European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation
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:
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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.
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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.
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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:
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Simple delivery of information–apps that display resuscitation algorithms.
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Interactive delivery of information–apps that use the geo-location of the user to display the location of the nearest AED.
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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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The members of the Education and implementation of resuscitation section Collaborators are listed in the Collaborators section.