European Resuscitation Council Guidelines for Resuscitation 2015

14 Pages·2015·0.65 MB·English

by  Robert Greif

Resuscitation95(2015)288–301

ContentslistsavailableatScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines for Resuscitation 2015

Section 10. Education and implementation of resuscitation

RobertGreifa,∗,AndrewS.Lockeyb,PatriciaConaghanc,AnneLippertd,WiebeDeVriese,
Koenra adG.Mo nsieursf ,g, onbehalf oftheE ducationan dimp lementati onof

resuscitationsectionCollaborators1

aDepartmentofAnaesthesiologyandPainMedicine,UniversityHospitalBernandUniversityofBern,Bern,Switzerland
bEmergencyD ep artment,Calder dale Roya lHospital, Halifax,Sa lterhebbl eHX3 0PW ,UK
cSchoolofNu rsing,Midwi fery&Soci alWor k,TheUn iversity ofMancheste r,Ma nche ster,UK
dDanish In stitutefo rMedicalS im ulatio n,Cen terf orHR,Capi tal RegionofDe nmark,Cope nhagen,Denmark
eKnowle dgeCent re,A CMTrai ningCentre ,Elburg ,Th eNe therlan ds
fEmergency Medicin e,Fa cultyofM edicine andHe alth Sciences,UniversityofAntwerp,Antwerp,Belgium
gFacultyofM edicinea ndHeal th Sciences,U niv ersityo fGhent,G hent,Belgi um

Introduction translationanddisseminationprocessfortheseguidelinesandthe

teachingmaterialforallcoursestofacilitatetheimplementation
Thechainofsurvival1wasextendedtotheformulaofsurvival2 of the 20 15 guide line s o n resusc ita tion in a time ly manner. This

because it was realised that the goal of saving more lives relies chapterprovidesthebasisofasuccessfuleducationalstrategyfor

not only on solid and high quality science but also the effective improvedCPReducation.
edu catio nof layp eopl eand healthc areprof essio nals .3Ul timately,

thosewhoareengagedinthecareofcardiacarrestvictimsshould
Summaryofchangessincethe2010ERCguidelines
beabletoimplementresourceefficientsystemsthatcanimprove

survivalaftercardiacarrest.
Thefollowingisasummaryofthemostimportantnewreviews
This chapter incorporates the 17 key educational PICO-
orchangesinrecommendationsforeducation,implementationand
questions (Population–Intervention–Control–Outcome) that
teamssincetheERC2010Guidelines:
wherereviewedbytheEducation,ImplementationandTeams(EIT)

TaskForceoftheInternationalLiaisonCommitteeonResuscitation

(ILCOR)from2011to2015.Thisevidencereviewandevaluation
Training
process followed the Grading of Recommendations, Assessment,
Develop ment and Ev aluation (G RADE) process desc ribed in the • High fidelity training manikins provide greater physical real-

Consensus on Science and Training Recommendations 2015 ism and their use is popular with learners. They are, however,
(CoSTR).4I tsum marises then ewtreatm entrecommendatio nsfor mor eexp ensiv eth an standard lowe rfidelity manik ins. Incentres

training and implementation. This chapter also covers the ERC thathavetheresourcestopurchaseandmaintainhighfidelity

basic principles of training and teaching of basic life support as manikins, we recommend their use. The use of lower fidelity

well as advanced level life support. There is a strong focus on manikinshoweverisappropriateforalllevelsoftrainingonERC

non-technicalskillsteaching(e.g.communicationskills,teamand courses.
leadershiptra ining) .TheERC por tfolioofcourses isalso inclu ded • Directive CPR feedback devices are useful for improving com-

in this chapter, which ends with an outlook about educational pression rate, depth, release, and hand position. Tonal devices

resuscitationresearchandfuturecoursedevelopments. improve compression rates only and may have a detrimen-

Delaysinprovidingtrainingmaterialsandfreeingstafffortrain- tal effect on compression depth while rescuers focus on the

ingwerecitedasreasonsfordelaysintheimplementationofthe rate.Thereisnocurrentevidencetolinktonaldeviceusewith
last guid elines .5– 7 Theref ore the ER C has carefully planne d the impr ovedo ut com esfollo winganE RC cou rse.
• Theinterv alsforretr ainingwil ldi ffera ccordingtothecharacter-

isticsoftheparticipants(e.g.layorhealthcare).Itisknownthat

CPR skills deteriorate within months of training and therefore
∗ Correspondingauthor. annu alret rainingstrat egiesm aynotb efr equente noug h.Whilst

E-mailaddress:[email protected](R.Greif).
1 Them embers oftheEducationand im plementationofresuscitationsection optimal intervals are not known, frequent ‘low dose’ retraining
Collabor atorsarel iste din theCollab orato rssection. maybebeneficial.

http://dx.doi.org/10.1016/j.resuscitation.2015.07.032
0300-9572/©2015EuropeanResuscitationCouncil.PublishedbyElsevierIrelandLtd.Allrightsreserved.
R.Greifetal./Resuscitation95(2015)288–301 289

• Traininginnon-technicalskills(e.g.communicationskills,team Mostresearchintheteachingofresuscitationhasbeenbased

leadership and team member roles) is an essential adjunct to on training adult rescuers in adult resuscitation skills. However

the training of technical skills. This type of training should be teaching children and young adults arguably requires different

incorporatedintolifesupportcourses. approaches,butmoreresearchisrequiredintothebestmethodsto
• Ambulancese rvic edi spatcher shaveaninfluentialroletoplayin teachtheseg rou psba siclifesu pp ort.22

guidinglayrescuershowtodeliverCPR.Thisroleneedsspecific One of the most important steps in increasing the rate of

traininginordertodeliverclearandeffectiveinstructionsina bystander resuscitation and improving survival worldwide is to

stressfulsituation. educateallschoolchildren.TheAmericanHeartAssociationadvo-

cated compulsory resuscitation training in American schools in
2011. 23 Prior to t his, the exper ience of tea ching CPR to scho ol
Implementation
childreninSeattleoverthelastthreedecadeshasresultedinsig-
• Data-drivenperformance-focuseddebriefinghasbeenshownto nificantly h igherb ystan der CPR rates andsurv ival rate.Sim ila rly,
improveper formanceofresuscita tionteams. We high lyrecom - Scandinav ianedu cationalre susc itation sch oolprogr amsr eportsig-
mendth eirusefortea ms managingpa tientsi nca rdiacar rest, nificantlyhigh erresuscita tionrates.24 Thisca nbeeasily achie ved
• Region al sy stem s includ ing cardia c arrest ce ntres a re to be by teachi ng child ren for just 2h per year , beg inn ing a t the age
encourag ed, as th ere is an a ssociatio n with increas ed su rv ival of twelve.22 At that a ge, scho ol c hildr en ha ve a positi ve attit ude
andimprove dn eurolo gi calo utcomeinv ictim sofout-of- hospital to wardlearning resu scita tionan dbothm edica lp rofessio nalsand
card iacarrest. teacher srequire trainingtoen able them tomaxi misethepoten tial
• The use of innovative technologies and social media can be ofthesec hildren .25Schoo lc hildren and the irteacher sare resusci-
ben eficia lfo rthedeplo ymentofrapi dres ponde rstovic tims of tat ionm ultipliersinbothpr ivateand pub licse ttingsas the children
out-of-hos pit alca rdiacarrest.N ov elsys temsarealso be ingdeve l- haveb eenshown to pass onthei rlea rningt ofamily m emb ers.The
opedtoalertby stander stoth eloca tionofth en eare stAED .Any propo rtion oftrai ned ind ivid uals insociety w illmar kedlyincre ase
techn olo gy th at improve s the delivery of sw ift bysta nder CPR inthelonge r term,le adingtoan inc reasein the overallra teoflay
withrapida cces stoanAED ist obeenco ur aged. re susc itation .26
• “It takes a s ys tem t o s ave a life”. [http://www. Healthcareprofessionalsworkinginavarietyofsettingsinclud-
res uscitatio nac ademy.co m/]H ealthc are systems witharespon- ing the comm unity, emerg ency me dic a l system s (EMS), general
sibility for the managemen t of patient s in card iac a rr est (e.g. hos pita l wards, and critical care areas sh ould all be taug ht CPR.
EMSor gan isati ons,cardiacar res tcentres )sh ouldev aluate their Whilst l ow qua lity compres sion s are c ommon b oth in term s of
proc essestoensure thatthe yarea bletode livercar ethaten sures incorre ctde pthand rate,interrup tion salsocon tribut et oineffe c-
thebesta chi evable surv ivalr ates . tiveCPR.2 7 Give nth atpo orperformanc eis associatedw it hlower
surv ivalrates,trai ning onthe secomponen ts shouldbea core aspect

ofanyresuscitationtraining.

