), https://doi.org/10.1016/j.tacc.2017.10.061
N. Mpotos, R. Greif / Trends in Anaesthesia and Critical Care xxx (2017) 1e4
are engaged and involved in the learning and can contribute to the process. Level 2 or learning: based on the participation of learners observed in level 1, this level measures the degree of acquired knowledge, skills, attitude, confidence and commitment that was intended. Level 3 or behaviour: measures how participants apply what they learned being back on their jobs. Processes and systems that reinforce, encourage and reward performance of critical behaviours on the job are driving forces. Level 4 or results of the training occur as targeted including support and accountability package. Short-term observations and measurements of critical behaviours are creating a positive impact on desired results. A weak point in education is to achieve the right skill level after teaching, training and testing. How are CPR teachers and teaching institutions going to predict what the real-life performance during cardiac arrest will be, especially in first responders and lay people [40]. We not only want that these lay persons act fast by recognising cardiac arrest and start bystander CPR, we know by now these fast actions are a key element to improve survival in out-ofhospital cardiac arrest. Ideally their CPR must be of good quality if it wants to make that difference. However, as these first responders are often not professionals and it is a difficulty to oblige them to achieve and maintain an expected CPR-performance standard, we and overall the victims of sudden cardiac arrest can be happy when bystanders do whatever they can [40]. Therefore, the 2015 international resuscitation guidelines and the ILCOR consensus on science and treatment recommendations emphasise on the emergency services dispatchers telephone instructed CPR and the community response to save lives by installing first responders networks [13,41]. Performing immediate CPR and early defibrillation requires awareness of the emergency situation and an early call for help. In this model the emergency system dispatcher becomes the coach triggering the right attitudes and actions just in time by phone contact. Perhaps this action we should also consider as “just in time training”, coupled with new technologies could provide new perspectives to on the spot education and at the same time an improvement of CPR quality. An important step would be a proper debriefing after such telephone instructed and taught CPR to improve the learning impact on the rescuer side as well as on the dispatcher side. So, these phone instructions and other mass training in CPR has a substantial potential impact on triggering a positive attitude towards helping others in emergencies and hopefully raising bystander rates, its quality and long term impact on survival remains unclear. In conclusion current methods to learn and maintain BLS are poorly adapted to individual learners and they do not really contain strategies for long-term skill mastery in all kind of learners. Considering the very large number of people who should be trained annually in BLS, ranging from health care providers to first responders at work, teachers, youth workers, firemen, safety staff and in the end every active member of the community, there is real need for changes. Bringing existing educational knowledge and efficient alternative training strategies together the entire CPR education could be more effective, requiring less training time, less time away from the job, family or friends and consequently having increased cost-saving benefits. Another future challenge consists in determining the content and educational strategy for BLS mass education. This should result in emphasizing and triggering the right attitudes during training by enabling participants to help in real emergencies. With a rigorous study methodology and standardized performance measures, we
3
