European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation

doi:10.1016/j.resuscitation.2015.07.032

Resuscitation

Volume 95, October 2015, Pages 288-301

https://doi.org/10.1016/j.resuscitation.2015.07.032 Get rights and content

Introduction

The chain of survival¹ was extended to the formula of survival² because it was realised that the goal of saving more lives relies not only on solid and high quality science but also the effective education of lay people and healthcare professionals.³ Ultimately, those who are engaged in the care of cardiac arrest victims should be able to implement resource efficient systems that can improve survival after cardiac arrest.

This chapter incorporates the 17 key educational PICO-questions (Population–Intervention–Control–Outcome) that where reviewed by the Education, Implementation and Teams (EIT) Task Force of the International Liaison Committee on Resuscitation (ILCOR) from 2011 to 2015. This evidence review and evaluation process followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process described in the Consensus on Science and Training Recommendations 2015 (CoSTR).⁴ It summarises the new treatment recommendations for training and implementation. This chapter also covers the ERC basic principles of training and teaching of basic life support as well as advanced level life support. There is a strong focus on non-technical skills teaching (e.g. communication skills, team and leadership training). The ERC portfolio of courses is also included in this chapter, which ends with an outlook about educational resuscitation research and future course developments.

Delays in providing training materials and freeing staff for training were cited as reasons for delays in the implementation of the last guidelines.5, 6, 7 Therefore the ERC has carefully planned the translation and dissemination process for these guidelines and the teaching material for all courses to facilitate the implementation of the 2015 guidelines on resuscitation in a timely manner. This chapter provides the basis of a successful educational strategy for improved CPR education.

The following is a summary of the most important new reviews or changes in recommendations for education, implementation and teams since the ERC 2010 Guidelines:

•
High fidelity training manikins provide greater physical realism and their use is popular with learners. They are, however, more expensive than standard lower fidelity manikins. In centres that have the resources to purchase and maintain high fidelity manikins, we recommend their use. The use of lower fidelity manikins however is appropriate for all levels of training on ERC courses.
•
Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Tonal devices improve compression rates only and may have a detrimental effect on compression depth while rescuers focus on the rate. There is no current evidence to link tonal device use with improved outcomes following an ERC course.
•
The intervals for retraining will differ according to the characteristics of the participants (e.g. lay or healthcare). It is known that CPR skills deteriorate within months of training and therefore annual retraining strategies may not be frequent enough. Whilst optimal intervals are not known, frequent ‘low dose’ retraining may be beneficial.
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Training in non-technical skills (e.g. communication skills, team leadership and team member roles) is an essential adjunct to the training of technical skills. This type of training should be incorporated into life support courses.
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Ambulance service dispatchers have an influential role to play in guiding lay rescuers how to deliver CPR. This role needs specific training in order to deliver clear and effective instructions in a stressful situation.

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Data-driven performance-focused debriefing has been shown to improve performance of resuscitation teams. We highly recommend their use for teams managing patients in cardiac arrest,
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Regional systems including cardiac arrest centres are to be encouraged, as there is an association with increased survival and improved neurological outcome in victims of out-of-hospital cardiac arrest.
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The use of innovative technologies and social media can be beneficial for the deployment of rapid responders to victims of out-of-hospital cardiac arrest. Novel systems are also being developed to alert bystanders to the location of the nearest AED. Any technology that improves the delivery of swift bystander CPR with rapid access to an AED is to be encouraged.
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“It takes a system to save a life”. [http://www.resuscitationacademy.com/] Healthcare systems with a responsibility for the management of patients in cardiac arrest (e.g. EMS organisations, cardiac arrest centres) should evaluate their processes to ensure that they are able to deliver care that ensures the best achievable survival rates.

Section snippets

Who to train

Basic Life Support (BLS) is the cornerstone of resuscitation and it is well established that bystander CPR is critical to survival in out-of-hospital cardiac arrests. Chest compressions and early defibrillation are the main determinants of survival from an out-of-hospital cardiac arrest and there is some evidence that the introduction of training for lay people has improved survival at 30 days and 1 year.8, 9

For this reason a primary educational goal in resuscitation should be the training of

Advanced level training

Advanced level courses are mainly directed at healthcare personnel. In general, they cover the knowledge, skills and attitudes needed to function as part of (and ultimately lead) a resuscitation team.