Basicleveltraining IthasbeenshownthatwelltrainedEMSdispatchersareable
toim prov ebys tander CPRa ndp atientou tcom es.28Howev ert here

Whototrain areconcernswiththeirabilitytorecognisecardiacarrestpartic-
ular lyinrela tiont oago nalbre ath ing.29 Con sequen tlytrai ningof

BasicLifeSupport(BLS)isthecornerstoneofresuscitationand EMSdispatchersshouldincludeafocusonidentificationandthe
it is we ll es tablished that b ysta nder CPR is cr itical to surv ival signi ficanceofag onalbr eathing, 30 andth ei mportanceof seizu res

in out-of-hospital cardiac arrests. Chest compressions and early asaspectsofcardiacarrest.InadditionEMSdispatchersneedtobe
de fibrillationaret hemain determ inants ofsurvivalfro man out- tau ghtsim pl ifiedscr iptsfor in structing bys tandersinCP R.30

of-hospital cardiac arrest and there is some evidence that the

introductionoftrainingforlaypeoplehasimprovedsurvivalat30
daysand1ye ar .8,9 Howtotrain

For this reason a primary educational goal in resuscitation
should beth etraini ng oflaype opleinCPR. There is evidencethat BLS/AEDcurriculashouldbetailoredtothetargetaudienceand
training la ype oplein BLS is effectiv ei nimp rovin gt henumb erof keptassim pleaspos sible.I ncr easinga cc ess todiffe rentmod ali-
peoplew illi ngtou nd ertak e BLSina rea lsituation. 10–1 2 Theter m tieso ft raining (e.g .theuse ofdigitalm edia,o nli ne,instru ctor-led
‘laypeo ple’inc lud esawide rang eo f capa bilitiesfromthosew ith- teac hi ng) and self- dire cted l earning , offer alt erna tive means of
out anyform alhealt h care trainin g tothosewit haro lewh ereit teachingb oth layandprofes sionalpro vider s.Theeffect iveness of
may be expecte dthatt heyw ouldpr ovi deCPR (e.g. li fegua rds,fir st thesedif feren tble nde dlearningap proachesr ema insunclearan d
aider s). Despite t he in crea se in a ccess to trai ning for lay peo ple, furthe r researc h is requ ired not only to link the imm ediate out-
thereis stillanu nwi llingness of someto p erformC PR. The reasons comes ofcourses to theteac hing app roa chb uta lsoultimate lyto
identi fie dfo rth isincludefear of infec tio n,fearof getti ngit wrong, identif yt heimpa cto nth eoutcom eofreall ifec ardia carrestsit u-
andfearo fleg alim plicati ons.1 3 ations.T rain ingsho uld be tailoredt ot hen eed sofdiff erentt ypes
T rain ing of f amily members of high risk patients can reduce oflearn ersand avariet yo fdifferen t teac hingm et hodsshou ldbe
anxietyoft hos efami lymember sa ndth epa tient,im prov eemo- us ed to en sure a cquisitio n and reten tion of r esuscitati on know l-
tionalad ju stmen t,ande mpowerin divi dual stofeelt hattheyw ould edge an dskills. Self-instruc tion programm es withsynchro nousor
be abl e to start CP R. F or high-ri sk populati on s (e .g. a reas where async hro noush andsonpractice (e.g.video,D VD,o n-linetrainin g,
the re is hi gh ris k of card iac arrest and low bys tand er resp onse), computergivin gfeed bac kduring train ing)ap pear tobean effective
recen te viden cesh ow sthats pecific facto rsca nbeidenti fiedwhich alternative toins tructor-l edcour sesforla ypeopl ea nd he althcare
will en able targ eted tr aini ng based on th e co m munity’s u nique providersle ar ningBLSskills. 31–35
char acterist ics.14,15T hereise vidence th atli kelyrescuersi nthese Those whoaree xpe ctedtoperformCPRregularlyneedtohave
populationsareunlikelyto se ektrainin gon their ownbutt ha tthey knowledg eofc urr entguidel ine sandbe able tousethe meff ect ively
gaincompet enc yinBLSs kil lsan d/orkno wle dgea ftert rain ing. 16–18 aspartofam u lti-profe ssionaltea m.T he sein div idu alsreq uiremore
They arewillingt o betr ained andar elikelytos hare trainingwith co mple x tr ainingincludingbo thtec hnical andnon-te chnical skills
other s.16 ,17,19–21 (e.g.team work,le adership, struc turedcom mu nicationskills) .36,37
290 R.Greifetal./Resuscitation95(2015)288–301

BasiclifesupportandAEDcurriculum themostfrequentlyusedmethodforbasiclifesupportandAED
trai ning.4 5 Whenco mpare dwitht rad itiona lins tructor-l edt rain-

Lay people are not only capable of effectively learning CPR, ing, well designed self-instruction programmes (e.g. video, DVD,
but ev idence show s t hat t hey can be taught to use AE Ds.38 com pute r supporte d feedback) wit h shortened instru ctor c oach-

The introduction of Public Access Defibrillator (PAD) schemes ing may be effective alternatives for laypeople and healthcare

has demonstrated the effectiveness of lay people in perform- providerslearningbasiclifesupportand,inparticular,forthetrain-
ing defibrillation,39 but thequestion rem ain swheth erl aypeople ingoflayp eoplein AED skil ls.18,33,3 4,46–4 9

require training to use AEDs or can use them without any prior If instructor-led training is not available then self-directed
input.40 The cur ric ulum for bas ic li fe su pport and AED tra ining train ing is an accep table pra gm atic option to use a n AED. Short

should be tailored to the target audience and kept as simple as video/computer self-instruction (with minimal or no instructor

possible.Whichevermodalityischosenfortheteaching,thefol- coaching) that includes synchronous hands-on practice in AED

lowingshouldbeconsideredascoreelementsoftheBLSandAED use(practice-while-you-watch)maybeconsideredasaneffective
curricu lum: alte rnativetoinstructor-ledAED cou rse s.48,50,51

Ultimately,itisknownthatrescuerscanuseAEDswithoutany
• WillingnesstostartCPR,includinganunderstandingofpersonal formaltraining . It hasbee nsh ownthat the pre sence ofanea rby
andenviron me ntal risk AEDis noguara nt eeo ftheir usage. 52Th ead vantageo fd e livering
• Reco gnitionofunco nsciousness,gaspingoragonalbreathingin train in g,t herefore,is th atit increasesgen eralaware ne ssoftheir

unresponsiveindividualsbyassessmentofresponsiveness,open- useandbenefit,whilstalsoprovidingaforumtodispelcommon

ingoftheairwayandassessmentofbreathingtoconfirmcardiac mythsabouttheiruse(e.g.thebeliefthattheymaydoharm).
arre st .41,4 2
• Goodqualitychestcompressions(adherencetorate,depth,full

recoilandminimisinghands-offtime)andrescuebreathing(ven-
tilatio ntim eandvolu me) Durationandfrequencyofinstructor-ledbasiclifesupportand
• Feedbac k/pro mp ts(humanfeedbackwithintheCPR-teamand/or AEDtrain ingc ourses

fromdevices)duringCPRtrainingtoimproveskillacquisitionand
reten tionduri ngbasi clif esuppor tt raining.43 The optimal duration of instructor-led BLS and AED training
courses hasnot beendete rm inedandislike lyto vary acco rdingto

StandardCPRversuschestcompression-onlyCPRteaching thecharacteristicsoftheparticipants(e.g.layorhealthcare;previ-
ous training),thecu rr icul um,theratio ofin stru ct orstopartici pants,

TheroleofstandardCPRversuschestcompression-onlyCPRis the amount of hands-on training and the use of end-of-course
discuss edin th eBLSCha pter ofthese ERCg uidelines.42Asimp lifie d, asse ssments .M oststudies showth atCP Rsk illsd eca ywithinthree
education -b ased ap proach i s s ugges ted to allow comm unities to tosixmonths after initialt rainin g.33,4 6,53– 55AED skills areret ained
trainallcitizensi nCPR: for lon gertha nBLS skills alone.56,57
Althou ghth ere issom eevidencethathigherfrequency,short