should continue the journey to develop the most appropriate CPR training strategy for everyone. References [1] P. Safar, On the history of modern resuscitation, Crit. Care Med. 24 (1996) S3eS11. [2] P. Safar, On the future of reanimatology, Acad. Emerg. Med. 7 (2000) 75e89. [3] K.H. Todd, A. Braslow, R.T. Brennan, et al., Randomized, controlled trial of video self-instruction versus traditional CPR training, Ann. Emerg. Med. 31 (1998) 364e369. [4] B. Lynch, E.L. Einspruch, G. Nichol, L.B. Becker, T.P. Aufderheide, A. Idris, Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study, Resuscitation 67 (2005) 31e43. [5] L. Wik, H. Myklebust, B.H. Auestad, P.A. Steen, Twelve-month retention of CPR skills with automatic correcting verbal feedback, Resuscitation 66 (2005) 27e30. [6] D. Hostler, H. Wang, K. Parrish, T.E. Platt, G. Guimond, The effect of a voice assist manikin (VAM) system on CPR quality among prehospital providers, Prehosp Emerg. Care 9 (2005) 53e60. [7] S. Reder, P. Cummings, L. Quan, Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students, Resuscitation 69 (2006) 443e453. [8] R. Schmidmaier, R. Ebersbach, M. Schiller, I. Hege, M. Holzer, M.R. Fischer, Using electronic flashcards to promote learning in medical students: retesting versus restudying, Med. Educ. 45 (2011) 1101e1110. [9] P. Iserbyt, N. Charlier, L. Mols, Learning basic life support (BLS) with tablet PCs in reciprocal learning at school: are videos superior to pictures? A randomized controlled trial, Resuscitation 85 (2014) 809e813. [10] K.G. Monsieurs, C. Vogels, L.L. Bossaert, et al., Learning effect of a novel interactive basic life support CD: the JUST system, Resuscitation 62 (2004) 159e165. [11] D. Niles, R.M. Sutton, A. Donoghue, et al., “Rolling Refreshers”: a novel approach to maintain CPR psychomotor skill competence, Resuscitation 80 (2009) 909e912. [12] N. Mpotos, B. De Wever, N. Cleymans, et al., Repetitive sessions of formative self-testing to refresh CPR skills: a randomised non-inferiority trial, Resuscitation 85 (2014) 1282e1286. [13] R. Greif, A.S. Lockey, P. Conaghan, et al., European resuscitation Council guidelines for resuscitation 2015. Section 10. Education and implementation of resuscitation, Resuscitation 95 (2015) 288e301. [14] J.P. Nolan, M.F. Hazinski, J.E. Billi, et al., Part 1: executive summary, Resuscitation 81 (2010) e1ee25. [15] J. Soar, M.E. Mancini, F. Bhanji, et al., Part 12: education, implementation, and teams, Resuscitation 81 (2010) e288ee332. [16] R.R. Seethala, E.C. Esposito, B.S. Abella, Approaches to improving cardiac arrest resuscitation performance, Curr. Opin. Crit. Care 16 (2010) 196e202. [17] M. Wissenberg, F.K. Lippert, F. Folke, et al., Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest, JAMA 310 (2013) 1377e1384. [18] K. Kragholm, M. Wissenberg, R.N. Mortensen, et al., Bystander efforts and 1year outcomes in out-of-hospital cardiac arrest, N. Engl. J. Med. 376 (2017) 1737e1747. [19] T. Verplancke, P. De Paepe, P.A. Calle, M. De Regge, G. Van Maele, K.G. Monsieurs, Determinants of the quality of basic life support by hospital nurses, Resuscitation 77 (2008) 75e80. €fling, et al., Public access resuscitation program [20] D. Andresen, H.R. Arntz, W. Gra including defibrillator training for laypersons: a randomized trial to evaluate the impact of training course duration, Resuscitation 76 (2008) 419e424. [21] N. Castle, H. Garton, G. Kenward, Confidence vs competence: basic life support skills of health professionals, Br. J. Nurs. 16 (2007) 664e666. [22] J. Christenson, S. Nafziger, S. Compton, et al., The effect of time on CPR and automated external defibrillator skills in the Public Access Defibrillation Trial, Resuscitation 74 (2007) 52e62. €ttiger, F. Semeraro, S. Wingen, “Kids save lives”: educating school[23] B.W. Bo children in cardiopulmonary resuscitation is a civic duty that needs support for implementation, J. Am. Heart Assoc. 6 (2017) e005738. [24] J. Breckwoldt, C. Lingemann, P. Wagner, Reanimationstraining für Laien in Erste-Hilfe-Kursen: vermittlung von Wissen, Fertigkeiten und Haltungen, Anaesthesist 65 (2016) 22e29. [25] D.L. Isbye, L.S. Rasmussen, C. Ringsted, F.K. Lippert, Disseminating cardiopulmonary resuscitation training by distributing 35 000 personal manikins among school children, Circulation 116 (2007) 1380e1385. [26] A.M. Nielsen, D.L. Isbye, F.K. Lippert, L.S. Rasmussen, Can mass education and a television campaign change the attitudes towards cardiopulmonary resuscitation in a rural community? Scand. J. Trauma Resusc. Emerg. Med. 21 (2013) 39. [27] A.M. Nielsen, D.L. Isbye, F.K. Lippert, L.S. Rasmussen, Persisting effect of community approaches to resuscitation, Resuscitation 85 (2014) 1450e1454. [28] T. Shimamoto, T. Iwami, T. Kitamura, et al., Dispatcher instruction of chest compression-only CPR increases actual provision of bystander CPR, Resuscitation 96 (2015) 9e15.