Implementation and change management

The formula for survival concludes with ‘Local Implementation’.² The combination of medical science and educational efficiency is not sufficient to improve survival if there is poor or absent implementation. Frequently, this implementation will also require some form of change management to embed new visions into a local culture. Quite often, the ‘easy fix’ will not be the sustainable solution and prolonged negotiation and diplomacy may be needed. A prime example of this is the implementation

Impact of guidelines

In each country, implementation is largely based on the internationally agreed guidelines for cardiac resuscitation. National strategies for education are dependent upon evidence-based solutions to the management of cardiac arrest. The most important question, therefore, should be whether these guidelines actually result in any meaningful and improved outcomes. The authors freely acknowledge a conflict of interest here—if we prove that our guidelines have no tangible benefit then we call into

Cardiac arrest centres

In the last few years, regional healthcare systems have emerged for the management of conditions like stroke, major trauma, and myocardial infarction. These have mainly been driven by centralisation of limited resources as opposed to evidence of benefit from randomised trials. There is emerging evidence that the transport of patients with out-of-hospital cardiac arrest to a specialised cardiac arrest centre may be associated with improved neurologically intact survival.157, 158, 159, 160, 161,

Use of technology and social media

The prevalence of smartphones and tablet devices has led to the generation of numerous approaches to implementation through the use of ‘apps’ and also social media. These fall into several categories:

(1)
Simple delivery of information–apps that display resuscitation algorithms.
(2)
Interactive delivery of information–apps that use the geo-location of the user to display the location of the nearest AED.
(3)
Interactive delivery of education–apps that engage with the user and create an immersive and

Measuring performance of resuscitation systems

As systems evolve to improve the outcomes from cardiac arrest, we need to accurately assess their impact. This is particularly important for larger systems with multi-factorial components any of which may be beneficial either in isolation or combination. For example, it has already been shown that further work needs to be done to evaluate the impact of cardiac arrest centres.

Measuring performance and implementing quality improvement initiatives will further enhance systems to deliver optimal

Debriefing after resuscitation in the clinical setting

Feedback to members of an in-hospital cardiac arrest team about their performance in an actual cardiac arrest (as opposed to the training environment) can lead to improved outcomes. This can either be real-time and data-driven (e.g. use of feedback devices on cardiac compression metrics) or in a structured post event performance focused debrief.102, 182 The ideal approach to debriefing is yet to be determined, including the interval between actual performance and the debriefing event. Although

Medical emergency teams for adults

When considering the chain of survival for cardiac arrest,¹ the first link is the early recognition of the deteriorating patient and prevention of cardiac arrest. A considerable amount of work has been done to evaluate the role of the Medical Emergency Team (MET) in this respect. We recommend their use and, in particular, the use of higher intensity systems (e.g. higher MET calling rates, senior medical staff on the team) as their use has been associated with a reduced incidence of

Training in resource limited settings

There are many different techniques for teaching ALS and BLS in resource limited settings. These include simulation, multi-media learning, self-directed learning, limited instruction, and self-directed computer-based learning. Some of these techniques are less expensive and require less instructor resources than a traditional teaching format. Some techniques also enable wider dissemination of ALS and BLS training. It is reasonable to suggest the use of these strategies in resource limited

Training in ethics and first aid

Insights into training health care professionals about DNAR issues and approaches to practicing procedures on the newly deceased are provided in the Ethics chapter of the ERC guidelines 2015.¹⁹⁸ The First Aid chapter of the 2015 ERC Guidelines provides guidelines about first aid education and training programs as well as public health campaigns.¹⁹⁹

The ERC resuscitation course program

The ERC has developed a wide range of courses targeting all levels of providers, from basic life support for lay rescuers to advanced life support for health care providers. ERC courses teach the competences to undertake resuscitation in the clinical setting at the level that they would be expected to perform. Besides resuscitation skills, emphasis is given to non-technical skills and leadership training, application of ethical principles and advanced educational strategies as well as

European resuscitation academy (ERA)—“It takes a system to save a life”

The ERA aims to improve survival from cardiac arrest through a focus on healthcare system improvements that bring the individual links in the Chain of Survival and the Formula for Survival together. Entire EMS staff (managers, administrative and medical directors, physicians, EMTs and dispatchers) from different health care systems and countries are invited to learn from the ERA Program (derived from the Seattle (US) based Resuscitation Academy [http://www.resuscitationacademy.com/] ten steps

Future direction for research and course development

The production of international guidelines for resuscitation is a constantly evolving exercise. High quality research continues to be published with evidence that may or may not suggest that the guidelines of today are acceptable.