• Allcitizensshouldbetaughthowtoperformchestcompressions bursttrainingcouldpotentiallyenhanceBLStrainingandreduce
asa minim umreq uire ment. skilld ecay,mo restu diesarenee dedtoco nfirm this.53, 55–57
• Ide a lly,fullCPR skills(compressionsandventilationusinga30:2 C urrent evide nce sho ws that pe rfo rmance in the use of an
ratio)sh oul dals obet aughttoallcit izen s. AED (e.g. speed of use, co rrect pad placem ent ) ca n b e f ur-
• When trainin g is tim e-limi ted o r opportunistic (e.g. EMS tele- ther impr oved w ith brie f trainin g of laypeople an d he alth care
phone instructi on stoabystande r,m assevents,pu blicc ampa igns, profe ssionals.49 ,58–60 Brief bedside boo ster CPR t rainin g of 2min
interne t-basedvira lv id eos),itsho uldfo cuson compre ssion-only hasalsobeenshowntoimp roveCPR quality irres pectiveo ftr ain ing
CPR. Local com mun ities ma y want t o con sid er their approach con tent (instr uctor, or automat edfe edback orboth)in Pa ediatric
base donth eirlocalpopu lation epide mi ology,cul turaln ormsand BasicLif eSupportp rov idersduring simulate dc ardiac ar rest61and
bystan de rresp onse rates. impro ved withfur thertraini ng.62
• Forthose initiallytr ainedincompression-onlyCPR,ventilation Peer-le d res uscitati on training has also been shown to be an
may be c overed i n subse qu ent training. Ideall y the se individ- effectiveme ansofdeliver ingBLS train ing. Peer-t utorsa nd ass es-
uals sho uldbetra in edincompre ssion-onl yCPRan dthen offered sors are compet en t, more av ailab le and le ss costly th an c linical
train inginc he stcomp res sionswithventilat iona tthe sam etrain- staff . Stu dent instru ctors d evelop s kills in te aching , asse ssment
ingsessi on . and a ppraisal , organisatio n and re search . S ustainabil ity is possi-
• Tho selaypersonswithadutyofcare,suchasfirstaidworkers, bleg ivensucce ssion-plannin gan dconsiste ntleadership. A1 5year
lifegua rds,andca rers, sh ould be taug htsta nd ardC PR i.e.chest rev iew o f peer led BLS teach ing in a major University m e dical
compressio nsa ndvent ilation. school dem onst rate d th at such p rog ra mmes can deliver greater
• Fortheresusc itati onofchildren,rescuersshouldbeencouraged partici pantsatisfactio nwit hlea rningoutcom eseq ualtop revious
to a ttem pt resuscita tio n using w hicheve r adult seq uence they lecture-bas edsessions.6 3
ha vebeent aught,astheo utcom eisworseif nothin gisdone. Non- Asthereis evidencethatfrequenttrainingimprovesCPRskills,
speci alists who w is h to learn p ae diatric r esuscita tio n bec ause respon der c on fidence a nd w illingne ss to per form CPR , it i s rec-
they have a res ponsi bili ty for children ( e.g. parents, t eachers, ommended thatorgan isatio nsandindiv id ualsrevie wthe n ee dfor
scho olnur se s,lifeguards),s hou ldbetau ghtt hatitisp referable morefreque ntre trainingbased ont helikelihoo dofcard iac arres tin
tomod ifyadul tbasiclifesu pporta nd givefiv eini tia lb reathsfol- theira rea.Retr ainingsho uldtak ep lace atleastev er y12–24 mont hs
low edby appro ximat ely 1minof CPR bef oret heygo forhel p,if forst uden tswhoaret akingB LSco urses .A dditi onalh ighfre quency,
therei sn o-onetogofor th em.4 4 low doseupd ateo rre trainin gin certains ettingsma ybec onsidered.
Itis recom mende d thatindivid u alsmor elikelyto enc ou ntercardiac

BasiclifesupportandAEDtrainingmethods arrestconsidermorefrequentretraining,duetotheevidencethat
skills decay wi thin 3 –12 mon ths after B LS t rai ning 33,46,53,54, 56,64
Therearenumerousmethodstodeliverbasiclifesupportand and e videnc e that freque nt train ing im pro ves CPR skills,34,65–69
AEDtrain ing .Traditiona lly,instru cto r-ledtr aining cou rsesrem ain resp ondercon fiden ce,65and willingn esstoperf ormC PR.34
R.Greifetal./Resuscitation95(2015)288–301 291

UseofCPRprompt/feedbackdevicesduringtraining to facilitate visualisation, understanding, cognitive processing

and execution of a skill. No studies have showed any advan-

The use of CPR prompt/feedback devices may be considered tage for different stepwise approaches despite their theoretical
during CPR tra inin g for lay people a nd healt hcare pr ofessionals. fram ewo rk.86,87

Devices can be prompting (i.e. signal to perform an action e.g.

metronome for compression rate or voice feedback), give feed- Basicsofsimulationtoteachonadvancedlevelcourses

back (i.e. after-event information based on effect of an action

suchasvisualdisplayofcompressiondepth),oracombinationof Simulationtrainingisanintegralpartofresuscitationtraining.

prompts and feedback. Training using a prompt/feedback device A systematic review and meta-analysis of 182 studies involving
can imp rove CPR skill perform ance.70 Instructors and re scuers 16 ,636partic ipantso nsim ulation-based tra inin gforres uscitation

should be made aware that a compressible support surface (e.g. showed improvement in knowledge and skill performance com-
mattre ss) may c ause so me p ro mpt/feedback devices to over esti- paredto trainingwitho ut simulation. 88
matedept hofc ompre ssion .71,72 Sim ul ationtra iningcan beusedtotrainarangeofrolesfromthe

A systematic appraisal of the literature determined in both firstrespondertotheresuscitationteammemberandultimately

manikinandhumanstudiesthataudiovisualfeedbackdevicesdur- theresuscitationteamleader.Itcanbeutilisedtotrainbothindi-

ingresuscitationresultedinrescuersprovidingchestcompression vidualandteambehaviour.Acriticaladjuncttothislearningisthe

parametersclosertorecommendationsbutnoevidencewasfound debriefingthatoccursattheconclusionofthescenario.
thatthistra nslates in toimprovedpatie nto utc omes.73S ubst antial Withth eex ception of sim ulationtra ini ngu singliveactors,the

variationintheabilityofCPRfeedbackdevicestoimproveperfor- majority of training involves the use of purpose built manikins.
mancew as foun d.74–76 High-fide lit ymaniki nscanpr ovid eph ysi calfindin gs,di splayvital

signs,physiologicallyrespondtointerventions(viacomputerinter-

Advancedleveltraining face) and enable procedures to be performed on them (e.g. bag

mask ventilation, intubation, intravenous or intra-osseous vas-
Advancedlevelcoursesaremainlydirectedathealthcareper- cular access).89 S imulation t raining usin g h igh-fidelity ve rsus

sonnel.Ingeneral,theycovertheknowledge,skillsandattitudes low-fidelity manikins seems to deliver a slight improvement in
needed to function aspa rtof( and ultimatelyl ead)a resu scitation trainingout comeonsk illperf orm ancea tt heend ofthecourse.9 0

team. When considering physical realism, these high-fidelity

manikins are more popular with candidates and faculty but

Pre-coursetrainingandpossiblealternativesstrategiestoimprove they are also much more expensive. Evidence that participants

CPRtraining in ERC courses learn more or better CPR by using high-fidelity

manikins is lacking. With this in mind, high-fidelity manikins

Avarietyofmethodscanbeusedtopreparecandidatesbefore can be used but if they are not available, the use of low-fidelity

attending a life support course. These include the provision of manikinsisacceptableforstandardadvancedlifesupporttraining.

pre-coursereading,intheformofmanualsand/ore-learning.Incor- Adherencetoreal-time2-mincyclesduringadvancedlifesup-

poratingapre-testintothepreparatoryworkmayfurtherenhance port simulations is an important part of realistic fidelity. It is
thesema te rials.77–8 2On esu chexample wasa CD-b asedpr e-course impo rtant that t he du ration of C PR c ycl es is no t deliber ate ly
e-lear ningprogramforA LSth atwasw ellr ec eivedbyt hepartici- decreased inord erto increase the num berofs ce nario s.91

pants. It was rated as improving their understanding of the key New teaching methods hold promise for the future but need

learningdomainsoftheALScoursebutfailedtoshowsuperiority more research before being adopted on a larger scale. Examples

forcognitiveorpsychomotorskillsduringastandardcardiacarrest includespecificallyteaching“action-linkedphrases”like“There’s
sim ulation.83 no puls e, I will sta rt chest compressions” which w ill g enerally
Evidence has emerged regarding blended learning models pro mptac ti on(e .g.che stcom pressions)whe ntaugh ton courses.92

(independent electronic learning coupled with a reduced dura- Anotherexampleis“Rapidcycledeliberatepractice”(RPSD)train-

tion instructor-led course). A pilot blended learning approach to ing, which has been shown to increase resuscitation skills in
ALS training includ ing e-le ar ning led to a 5.7% low er pass ra te paed iatricr eside nts.93 Aftera nin itialunin terruptedscen arioa nd

incardiacarrestscenariotesting,butsimilarscoresonaknowl- debriefing, the next scenarios are short, and interrupted at pre-

edge and skills assessments, and reduced costs by more than determinedpointstogivedirectfeedbackonspecificprocedures
half. Ther e was no significant diff erence in overa ll p ass ra tes.84 oractions.