Please cite this article in press as: N. Mpotos, R. Greif, On the future of Basic Life Support training, Trends in Anaesthesia and Critical Care (2017), https://doi.org/10.1016/j.tacc.2017.10.061
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[29] R.J. Min Ko, V.X. Wu, S.H. Lim, W.W. San Tam, S.Y. Liaw, Compression-only cardiopulmonary resuscitation in improving bystanders' cardiopulmonary resuscitation performance: a literature review, Emerg. Med. J. 33 (2016) 882e888. [30] K.G. Monsieurs, J.P. Nolan, L.L. Bossaert, et al., European resuscitation Council guidelines for resuscitation 2015, Resuscitation 95 (2015) 1e80. [31] I.G. Stiell, S.P. Brown, J. Christenson, et al., What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?*, Crit. Care Med. 40 (4) (2012) 1192e1198. [32] I.G. Stiell, S.P. Brown, G. Nichol, et al., What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation 130 (2014) 1962e1970. [33] V. Wass, C. Van Der Vleuten, J. Shatzer, R. Jones, Assessment of clinical competence, Lancet 357 (2001) 945e949. €hler, B.S. Abella, Uniform [34] J. Kramer-Johansen, D.P. Edelson, H. Losert, K. Ko reporting of measured quality of cardiopulmonary resuscitation (CPR), Resuscitation 74 (2007) 406e417. [35] R. Greif, D. Stumpf, S. Neuhold, et al., Effective compression ratio-A new measurement of the quality of thorax compression during CPR, Resuscitation 84 (2013) 672e677.
[36] N. Mpotos, M. Valcke, C. Van der Vleuten, K. Monsieurs, Studies claiming efficacy of CPR training interventions: which skills should be assessed and how should data be reported to allow comparison? Resuscitation 83 (2012) e217; author reply e219. [37] N. Mpotos, K. Decaluwe, V. Van Belleghem, et al., Automated testing combined with automated retraining to improve CPR skill level in emergency nurses, Nurse Educ. Pract. 15 (2015) 212e217. [38] E.A. Hunt, J.M. Duval-Arnould, K.L. Nelson-McMillan, et al., Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training, Resuscitation 85 (7) (2014) 945e951. [39] J.H. Barsuk, E.R. Cohen, D.B. Wayne, V.J. Siddall, W.C. Mcgaghie, Developing a simulation-based mastery learning curriculum: lessons from 11 Years of advanced cardiac life support, Simul. Healthc. J. Soc. Simul. Healthc. 11 (2016) 52e59. [40] M.J. Hsieh, F. Bhanji, W.C. Chiang, C.W. Yang, K.L. Chien, M.H.M. Ma, Comparing the effect of self-instruction with that of traditional instruction in basic life support coursesda systematic review, Resuscitation 108 (2016) 8e19. [41] J.C. Finn, F. Bhanji, A. Lockey, et al., Part 8: education, implementation, and teams, Resuscitation 95 (2015) e203ee224.