In parallel with this, the science of education also continues to evolve. Our methods for teaching these guidelines have changed substantially over the years from the early days of didactic theoretical delivery of teaching to contemporary interactive, hands-on methods

Conflicts of interest

Robert Greif	Editor for Trends in Anesthesia and Critical Care.
Andrew S. Lockey	Medical Advisor “First on Scene First Aid Company”.
Anne Lippert	No conflict of interest reported.
Koenraad G. Monsieurs	No conflict of interest reported.
Patricia Conoghan	No conflict of interest reported.
Wiebe De Vries	Training Organisation ACM employee.

Acknowledgement

The Writing Group acknowledges the significant contributions to this chapter by the late Sam Richmond.

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Effectiveness of a dispatcher-assisted cardiopulmonary resuscitation using an animated image: Simulation study
2024, American Journal of Emergency Medicine
Considering the few studies evaluating bystander cardiopulmonary resuscitation (CPR) performance, we sought to analyze differences in bystander CPR performance with and without the use of our self-developed animated GIFs based on dispatcher-assisted CPR simulation.
A total of 80 adults who had not received CPR training over the past two years participated in the study. Among them, 40 people were classified into the auditory group (receiving CPR instructions only over the phone), and the other 40 people were classified into the audiovisual group (receiving CPR instructions over the phone after receiving images on a smartphone). All participants were asked to perform adult and infant CPR for 2 min. CPR performance was recorded using two video cameras (front and side) and analyzed by two emergency physicians, whereas CPR quality was measured using Resusci Anne & Baby QCPR Mk II (Laerdal).
In the adult CPR study, the audiovisual group had higher performance scores for adequacy of “knee position,” “hand posture,” “elbow extension,” and “vertical compression,” as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). No significant difference in CPR quality was observed between the two groups. In the infant CPR study, audiovisual group had higher performance scores in adequacy of “compression site,” “finger posture,” and “vertical compression,” as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). Regarding CPR quality, the audiovisual group had higher scores for “adequate compression rate ratio” (p = 0.047).
Audiovisual guidance using animated GIFs more effectively improved CPR Standard Posture Completeness and Instruction Performance than did traditional auditory guidance.
Basic life support training for people with disabilities. A scoping review
2023, Resuscitation Plus
The integration of populations with various types of disabilities into basic life support (BLS) training programs could contribute to a potential increase in trained laypersons with BLS knowledge and, consequently, in survival rates. The objective of this study was to analyze the distinct educational methods which exist today on BLS for people with some type of specific disability, and to evaluate their impact on the quality of BLS maneuvers.
A scoping review in which the different training strategies in BLS for people with distinctive disabilities were analyzed was carried out. Previous studies were sought and researched in MEDLINE, EMBASE, and the Cochrane Library from the beginning up to 4 August 2023.
A total of 14 studies were thoroughly analyzed. The BLS training strategies for people with disabilities were classified according to the following criteria: objective (training, content validation or analysis of learning barriers), target population (visual, hearing, physical disabilities or Down syndrome), training resources (training with/without adaptation), contents (BLS and use of the automated external defibrillator) and evaluation instrument (i.e., the simulation test and knowledge questionnaire). The variety of BLS training programs for such population is limited. Likewise, people with different disabilities are able to effectively learn BLS maneuvers, although with mixed results, mainly in those regarding the CPR quality.
People with visual, hearing disabilities or Down syndrome are able to effectively learn BLS maneuvers.
Development and validation of the questionnaire on resuscitation-related knowledge and attitude for adolescents
2023, Evaluation and Program Planning
Team situational awareness in the context of hospital emergency: A concept analysis
2023, International Emergency Nursing
Successful management of in-hospital life threatening and emergency conditions require a well working, collaborative team. One of the vital skills that enhance team coordination of information and actions is team situational awareness (TSA). Although the concept of TSA has been long known in military and aviation settings, the concept has not been well investigated in the hospital emergency context.
This analysis was to explore the concept of “TSA” in the context of hospital emergency to explain its meaning for optimum understanding and use in clinical practice and future research.
TSA encompasses two types of situational awareness, each equally important: complementary (individual) and shared situational awareness (SA). The three defining attributes of complementary SA are the perception, comprehension, and projection, meanwhile, the three defining attributes of shared SA include: (1) information is clearly shared; (2) interpreted in the same way; and (3) the same projection of actions formed to guide expectation. Although, TSA is related to other terms in literature, there is increasing acknowledgment that the concept has an impact on team performance. Finally, the two types of TSA should be considered when assessing team performance
TSA is acknowledged in different fields requiring human control as a significant construct for team performance. Yet it needs to be examined in the emergency hospital context, systematically investigated and agreeably recognized as a fundamental factor in team performance.