This UK-based e-learning-ALS course was subsequently imple-

mented and a further study of 27,170 candidates demonstrated Trainingofnon-technicalskills(NTS)includingleadershipand
equivale nce to traditio nalins tru ctor-led learning.85 Theonlinee- teamtra ini ngtoimprove CPRo utcom e

learning program of 6–8h was to be completed by candidates

priortoattendingaone-daymodifiedinstructor-ledALS-course. Accomplishingsuccessfulresuscitationisateamperformancein

e-ALS scores were significantly higher on the pre- and post- mostinstancesandaswithanyotherskill,effectiveteamworkand
course MCQa ndfir stattemptCA S-testp ass rate wash ighe rthan leade rshipskill sne ed tobe tra ined.9 4,95 F orexamp le,theim ple-

compared to standard ALS courses (overall pass rate similar in mentationofteamtrainingprogrammesresultedinanincreasein
both). Con sid ering ben efits such as increas ed ca ndid ate auto n- hospital su rv ival fr om paed iatric cardiac arrest96 a nd in surgic al
omy,im provedcost -effective ness, dec reasedinst ructorburd enand patients .97

improvedstandardisationofcoursematerialthesereportsencour- Training in non-technical skills, such as effective communi-

agefurtherdisseminationofthee-learningcoursesforCPRtraining. cation, situational awareness, leadership and followership, using

crisisresourcemanagementprinciplespurposefullyinsimulations,

Principlesofteachingskills hasbeenshowntotransferlearningfromsimulationintoclinical
prac tise.9 8,99 Res us citationt eamper forma ncehasbee nsh ownto

CPRskillscanbetaughtinastepwiseprocess:dissectingthe improveinactualcardiacarrestorsimulatedin-hospitaladvanced

components of a skill into a real-time demonstration, explain- lifesupportscenarios,whenspecificteamorleadershiptrainingis
ing the facts , d em onst ratio n by the par ticipants, and p racticing add edtoad vancedlev elcou rses.100 –104 B y deliveringt raining in
292 R.Greifetal./Resuscitation95(2015)288–301

an environment as close to real-life experience as possible, con- with the environment145 and identify common system and user
cep tsregardingt ea mwor kin gcanbe addressed att helevelo fthe error s.142 ,146,147
indivi dual.105,10 6
Specificteamtrainingcanincreaseteamperformance,leader- Briefinganddebriefingaftercardiacarrestsimulation
shipskills, andta skmana gem entperf orman ceandtheeff ectcan
lastf orup toon eye ar.94,95,100,101, 107–111Onthe oth erh and,le ad- Debriefingaftercardiacarrestsimulationisanessentialpartof
ersh ip trai nin g in addition to CPR skills ha s be en sh own n ot to thelearningp roces s.Ifthe simula tedscenari o trai ningisfo llow ed
improv eactual CP Rskills.11 2 byd ebriefing thenlea rn ing willoccur, asoppos edtosce na riotrain-
Asses sment instr uments(mainlychecklists)havebeendevel- ing withoutd ebrie fing.148T hei dealfo rm atofdeb rie finghas yetto
oped,validated ,andrecomm endedf orindividu altea mme mbers. bed etermin ed.Studieshavef ailed toshow a difference wit han d
Rating scales e xist for the assess me nt of team per formance, wi thouttheuse ofvideo clips forde br iefing. 14 9,150
which can su bsequ entl y be used to del ive r feed back on team
perform anc e.113–116
Implementationandchangemanagement

Trainingintervalsandassessmentofcompetences
The formula for survival concludes with ‘Local
Implem entation’.2 The combinatio n of medic al scie nce and
Little evidence exists about the retention of knowledge after
ALScour ses.117 It isbelie vedth atle arnerswi th increasedcl inical educational efficiency is not sufficient to improve survival if there
ispoororabsentimplementation.Frequently,thisimplementation
experiencehaveimprovedlong-termretentionofknowledgeand
skills.118,119 Wri tten tests in ALS cou rses do n ot reliably pre dict will also require some form of change management to embed new
visionsintoalocalculture.Quiteoften,the‘easyfix’willnotbe
practicalskillperformanceandshouldnotbeusedasasubstitute
fordemo nstra tionofclinic alsk illperfo rma nc e.120,1 21 A ssessment the sustainable solution and prolonged negotiation and diplomacy
may be needed. A prime example of this is the implementation
attheendoftrainingseemstohaveabeneficialeffectonsubse-
qu ent perf orm ancean dreten tio n.122, 12 3 of CPR training on the school curriculum–countries that have
achievedthisgoalhavesometimesspentyearscampaigningand
There is emerging evidence that frequent manikin-based
persuading governments for this change to be adopted. Change
refresher training in the form of low-dose in-situ training may
canbedrivenfrombelow,buttobesustainableitusuallyneeds
save costs, reduce the total time for retraining, and it seems to
bepr eferre dbythe lear ners. 124,125 Re freshertrain ing is invariab ly top down buy-in as well.
Thissectionwasnotpresentinthe2010ERCGuidelinesandhas
requiredtomaintainknowledgeandskills;however,theoptimal
frequenc yfo rrefresh ertrainingi sunc lear.12 4,126–128 been added in recognition of its importance in the quest to improve
survival.
A simulation-enhanced booster session nine months after

a neonatal resuscitation training program demonstrated better
p rocedural skill and team work b ehaviour at fifteen mon ths.129 Impactofguidelines

Teamworkbehaviourswerefurtherenhancedwhenresidentswere
engaged in clinical re susci tation or by exp osure to delib erate Ineachcountry,implementationislargelybasedontheinter-
practice wit hsimula tion. natio nally agreed g uidelines for ca rd iac resu scitat ion . Na tional
strategies foreduc ationarede pen dentupo nevidence-ba sedsolu-

Useofchecklists,feedbackdevices,andin-situtraining tions to the management of cardiac arrest. The most important
quest ion , th erefore, should b e wheth er thes e gu idelin es actually

Cognitive aids such as checklists may improve adherence to result in any meaningful and improved outcomes. The authors
guidelines as lon g as t hey do not c ause delays in starting C PR freely ack now ledgeaconfl icto finteresth ere—ifwep rove thatour
and the co rre ct ch eck list is us ed d uring simulat ion 130 and real guidel ineshaveno ta ngibleb en efitthen wecall int oques tion the
pati ent cardiac arrest.131 Fo rexam ple,th eimplementationo fan resourcest hath ave beeninv estedt ogen erat eth em. Theevide nce
Advanc edTraum aLifeSuppo rtcheckl istim provedadheren ce to suggestsa pos itive benefi twhenc on sidering surviv alto hospital
protocol d riven ta sk p erforman ce, fr equ ency and speed of ta sk discharge ,8 ,151–156 r eturno fspon taneouscirc ulation,8, 151 –155 and
completi on.132 CPRperformance.8,153Irre sp ective,thelik elihoodofbenefitishigh

Feedbackdevicesthatprovidedirectivefeedbackincompres- relativetopossibleharm.

sionrate,depth,release,andhandpositionduringtrainingmaybe

consideredtoimprovethelevelofskillacquisitionbytheendof Cardiacarrestcentres
course.61,74 ,76, 133–137 In the ir abs en ce, t onal guidan ce (e.g. mu sic

or metronome) during training may improve compression rates Inthelastfewyears,regionalhealthcaresystemshaveemerged

only.Thereisevidencethattonalguidancecanreducecompression forthemanagementofconditionslikestroke,majortrauma,and
depth asth e candidate foc useso ntherat e.137 –139 CP Rpromptor my ocar dialinfarction .T hesehavem ain lybeen driven bycent rali-

feedbackdevicesimproveCPRskillacquisitionandretentioninBLS sationoflimitedresourcesasopposedtoevidenceofbenefitfrom

andmightalsobeusedtoimproveproperapplicationofthesebasic randomisedtrials.Thereisemergingevidencethatthetransport

CPRskillsduringadvancedleveltraining.However,theuseofCPR ofpatientswithout-of-hospitalcardiacarresttoaspecialisedcar-

feedbackorpromptdevicesduringCPRshouldonlybeconsidered diacarrestcentremaybeassociatedwithimprovedneurologically
as part o f a broader system of car e tha t shoul d inc lud e compre- intac tsurv ival.157 –170T he studiescu rrent lyavailable hadinconsis-
he nsive CP R quality improve me ntin itiati ves,140 ratherth anasan tencie sintermsofthespe cificfac torsthata llegedlyc ontr ibutedto

isolatedintervention. betteroutcomes.Moreresearchneedstobeperformedtoidentify

In-situsimulationscanofferopportunitiestotrainthefullteam thespecificaspectsofacardiacarrestcentrethatimproveoutcome,
141aswel lasprovide insi ghtin totheworkfl ow ont heo rga nisa- asw ellast heinflu en c eofjou rneyt imesa ndw hethers econdary
tional level .14 2 Furthe rmorei tmig htb eeas ierto inc lud etraining tra nsfer st osu chcentres co uldalso obtain the sameben efit.