Please cite this article in press as: N. Mpotos, R. Greif, On the future of Basic Life Support training, Trends in Anaesthesia and Critical Care (2017), https://doi.org/10.1016/j.tacc.2017.10.061
Contents lists available at ScienceDirect
Trends in Anaesthesia and Critical Care journal homepage: www.elsevier.com/locate/tacc
On the future of Basic Life Support training Nicolas Mpotos a, b, c, *, Robert Greif d, e a
Emergency Department, St. Lucas General Hospital, Groenebriel 1, B-9000 Ghent, Belgium Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium c Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium d Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, 3010 Bern, Switzerland e University of Bern, Bern 3010, Switzerland b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 17 August 2017 Accepted 3 October 2017
Most but not all of the steps of cardiopulmonary resuscitation (CPR) were known by 1900. They were however not implemented because established opinion leaders feared change at that time; researchers in laboratories, clinicians, and rescuers did not communicate their findings resulting in no one putting together effective steps for a lifesaving approach to the sudden cardiac arrest [1]. By discussing the training strategies and contents, the present opinion paper aims to highlight the parallels with basic life support (BLS) training and future potentials for the 21st century. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Basic Life Support Cardiopulmonary resuscitation Education Training Standards
The title of this article is adapted from a presentation entitled “on the future of reanimatology” given at the 1999 Society for Academic Emergency Medicine annual meeting by Dr. Peter Safar [2]. He presented a brief history of past accomplishments, recent findings, and future potentials for resuscitation research. Dr. Safar recalled that by 1900, most but not all of the steps of cardiopulmonary resuscitation (CPR) were known. They were however not implemented because, in his words “dictatorial professors” feared change; researchers in laboratories, clinicians, and rescuers did not communicate their experiences with the result that no one was able to put together an effective system of lifesaving steps [1]. In this present opinion paper we aim to discuss parallels with CPR training and future potentials for the 21st century. Nearly 55 years have passed since cardiologist Leonard Scherlis started the American Heart Association's CPR Committee in 1963, and in the same year, the American Heart Association (AHA) formally endorsed CPR. Since then not only the AHA but also other international and national organizations have set up educational systems to teach lifesaving techniques effectively. However, over many decades the survival of patients after cardiac arrest did not change that much despite the introduction of new drugs, resuscitation techniques, and better organized rescue systems.
* Corresponding author. St. Lucas General Hospital, Emergency Department, Groenebriel 1, B-9000 Ghent, Belgium. E-mail address: [email protected] (N. Mpotos).
On the other hand we observed that over more then 20 years several alternatives to instructor-led Basic Life Support (BLS) training, such as self-instruction using videos or digital versatile discs (DVDs) with or without a manikin [3,4], the use of automated voice feedback [5,6], computers [7], electronic flashcards [8], peer learning with apps [9], micro-simulation [10], micro-trainings [11], repetitive automated testing [12] were investigated in an attempt to improve CPR quality. Several of these educational interventions are superior or equal to traditional BLS courses which in general last a couple of hours (including didactic lectures and some hands-on training). Despite those diverse training alternatives, BSL skills are still poorly acquired and retention deteriorates in as little as three to 6 months [13]. Perhaps the answer to better skill acquisition and retention lies in the training strategy rather then the training method. Already in 2010, the Consensus of Science and Treatment Recommendation Statement (CoSTR) of the International Liaison Committee on Resuscitation which inspired the publication of the European Resucitation Council's (ERC) guidelines, mentioned that training should be tailored to the needs of different types of learners and learning styles to ensure acquisition and retention of skills [14,15]. Despite this knowledge, initial BLS training continues to be a “once and done or single learning” strategy, often without measurable educational objectives to attain beyond the level 1 in the Kirkpatrick Model (Fig. 1). Some students learn very fast and need only a bit of guidance, while others learn slowly and need hard work, regular attention
https://doi.org/10.1016/j.tacc.2017.10.061 2210-8440/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Mpotos, R. Greif, On the future of Basic Life Support training, Trends in Anaesthesia and Critical Care (2017), https://doi.org/10.1016/j.tacc.2017.10.061
2
N. Mpotos, R. Greif / Trends in Anaesthesia and Critical Care xxx (2017) 1e4
Fig. 1. Kirkpatrick Model. (http://www.kirkpatrickpartners.com/Our-Philosophy/The-New-World-KirkpatrickModel).