Effect of a specific training intervention with task interruptions on the quality of simulated advance life support: A randomized multi centered controlled simulation study
2023, Australasian Emergency Care
Task interruptions (TI) are frequent disturbances for emergency professionals performing advanced life support (ALS). The aim of our study was to evaluate a specific training intervention with TI on the quality of simulated ALS.
During this multi centered randomized controlled trial, each team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or intervention (with TI). The primary outcome was non-technical skills assessed with the TEAM score. We also measured the no flow time, the Cardiff score and chest compression depth and rate.
On a total of 21 included teams, 11 were randomized to a control training session and 10 to the specific TI training. During training, teams’ characteristics and skills were similar between the two groups. During the evaluation session, the TEAM score was not different between groups: median score for control group 33,5 vs 31,5 for intervention group. We also report similar no flow time and Cardiff score.
In this simulated ALS study, a specific training intervention with TI did not improve technical and non-technical skills. Further research is required to limit the impact of TI in emergency settings.
RCParvulari training: A basic life support training methodology applied to 5-year-old students: Effectiveness in a cluster-randomized clinical trail
2023, Anales de Pediatria
La formación en soporte vital básico en edad escolar es un tema de actualidad, ya que, con una formación adecuada, todo individuo puede ayudar a salvar una vida.
Ensayo clínico por conglomerados basado en un cuestionario ad hoc, autoadministrable y semiestructurado. La población diana fueron alumnos de entre cuatro y seis años de 49 centros educativos. Los centros se aleatorizaron en grupo intervención y control. El grupo intervención recibió la metodología RCParvulari®, consistente en una formación teórico-práctica sobre el primer anillo de la cadena de supervivencia. El grupo control solo recibió una formación teórica. Los sujetos de estudio fueron evaluados preintervención, postintervención y entre tres y 12 meses después mediante un cuestionario. Se valoró adquisición y retención a lo largo del tiempo de la información recibida, en comparación con la formación previa en ambos grupos.
Participaron un total de 1.327 escolares (79% de la población diana). El nivel de conocimientos adquiridos inmediatamente después de la formación y pasados tres a 12 meses aumentó más respecto al basal en el grupo intervención que en el grupo control con diferencias significativas (p < 0,001), tanto al reconocer y llamar al número de emergencias 112, como al recordar la mnemotecnia «boca-nariz-ojos».
La metodología RCParvulari® contribuyó de forma significativa a mejorar la capacidad del alumnado de quinto curso de educación infantil para reconocer una eventual emergencia médica, poner en marcha la cadena de la supervivencia alertando a un adulto y llamando al número de emergencias 112.
Basic life support training in school age is a topical issue because, with adequate training, any person can help save a life.
Cluster clinical trial with data collection through an ad hoc self-administered, semi-structured questionnaire. The target population encompassed the students aged 4–6 years enrolled in 49 educational centres. The centres were randomly allocated to the intervention or control group. The intervention group was trained with the RCParvulari® methodology, consisting of theoretical and practical training on the first link of the chain of survival. The control group only received theoretical training. We evaluated participants before and immediately after the intervention and between 3 and 12 months post-intervention by means of the questionnaire. We assessed the acquisition and retention over time of the knowledge and skills covered in the training compared to previous trainings in both groups.
A total of 1327 schoolchildren (79% of the target population) participated. The level of knowledge acquired immediately after training and after 3–12 months compared to baseline was significantly better (P<.001) in the intervention group than in the control group, both in early recognition and contacting of emergency services (112) and in remembering the “mouth-nose-eyes” mnemonic.
The RCParvulari® methodology significantly contributed to an improved ability to recognize a possible medical emergency, start the chain of survival by alerting an adult and call the 112 emergency number in students in the last year of preschool education.

View all citing articles on Scopus

¹: The members of the Education and implementation of resuscitation section Collaborators are listed in the Collaborators section.

View full text

European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation

Introduction

Section snippets

Who to train

Advanced level training

Implementation and change management

Impact of guidelines

Cardiac arrest centres

Use of technology and social media

Measuring performance of resuscitation systems

Debriefing after resuscitation in the clinical setting

Medical emergency teams for adults

Training in resource limited settings

Training in ethics and first aid

The ERC resuscitation course program

European resuscitation academy (ERA)—“It takes a system to save a life”

Future direction for research and course development

Conflicts of interest

Acknowledgement

First page preview

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Scand J Trauma Resuscitation Emergency Med

Resuscitation

J Emergency Med

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

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Br J Anaesth

Resuscitation

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Lancet

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