of a full team of care providers across disciplines in-situ and Scenario-based simulation training and re-training, regular
th is can impro ve advan ced life su pport provider kn owledg e,143 practiceandateam approachto devicep lacem entarenece ssaryfor
skill perf ormance ,144 confid ence andpre paredness ,141 familiarity coronary cat h eteris ationlabo ra torype rsonnel.W hen introduc ing
R.Greifetal./Resuscitation95(2015)288–301 293

mechanical chest compression devices into clinical practice a Medicalemergencyteamsforadults
significant learnin g curve was observe d.171 During prolonge d
resuscitatio nefforts inthec orona rycatheterisationlabo ratory,the Whenconsideringthechainofsurvivalforcardiacarrest,1the

implementationofastructuredresuscitationapproachimproved firstlinkistheearlyrecognitionofthedeterioratingpatientand
teamwork.172 prev entio n ofc ardiac arrest.Aco ns ider ableamount ofwork has

been done to evaluate the role of the Medical Emergency Team

(MET)inthisrespect.Werecommendtheiruseand,inparticular,
Useoftechnologyandsocialmedia
theuseofhigherintensitysystems(e.g.higherMETcallingrates,

seniormedicalstaffontheteam)astheirusehasbeenassociated
The prevalence of smartphones and tablet devices has led to the witha reduced inci den ceo fcard iac /respi rato rya rrest1 83–189 and
generation of numerous approaches to implementation through impr ov edsurviv alrates.18 4,18 6–189,183,190
theuseof‘apps’andalsosocialmedia.Thesefallintoseveralcate-
Itisrecommendedthatthesesystemsinclude:
gories:
(1) staffeducationaboutthesignsofpatientdeterioration

(1) Simpledeliveryofinformation–appsthatdisplayresuscitation (2) appropriateandregularvitalsignsmonitoringofpatients

algorithms. (3) clearguidance(e.g.viacallingcriteriaorearlywarningscores)

(2) Interactive delivery of information–apps that use the geo- toassiststaffintheearlydetectionofpatientdeterioration

locationoftheusertodisplaythelocationofthenearestAED. (4) aclearuniformsystemofcallingforassistance

(3) Interactive delivery of education–apps that engage with the (5) aclinicalresponsetocallsforassistance.

user and create an immersive and interactive means of edu-

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

learningprogrammewithabbreviatedinstructor-ledtraining
There are many different techniques for teaching ALS and
has been shown to be equivalent to standard training for
adv anced lifesup por tco urses.85 BLS in resource limited settings. These include simulation, multi-
media learning, self-directed learning, limited instruction, and
(5) Feedback devices—real time use of the accelerometer to
self-directedcomputer-basedlearning.Someofthesetechniques
improverate,depthofcompressionsaswellasrecordingdata
fordebri efing .173 are less expensive and require less instructor resources than a
traditionalteachingformat.Sometechniquesalsoenablewiderdis-
(6) Notificationandactivationofbystanderschemes—ifindividuals
seminationofALSandBLStraining.Itisreasonabletosuggestthe
arewillingandabletoprovidebasiclifesupportinacommu-
use of these strategies in resource limited settings, although the
nity,theuseofthesesystemsmayleadtofasterresponsetimes
when co mpa re d with emerge ncy servi ce attend ance.174,1 75 ocoputinmtrayl tsotraanteogthy eirs. 1y9e1t– 1t9o7 be determined and will differ from one
(7) Useofsocialmediatodisseminateinformationtoawideraudi-

enceandassistwithcampaignstoeffectchange.
Traininginethicsandfirstaid

Ultimately,technologyandsocialmediaarepowerfulvectors Insights into training health care professionals about DNAR
forimplement ationandch ang emana gemen t.T heirdevel opment issues and appr oaches t o pract icing procedures o n the newly
and use should be e nco uraged and analysed t o asse ss the actual deceas edar eprovidedi nth eEthicsch apterofthe ERC gui delines
imp acto nsurvi val. 2015.198T he FirstAidc ha pter ofthe 2015ER CG uid eline sprovides

guidelinesaboutfirstaideducationandtrainingprogramsaswell
aspublich ealthc amp aign s.199
Measuringperformanceofresuscitationsystems

Assystemsevolvetoimprovetheoutcomesfromcardiacarrest, TheERCresuscitationcourseprogram

we need to accurately assess their impact. This is particularly
imp ortan tfo rlargersys temsw ithmu lti-facto rialco m ponentsany TheERChasdevelopedawiderangeofcoursestargetingalllev-
ofwhichm ay beben eficiale ither inisolationor combination. For elsofp rovid ers ,frombasic l ifesup portf or layresc uerstoad van ced
ex ample, itha sa lreadybee nshow n thatfurth er workneedsto be life su pportfor health care pro viders. ERC co ursestea ch thecom-
donetoe va luat etheim pacto fcardi acar restcen tres. pet ences to un dertake resu scitation i n th e clinica l setti ng a t the
M eas uring pe rfor mance an d imple menti ng quality improve- levelthat th eywouldb eexpectedto p erfo rm.Besi desres usc ita-
ment initiativ es will furthe r enh ance systems t o delive r optimal tions kills ,emp hasisis giv entonon -te chnicalsk illsand leadership
result s.102,176–18 1 train ing,ap plication of ethica lp rinciplesanda dvanc ede ducational

strategiesaswellasorganisationalimprovementsonasystemlevel

toimprovesurvivalaftercardiacarrest.Specificcoursesteachthese
Debriefingafterresuscitationintheclinicalsetting co mpetenc eswhilst othe rstrain howco mpeten cesaret obeta ught.

ERC courses focus on teaching in small groups with a high
Feedbacktomembersofanin-hospitalcardiacarrestteamabout instruct or to ca ndida te r atio using b lended learnin g str ate gies,
their perform a nce in an ac tua l cardiac a rrest (a s oppo sed t o the includingi nte ractivedis cussio n,wor kshopsan dhands- onpractice
traini ng environm ent ) c an lead to imp roved outc omes. Th is can forskillsa ndsimulat ionsusingr esuscitation ma nikins.200 ,201
eitherb ereal-timeand dat a-dri ven (e.g.use offeedback dev ices Up-to -dat e informatio n abo ut ERC cours es is available in the
oncar dia ccompres sion metrics)ori nast ruct ure dpostev entper- “ERCcourseru les”ontheER Cwebs ite[h ttps://w w w.erc.edu /ind ex.
for mancef ocuseddebri ef.102,182 Th ei d ealapproac hto debrie fing php/d oclibra ry/en /]. The cou rse rule s describe in detail the ERC
isyettob edeterm ined,includingthe inter valbetwee n actualper- terminologyanddefi nitio ns;spec ificso ftheorga nis ationa ndm an-
fo rma nc ea ndthedebri efingeven t.A lthough itseems intuitiv eto agementofd iffe rentERCco urseform at san dqualityco ntro l;the
provide th is le vel of debriefi ng for out-of-ho sp ital ca rdiac arre st instructo rd evelopme ntup tocou rsedirect or,in structo rtrainer and
perform ance ,noe vid enceexists tos upportorrefute itsben efit. ERCeduca tor;theERCa sse ss menta ndcertifi cation/rec ertifica tion
294 R.Greifetal./Resuscitation95(2015)288–301

process; and the ERC professional behavioural guides including EducatorMasterClass),isresponsiblefordeliveringtheeducational

complaintsprocedures. principlesofERCcourses.

Ethos Fromtheinstructorcandidate(IC)stagetofullinstructor(FI)

Following successful completion of a GIC, IPs are granted IC
InstructorsonERCcoursesaretrainedinteachingandassess- status and no rmally wi ll teach on two p rovi der cou rses, und er
ment. The et hos is to crea te a supp ort ive, lear ner- centred superv ision oftheco urse faculty ,re ceiv ingconstr uctivean dcor-
enviro nmen tthat pro mot eslearn ing ,enhancing understandingof rectivefeed bac ko nhisor herper formance withtheaim ofb eing
knowledge a nd r etention o f skills. F irst names are encourag ed promot ed to FI s tat us. Th is fe edback enhan ces t each ing pr actice
amongboth facu ltyandca ndi datest ored uceapp rehe nsion.Inter- duringthe GI Ca ndasa nICi nthefirst provider coursesb yformu-
actions betw een fac ulty and candi dat es are driven to learn from latingl earn ing goal sfo rs ub se que ntco urses.
eachot her’sexpe riences .Aim edchange sin behavi our aree labo-

ratedbyencouragementwithconstructiveandcorrectivefeedback
Coursedirector(CD)status
as well as debriefing on performance. A mentor/mentee system

isusedtoenhancefeedbackandsupportforthecandidate.Some
st ressis in evitable, 202particu larly during asse ssm ent,butin struc- An approved Course Director leads each ERC course. CDs are pro-
posedbyNCDsandapprovedbytheirNRCortherespectiveICC.
torsaimtoenablethecandidatestodotheirbest.ERCcoursesare
CDsareseniorinstructorswhoareclinicallycredible,havedemon-
drivenbytheultimategoaltoimproveresuscitationperformance
stratedexcellentqualitiesasateacher,mentor,andassessor,and
toincreasesurvivalofcardiacarrestvictims.
possesstheskillstoleadafacultyofinstructors.