and lot of supervision and input from a dedicated teacher. Different students have different learning attitudes and learning habits, but it's obvious that a “one size fits all” strategy or a “once and done single learning” strategy will only suit the fast and maybe only the bright learners. However, if international CPR organizations really want to increase survival, educational strategies need to address all citizens including a large group of “slower” learners. If their learning needs are not addressed properly, all the efforts will result in poor skill acquisition and in term even less retention. By adopting 21st century educational strategies with straight forward learning and evaluation objectives, strategies such as selfinstruction allowing multiple training opportunities, organising shorter but more frequent BLS training refreshers aiming at the mastery of BLS skills, the quality of resuscitation performance in real life could be increased. It has been shown that low level short BLS training sessions for a very broad population was likely to improve the BLS performance and resulting in better survival rates [16e18]. In addition to the training strategy and despite the international recommendations to retrain BLS skills at least once a year, retraining intervals are often much longer [19]. In fact many official instances, such as accreditation organisms or training organizations, are satisfied with 2 year or even longer retraining intervals. Most of the time logistic impairments, the large amount of personnel to train in BLS, finding time in a busy work schedule or financial matters are the barriers to prevent more frequent training. The use of more frequent (automated) assessments could identify those individuals who require refresher training to help maintain their knowledge and skills [5,11,12,20e22]. An equally important shortcoming of most training strategies is the fact that they generally focus on the “visible outcome of learning”, knowledge and skills, which is the part being certified and known to others. The “invisible outcomes” like attitude towards helping others, first aid and BLS is rarely approached. Especially when targeting larger populations like school children, first responders, security and rescue personnel, building a strong base for these “invisible” attitudes form the backbone for the effective acquisition of knowledge and skills. Adopting these “positive” attitudes is broader then performing BLS skills alone, but also need to focus on prevention of cardiac arrest, such as healthy life style and early recognition of pre-arrest situations. Ideally this education starts at school and should be perceived as a social responsibility [23]. Breckwoldt and colleagues, reviewing 20 BLS courses in Berlin found that on the one hand teachers did not always comply to the current guidelines and on the other hand that there was insufficient emphasis on reducing fear to act in a real time situation [24]. The open question is how to overcome that? Several attempts to hold world records in mass BLS training are examples of disseminating knowledge and/or skills on a very large scale. By mediatising the topic they contribute to facilitate and increase awareness and shape the right attitudes to immediately help persons needing help without prejudice. The Danish experiment of
mass distribution of manikins among schoolchildren is another example of getting beyond “simple” skills training. In this experiment a substantial observed multiplier effect demonstrated the potential of mass education and dissemination of knowledge [25]. Furthermore, a targeted media campaign together with widespread education can significantly increase the willingness to use an AED, and increase the confidence in providing chest compressions and mouth-to-mouth ventilations [26]. In this trial Nielsen and colleagues reported that almost all participants with a BLS course in the past 5 years had a significantly greater willingness to perform BLS including the use of an AED. In a 3-year follow-up period after that intervention, the authors observed a persistent significant increase in the bystander BLS rate, however without significant difference in 30-day survival [27]. After discussing the strategy to teach knowledge and skills and shaping the right attitudes towards CPR, we also need to look into the BLS course content. Despite the recommendation for 30:2 CPR, compression-only CPR has been advocated as a preferable approach for bystanders since the elimination of mouth-to-mouth ventilation addresses some of the barriers to performing CPR [28]. A recent review on chest-compression-only CPR confirms it is faster to initiate CPR and delivers more compressions, however compressions are often shallower due to fatigue and the long term skill retention is unclear [29]. Since the confidence in the equivalence between chest compression-only and standard CPR is not sufficient to change current practice to compression only CPR, the ERC recommend the teaching of 30:2 CPR [13]. Only when a bystander has not been trained in adult CPR, the emergency medical dispatcher should instruct him or her to give chest-compressiononly CPR while awaiting the arrival of professional help [30]. Proper compression depth of at least 5 cm is the major determinant of survival after cardiac arrest [31,32]. However, most teaching strategies do not measure the achieved depth in an objective way and more important, no predefined bench of “good quality” is defined (e.g. proportion of compressions with adequate depth or effective compression ratio) [33e36]. Multiple repetitive formative tests