Coursemanagement
GeneralERCcourseprinciples [ERCcourserulesonwww.erc.edu]

ERCcoursesareoverseenbytheJointInternationalCourseCom-
ContentofERCcourses
mittee (JICC) consisting of the chairpersons of the International
All ERC courses follow contemporary ERC guidelines. Each
CourseCommittees(ICC)forallERC-coursetypes(BLS/AED,Imme-
coursehasitsspecificcoursemanualorteachingbookletproviding
diateLifeSupport(ILS),ALS,NeonatalLifeSupport(NLS),European
therequiredpre-courseknowledge.Candidatesreceivethemanual
PaediatricImmediateLifeSupport/EuropeanPaediatricAdvanced
inadvancetoprepareforeachcoursewithamandatorypre-course
LiveSupport(EPILS/EPALS),GenericInstructorCourse(GIC))andis
MCQ(exceptforBLS/AED,ILSandEPILS)thataimstoensurethat
ledbytheBoardDirectorforTrainingandEducation(DTE).Onthe
candidatesreadthematerialsbeforeattendingthecourse.
nationallevel,eachNationalResuscitationCouncil(NRC)assigns
AllERCcoursescompriseinteractivelectureandgroupdiscuss-
NationalCourseDirectors(NCD)foreachcoursetype.
ions, small group workshops, hands-on skills teaching and, for
TheERChasdevelopedaweb-basedcoursemanagementsystem
advanced level training, clinically orientated Cardiac Arrest Sim-
[http://courses.erc.edu] for the administration of these courses.
ulation(CAS)andemergencycasescenarios.Mostcourseformats
Candidates may sign up online to a course, or may contact the
includeoptionsenablinginstructorstotailortheirteachingtothe
courseorganisertoregistertheirinterestinaspecificcourse.At
candidates’localneeds.
theendofthecoursethesystemwillgenerateuniquenumbered

coursecertificatesforsuccessfulcandidatesandalsoeachfaculty
Immediateandadvancedlifesupportcourses
member.Forqualitycontrolanevaluationtoolisavailableforeach
Immediateandadvancedlifesupportcoursestargetthetraining
course and results are accessible for NRCs, NCDs and ICC mem-
ofhealthcareproviders.Curriculahavecorecontentandcanbetail-
bers.Participantswhosuccessfullycompleteprovidercoursesare
oredtomatchindividuallearningneeds,patientcasemixandthe
referredtoas‘providers’.
individual’srolewithinthehealthcaresystemsresponsetocardiac

arrest.Coremodulesforthesecoursesinclude:
Language
Initially,theERCcoursesweretaughtinEnglishbyaninterna- • Cardiacarrestprevention.203,204
tionalfacult y.A sloc alinstru ctors havebe en trained ,a nd manuals • Highqu alityc hestcompressions(adherencetorate,depth,full
andco ursema ter ialsh avebeentra nslat edint odiffere ntla nguages, recoi landmi nimizi nghands-offti me)andven tila tion usingb asic
man yNRCs arenow able tode livertheir cou rsesloca llyintheir skills (e.g. pocketmas k,bagmas k).
native langu age .Itis impo rta ntthatt hisdo esnotc omprom is ethe • Defib rillat ion,wit hchar ging duringcompressionsforhands-free
quality controlo fc ou rsesandin struc tor devel opm entandthep ro- defibrillation.
cessof translat ion ofnew gui delinesan dcoursemate rial ssh ould • Advancedlifesupportalgorithmsandcardiacarrestdrugs.
notd el aytheimple m entat ionofnew guid elines. 5 • Non-techn ical skills(e .g.leadersh ipan dteam traini ng,commu-
nication).
Instructordevelopment
Immediate life support courses. ILS courses for adults and EPILS

Individuals who have passed and demonstrated a high level courses for children are one-day courses focusing on the causes
of performanc e dur ing a provide r cou rse and, impo rta ntly, have andpre ven tionofca rdia carrest, theABCD Eapproa ch toth ecrit-
sh own qualities of lead e rship and team w orki ng, shown cl inical icall yillpatient ,st artinge ffective BL S/AED,i nitiatingt he cha inof
credibi lity,with ski llsthatinclu deb einga rticulate, support ive,and surviv al ,andbas icCPRsk ills(e.g. effectivec hestcomp res sionan d
motivated may be id entifi ed by t he co urse facul ty as Instru ctor safedeliv ery ofad efib rillati onsh ock,basi cairw aymanagem ent,
Potential( IP).In div idualswit hIP in anyadv ancedc ou rsewillbe chok ing,intra ve no usorintra-os seousa ccess, anddru gsduringcar-
invitedto tak etheERCG eneri cIn st ruct orCourse (GIC).I Psaf ter diacarre st).205These co ursesaredesig nedto bes imple torunw ith
BLS/AED c ourse s w ill b e invited to take t he BLS/ AED in str uctor smal lgroupsofcandi dates.Th eai mistotra in ca ndidate si nth euse
Course. ofthe equipm e nt(e.g.defi brill ator ty pe )tha tisavailabl e inth eir

AttheGIC,anERCeducatorwhohasundertakenspecifictraining clinicalsettingandthemanagementofthefirstminutesofcardiac
inme dica led uc ation andint hep rinc iplesofadu ltlearni ng(ERC arrestu ntilpro fess iona lrescuersarri ve .
R.Greifetal./Resuscitation95(2015)288–301 295

Advanced life support courses. ALS courses for adults, EPALS for medicalandnursingstudents,andthosewhoarelesslikelytoman-

neonatesandchildren,andNLScoursesfornewbornsbuildupon ageacardiacarrest).CombinedBLS/AEDcoursesareencouraged.

theknowledgeandskillsfromtherespectiveBasicand/orImme- BLS/AED courses aim to enable each candidate to gain com-

diateLifeSupportcourses.Thisprovidesthefoundationforthese petency in recognising a cardiac arrest, immediate instigation of

2-dayadvancedcoursesplacingemphasisonsafedefibrillationand effectivechestcompression,callingappropriatehelptothescene

ECGinterpretation,themanagementoftheairway,ventilationand andsafeuseofanAED.Thesecoursesteachchildrenandadultsin

vascularaccess,themanagementofperi-arrestrhythms,andspe- CPRcompetencesforchildrenandadultsincardiacarrest.

cial circumstances relating to severe illness, injury, and cardiac TheERCBLS/AEDinstructorcourseofferscandidateswhohold

arrest. Post-resuscitation care, ethical aspects related to resusci- a valid BLS/AED certificate and who are identified as instructor

tation and care of the bereaved are also included. These courses potentialtheopportunitytotraintobeBLS/AEDinstructors.

shouldenableproviderstocoverthefirsthourofcriticalillnessor

injuryandcardiacarrest.Theyarenotdesignedtoprovideinstruc- Immediate life support (ILS) course. The ILS course teaches the
tionin adv ancedin tensiv ecare or card iology. majorityo fhe althcare profe ssionals from all discipli nesand pro-

fessionswhofaceadultcardiacarrestsrarelybutarepotentialfirst
Thefacultymeeting respond ers o r res uscita tion tea m mem bers. 208 App lied ILS c om-
T hefacu ltymeetingusuallytakesplaceatthestartandatthe petencessh ou ldresultinsu ccessf ulresuscitationwhilst aw aiting
endof eachco urseday andisl edby theco ur sed irecto r.Th e aim the arriv al of th e resu sci tation team covering th e first minutes
isto br iefth eteach ing facu lty and to ass essthe performa nce and of C PR.209 In a c ohort study after i mplemen tatio n of an ILS-
pr og resso fea chcandid ate.Du ring th efinal facu ltymeetinge ach pr ogramme th e numbe r of ca rdiac arrest calls and t rue ar rests
candidat e’s perfo rmance is review ed to m ake a d ecision a bout decreasedw hile pre-arres tc allsincre aseda swell asin itials urvival
successfulc ourseparticip ati onandwh eth ercan di dateswh ohave andsurviv altod ischarge.21 0
met the re quired criteria are o ffer ed instru ctor potent ial st atus.

Instructorcandidatesonthecoursesarealsoassessedontheirper-
Advancedlifesupport(ALS)course. ThetargetcandidatesfortheALS
formance.Facultymeetingsalsoprovideanopportunitytodebrief
coursearephysicians,nurses,EMSpersonnel,andselectedhospital
thefacultyattheendofthecourse.
technicianswhomayberesuscitationteamleadersandmembers
foradultCP R.211, 212
Assessmentandfeedback
BeyondtheexpectedBLSandILScompetencestobemastered
Throughoutthecourse,thefacultyassesseseachcandidatefor-
bythecandidates,thiscourseformatteachesthemanagementof
mativelyandindividually.Candidates’performancesandattitudes
cardiacarrestfromadiversityofcausesandthemanagementof
are discussed at the daily faculty meetings, with mentoring and
peri-arrestproblemsandconcentratesontheapplicationofnon-
feedbackgivenasrequired.Instructorsaretaughttouseaframe-
technical skills with emphasis on team-cooperation under clear
work aimed at providing timely, constructive, goal orientated,
teamleadership.
studentcentredandactionplannedfeedbacktoenablethelearner

toachievethedesiredoutcome.
Newbornlifesupport(NLS)course. Thisone-dayinter-professional
The standard ERC feedback format is the Learning Conversa-
course aims to give healthcare workers likely to be present at
tion. The learning conversation starts with an invitation to reflect the bir th of ba bies (e.g. midw ives,213 nurses , E MS personn el,
anditisprimarilycentredonanyissuethatthecandidatewishes
physicians)thebackgroundknowledgeandskillstoapproachthe
todiscuss.Thisisfollowedbyadiscussionofanykeyareasthat
managementandresuscitationofthenewlybornduringthefirst
theinstructorwishestodiscuss,alongwithcontributionsfromthe
10-20min. NLS places appropriate emphasis on airway manage-
groupandotherinstructors.Anyimportantperformanceissuesare
ment, chest compression, umbilical venous access and drugs for
then summarised with specific action points for the candidate to newbo rnCP R.214
improvetheirfurtherperformance.

Candidates’performancesarecontinuouslyassessedthrough-
outBLS,ILS,and GICcourses,m eas uringtheirco mpetence sagainst Europeanpaediatricimmediatelifesupport(EPILS)course. EPILSisa
pre- dete rmi ned crit eria; no summative test s are require d to be one-dayc ourse(5t o8h)that tra insnur ses,EM Sperso nnel, an d
certified. doctors who ar e n ot p ar t of a paed iatric re susci tation team to

TowardstheendofNLSandALScoursesaCardiacArrestSimu- recognise and treat critically-ill infants and children, to prevent
lationTest( CAS T)as se sses thec and idates’a p pliedkn owledg eand cardioresp irato ryar restandtot reatchil dren incardio res piratory
skillsd urin gasim ulatedca rdia carrestinc ludingle adingacar diac arrestduringthe firstfe wm in utesw hilstaw ai tingthearrivalof
arrest team. T hereliabili tyand measu rementpr operties o fCAST a resu scitatio n te am. Shor t practic al simu lations ad apt ed to t he
haveb eenes tabl ished.121,20 6,207 Theircorekno wledgeis ass essed w orkplaceand tothe actual clinicalro leofcandid atesareu se dto
with anMC Q. teachthec orec om pe tencies .

Mentoring Europeanpaediatricadvancedlifesupport(EPALS)course. EPALSis

Mentoring is an essential part of all ERC courses and enables designed for healthcare workers who are involved in the resus-

candidatestohaveanominatedrolemodel.Groupor1:1mentoring citation of newborns, infants or children providing sufficient

happensduringERCcoursesonaregularbasis. competencestomanagecriticallyillorinjuredchildrenduringthe
firsthourofil lne ss.215–21 8Refresh er tra iningin paediatr icbasic life

SpecificformatsofERCresuscitationcourses supportandreliefofforeignbodyairwayobstructionisincluded.

Basic life support and automated external defibrillation (BLS/AED) EPALSputsgreatemphasisontherecognitionandcontinuous

providercoursesandBLS/AEDinstructorcourse. BLS/AEDcoursesare assessmentandtimelytreatmentofthesickchild(e.g.cardiacand

appropriateforallcitizensincludinglaypersonsandtrainedfirst respiratoryfailure,arrestandtraumasimulations).Aspectsofteam

responders(first-aidworkers,lifeguards),thosewithadutyofcare workingandteamleadershipareintegratedinthetraining,includ-

forothers(e.g.schoolteachers,careworkers,securitypersonnel) ingproblemanticipationandsituationalawareness.Dependingon

andultimatelyallclinicalandnon-clinicalhealthcareprofessionals localneedsandcircumstancesEPALSmayfurtherincludemodules

(includingEMSsystemsdispatchers,generalpractitioners,dentists, onnewbornresuscitation,post-arrestcareandhandover,and/or
296 R.Greifetal./Resuscitation95(2015)288–301

modules on more advanced knowledge or technical skills. These Futuredirectionforresearchandcoursedevelopment

lattermodulesarebeingcontinuouslydeveloped.

Theproductionofinternationalguidelinesforresuscitationis

aconstantlyevolvingexercise.Highqualityresearchcontinuesto

bepublishedwithevidencethatmayormaynotsuggestthatthe
Genericinstructorcourse(GIC). TheGICisforcandidateswhohave
guidelinesoftodayareacceptable.
beenrecommendedasinstructorpotential(IP)emanatingfromany
Inparallelwiththis,thescienceofeducationalsocontinuesto
ERCprovidercourses(excepttheBLS/AEDcoursethathasasepa-
evolve.Ourmethodsforteachingtheseguidelineshavechanged
rateinstructorcourse)orwithIPstatusfromcertainotherprovider
substantiallyovertheyearsfromtheearlydaysofdidactictheo-
courses (e.g. European Trauma Course). The GIC puts emphasis
reticaldeliveryofteachingtocontemporaryinteractive,hands-on
ondevelopingteachingandconstructiveandcorrectivefeedback
methodsthatalsoutilisetechnologyandsocialmedia.
andmentoring.Coreknowledgeoftheoriginalprovidercourseis
Thereisstillapaucityofhighqualityevidenceaboutthebest
assumed.
methodsofteaching,primarilybecausethenumbersofcandidates
AnERCeducatorleadstheeducationalprocess,thediscussions
neededtoproducestatisticalsignificanceformeaningfuloutcomes
and provides critical feedback. The Educator delivers interactive
(e.g.increaseinpatientsurvival)wouldneedtobemassive.There
sessionscoveringthetheoryofadultlearning,effectiveteachingof
isarolethereforeforinternationalcollaborationtoachievesuch
skillsandsimulatedscenarios,assessmentandeffectivefeedback,
numbersinasimilarstyletothecollaborationsusedtoassesssome
andleadershipandnon-technicalskillsthroughaseriesofinterac-
of the clinical content to the guidelines. Until the time that sta-
tivesessions.Thefacultydemonstrateseachofthesecompetencies,
tistical significance is achieved, it is essential that we continue
followedbyopportunitiesforthecandidatestopractise.
to evaluate our educational methods and assess the educational
Abbreviatedmaterialfromtheoriginalprovidercourseisused
importanceorrelevanceofthefindings.
forthesimulatedteachingsessions.TheGICemphasisesthecon-
Newinsightsabouteducationalprocess,neuro-scienceimpact
cept of constructive and corrective feedback to develop future
on training and rapid developments in social media and online
learningstrategiesthusprovidinganopportunityforeachcandi-
applications mean that our approach to education is constantly
datetoadopttheinstructorrole.
changing.Thischapterhighlightscurrentchangesandwhatmay

changeinthenearfuture.