were able to train people to a predefined success level and even although there was a small decay in skills after 5 months, compression depth was still adequate in 80% of the participants [12,37]. Other authors also described the efficiency of rapid cycle deliberate practice or training based on mastery learning principles [38,39]. Combining such strategies of multiple short sessions, together with objective measurements and straight forward learning outcomes might ultimately result in better acquisition and retention of BLS skills for every type of learner. Furthermore, by translating the principles of mastery learning into a CPR game with multiple short gaming levels which gradually train people to a good level of CPR quality, new technologies might offer a perspective to overcome the deficits of traditional approaches. In the 1950's Don Kirkpatrick proposed to rank the result of education in a model which is in the meantime used worldwide as the standard evaluation of training effectiveness. At the lowest level 1 it rates the reaction of participants response to the training. Level 2 “Learning” measures if they actually learned the material. Level 3 “Behaviour” considers if they are using what they learned on the job, and Level 4 “Results” evaluates if the training positively impacted the organization. The model is applied before, during and after training to both maximize and demonstrate training's value to the organization. All of our work is based on the sound principles of the updated Kirkpatrick Model e the “New World Kirkpatrick Model” (Fig. 1): Level 1 or reaction: measures the degree to which participants find the training favourable and relevant for their job. How they
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are engaged and involved in the learning and can contribute to the process. Level 2 or learning: based on the participation of learners observed in level 1, this level measures the degree of acquired knowledge, skills, attitude, confidence and commitment that was intended. Level 3 or behaviour: measures how participants apply what they learned being back on their jobs. Processes and systems that reinforce, encourage and reward performance of critical behaviours on the job are driving forces. Level 4 or results of the training occur as targeted including support and accountability package. Short-term observations and measurements of critical behaviours are creating a positive impact on desired results. A weak point in education is to achieve the right skill level after teaching, training and testing. How are CPR teachers and teaching institutions going to predict what the real-life performance during cardiac arrest will be, especially in first responders and lay people [40]. We not only want that these lay persons act fast by recognising cardiac arrest and start bystander CPR, we know by now these fast actions are a key element to improve survival in out-ofhospital cardiac arrest. Ideally their CPR must be of good quality if it wants to make that difference. However, as these first responders are often not professionals and it is a difficulty to oblige them to achieve and maintain an expected CPR-performance standard, we and overall the victims of sudden cardiac arrest can be happy when bystanders do whatever they can [40]. Therefore, the 2015 international resuscitation guidelines and the ILCOR consensus on science and treatment recommendations emphasise on the emergency services dispatchers telephone instructed CPR and the community response to save lives by installing first responders networks [13,41]. Performing immediate CPR and early defibrillation requires awareness of the emergency situation and an early call for help. In this model the emergency system dispatcher becomes the coach triggering the right attitudes and actions just in time by phone contact. Perhaps this action we should also consider as “just in time training”, coupled with new technologies could provide new perspectives to on the spot education and at the same time an improvement of CPR quality. An important step would be a proper debriefing after such telephone instructed and taught CPR to improve the learning impact on the rescuer side as well as on the dispatcher side. So, these phone instructions and other mass training in CPR has a substantial potential impact on triggering a positive attitude towards helping others in emergencies and hopefully raising bystander rates, its quality and long term impact on survival remains unclear. In conclusion current methods to learn and maintain BLS are poorly adapted to individual learners and they do not really contain strategies for long-term skill mastery in all kind of learners. Considering the very large number of people who should be trained annually in BLS, ranging from health care providers to first responders at work, teachers, youth workers, firemen, safety staff and in the end every active member of the community, there is real need for changes. Bringing existing educational knowledge and efficient alternative training strategies together the entire CPR education could be more effective, requiring less training time, less time away from the job, family or friends and consequently having increased cost-saving benefits. Another future challenge consists in determining the content and educational strategy for BLS mass education. This should result in emphasizing and triggering the right attitudes during training by enabling participants to help in real emergencies. With a rigorous study methodology and standardized performance measures, we
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