Educatormasterclass(EMC). ERCeducatorsareanessentialmanda- Recommendationsforeducationalresearchinresuscitation

torycomponentoftheGICfaculty.Atwo-dayeducatormasterclass
teach esexperien ce dpr ovid ercour se instruct orswitha demon stra- Everyeducationalinterventionshouldbeevaluatedtoensure
bleinte restineduca tiontob ecome ERCeducat ors.N R Cspropose that it re liably achie ves the learn ing obj ect ives and a t i ts best
suit ablecan did ateswho are thensh ortli stedbythe ERCW orking impr ov es patie nt outcom e in a cardia c arrest sit uatio n. The aim
Group o n Educatio n bas ed on sp ecific crite ria (inc ludi ng moti- istoensur ethatle arnersno to nl yacquire skills andknowl edge but
vation , qu alification in med ica l educat ion or d ocumentat ion of al so retaint hem tobeab leto pro videade quate acti onsdepend ing
demon stratedspecia lco mmitme nttoeduc atio nalpracticeove ra on t he lev el of tra ini ng. E va luation at the lev el of p atient out-
numberofyea rswithi ntheERC). com eis diffic ult toachiev e,assevera lo ther param et ersinflu ence
EMC in struct ors are ex perienced educators assigned by the patien t outcome ,s uchasch an gesing uideli nes,change sincase-
Working Group on Edu cation and th e Director of Train ing and mix, an d organis ation al c hanges. Th e level of o utcome stu died,
Education .TheE MC coversthe theor etic alframew or kforERC edu- shou ldbe determineddu ringthep lanni ngph ase oftheedu cational
cators, ass essm ent and qu ality control, t eaching me tho dolo gies, event.2 19 Itisdifficult toasse ssb ehaviour inthe cl inic alsettingso
critical appraisal, t he m entor r ole, mul ti-profess ional education this attribu te is more co mmon ly assessed w ith simulat ion usi ng
strateg ies and con tinu ous dev elopm ent of the ERC tea ching fac- man ikins. Gen er alisab ility from m anikin s tudie s is questio nable,
ulty.Thef orma toftheEM Cisaseriesof clo sed disc ussions,s mall though,an dthatistherea sonw hysolitt lehigh- lev elevidenceis
break out groups an dpr oblem so lvings es sions.C andidatesar efor- foundin the liter atu re.
matively assesse dthr oughout theEM C. Edu ca tion inresuscitationisstillarelativelynewfieldlacking
highqualityre se arch.Studiesa re hete r ogenousin desi gnan dprone

toriskofbiasandthereforedifficulttocompare.Aresearchcompass

toguidefuturestudiesineducationhasbeendevisedataresearch
Europeanresuscitationacademy(ERA)—“Ittakesasystem su mmit. 220

tosavealife”

Futurecoursedevelopment
TheERAaimstoimprovesurvivalfromcardiacarrestthrough

a focus on healthcare system improvements that bring the indi- TheeducationalstrategyoftheERCisbasedonuniforminstruc-
v iduall ink sintheCha inofSu rvivalandtheF orm ulafor Sur vival tor cou rses and sta ndardise d pro vide r c ourse cu rricula. T his will
togeth er.En tir eEM Sstaf f(m anagers ,ad min istrative and medical evo lveasm oreb lendedlearni ngmetho dsbeco meavailab le.F lexi-
directors, physic ians, EMT sanddispat chers)fromdif feren thealth bilityis n eeded inteach ingCPRo nallleve lsasdiffe rentmed ialike
caresyste msandcou ntries are invitedtolea rnfro mtheER APro- DVD, In terneta nd on-linet raini ng inc rease the learning benefi t.
gram (derive dfro mtheSea ttle (US)ba sed Resu scitat ion Acad emy Ne wcurric ula shoulda llowthi sflexibili ty.S omecor e-content
[http: //www.r esusc itati onacad emy.c om/] tenstepsfori mproving modules willbeth e‘hear t’ofan yER C-coursew hichw illallowthe
cardiacarrestsurvival)togetherwiththel oca lhost hea lthinstitu- customis ation o feac hcour se form atwithadd itional opti onalc on-
tions.T heERA putsem phasison defi nin gthe local cardia carrest tent(medicala sw ella snon-t echnica laspe cts)tosup portand train
surviv al ra te b y und erstandin g th e impor tanc e of r eportin g data learn ersaccor di ngto lo calneeds.Som einstitu tio nswill, fors ome
inastan dard ised Utsteintempl ate. Participating EM Ssystem sare learners , have very s pecia lised m odule s (e.g. cardia c ar rest after
en co uragedtodev elopcon cretemea surestoimpr ovec ardiacarr est cardiac s urger y, ad vanced neon atal sup port at an IC U, obs tetric
survival foll ow ed by a ppropria te measu rem ents of these a ction resuscit ation,res uscitation duringsu rgeryin the op erati onroom)
plans. thatcanbead dedtothesta ndardc ore-con ten tof thecours e.
R.Greifetal./Resuscitation95(2015)288–301 297

Newteachingtechnology(IT-basedlearninglikewebinars,e- MaaretCastrén,DepartmentofEmergencyMedicineandServices,

learningmodulesontheERCvirtuallearningenvironment)willbe Helsinki University Hospital and Helsinki University, Helsinki,

adoptedandthisneedstobeaddressedintheGICaswellasinthe Finland

supervisionandmentoringofallinstructors,coursedirectorsand AnthonyJ.Handley,HillcrestCottage,Hadstock,Cambridge,UK

educators. Carsten Lott, Department of Anesthesiology, University Medical

Learnersusingvideo-oronlinetrainingmaynolongerneeda Center,JohannesGutenberg-University,Mainz,Germany

printedmanual,astheywillhaveimmediateaccesstothecontent IanMaconochie,PaediatricEmergencyMedicine,ImperialCollege

ontheInternet.Thiswillprovidesubstantiallymoreopportunity HealthcareNHSTrustandBRCImperialNIHRGrantHolder,Impe-

tointegratepictures,demonstrationvideosofskillsandteamper- rialCollegeLondon,London,UK

formance,self-assessmenttestswithguidanceofhowtoimprove, Jerry P. Nolan, Department of Anaesthesia and Intensive Care

andlinkedliteraturetodeepeninterests.Avirtuallearningenvi- Medicine,RoyalUnitedHospital,Bath,Bristol,UK;BristolUniver-

ronment(VLE)willfurthermoremonitorandsupporttheongoing sity,Bristol,UK

learningtrajectoryofeachindividualintermsofknowledge,skills, Gavin Perkins, Warwick Medical School, University of Warwick,

attitudesandglobalperformancefromproviderstoinstructorsas Coventry,UK;CriticalCareUnit,HeartofEnglandNHSFoundation

wellascourseorganisers. Trust,Birmingham,UK

Readingandlearningknowledge-basedfacts,thinkingthrough ViolettaRaffay,MunicipalInstituteforEmergencyMedicineNovi

procedures and action strategies, and discussing open questions Sad,NoviSad,Serbia

canallbedonebeforecandidatescometothecoursevenue.Highly Charlotte Ringsted, Faculty of Health, Aarhus University, Aarhus,

motivatedcourseparticipantswillcometothecoursecentrewith Denmark

ahighlevelofknowledge,aclearvisionwhentoapplywhichpro- JasmeetSoar,AnaesthesiaandIntensiveCareMedicine,Southmead

ceduresandhowtointeractwithateamtoperformqualityCPR. Hospital,Bristol,UK

Duetoincreasingconstraintsonstudyandteachingleave,thetime JoachimSchlieber,TraumaHospitalSalzburg,Salzburg,Austria

spentatthecoursecentreneedstobefocusedonthetranslation Patrick Van de Voorde, University Hospital and University Ghent,

ofthelearnedconceptsinthesimulatedscenarios.Thiswillenable FederalDepartmentHealth,Ghent,Belgium

candidatestotryout,rehearseandexecutelife-savingtechniques, Jonathan Wyllie, James Cook University Hospital, Middlesbrough,

usingbestmedicalpracticeandteamleadershipandmanagement. UK

Thisshouldultimatelyenableproviderstoincreasesurvivalafter DavidZideman,ImperialCollegeHealthcareNHSTrust,London,UK

cardiacarrestintheclinicalsetting.

Highfrequencytrainingwillbeveryshortandmightnotnec-
Conflictsofinterest
essarily need personal coaching by an instructor or mentor. The

training environment should be brought to the learners, so that RobertGreif EditorforTrendsinAnesthesiaandCriticalCare.

they can experience it during daily activities to reach the high AndrewS.Lockey MedicalAdvisor“FirstonSceneFirstAidCompany”.
frequ ency objective. A briefan nualC PRcompe ten cetes tma ybe AnneLip pe rt Noconfl ictofint erest rep orted.
Koenr aadG.Monsieurs No conflict of interest reported.
usedtofilteroutthosewhodonotachieveinstitutionallydefined
PatriciaConoghan Noconflictofinterestreported.
levelsofcompetence.Somemightneedbrieftrainingundersuper-
WiebeDeVries TrainingOrganisationACMemployee.
vision to reach comp etenc e, whe reas other s may n eed a longer

formal refresher process. Course organisers have to plan their

courses in a flexible way, allowing a shorter duration for target Acknowledgement

groups with extra background, and more hands-on time for lay

rescuers. TheWritingGroupacknowledgesthesignificantcontributions

Theuseofhighfidelitymanikinsandadvancedfeedbackdevices tothischapterbythelateSamRichmond.

will be available for countries and organisations with the finan-

cial capacity, but not for all countries and organisations. When
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