Education in resuscitation: an ILCOR symposium: Utstein Abbey: Stavanger, Norway: June 22-24, 2001.

Abstract

HomeCirculationVol. 108, No. 20Education in Resuscitation Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBEducation in ResuscitationAn ILCOR Symposium: Utstein Abbey: Stavanger, Norway: June 22–24, 2001 Writing Group: Douglas A. Chamberlain, CBE, MD (Cochair), Mary Fran Hazinski, RN, MSN (Cochair), On behalf of the European Resuscitation Council, the American Heart Association, the Heart and Stroke Foundation of Canada, the Resuscitation Council of Southern Africa, the Australia and New Zealand Resuscitation Council the Consejo Latino-Americano de Resusucitación Writing Group: Search for more papers by this author , Douglas A. ChamberlainDouglas A. Chamberlain Search for more papers by this author , Mary Fran HazinskiMary Fran Hazinski Search for more papers by this author , On behalf of the European Resuscitation Council, the American Heart Association, the Heart and Stroke Foundation of Canada, the Resuscitation Council of Southern Africa, the Australia and New Zealand Resuscitation Council Search for more papers by this author and on behalf of the Consejo Latino-Americano de Resusucitación Search for more papers by this author Originally published18 Nov 2003https://doi.org/10.1161/01.CIR.0000099898.11954.3BCirculation. 2003;108:2575–2594The Need for ChangeThe value of bystander cardiopulmonary resuscitation (CPR) has been well defined by studies in many countries and communities. Randomized clinical trials are inappropriate in this setting and cannot accurately determine the degree of benefit conferred, but observational data from 17 papers published before 19911 and 2 nationwide studies since that time2,3 suggest that the odds ratio for improved survival of victims of collapse is ≈2.5. This benefit is achieved principally by extending the period for which defibrillation can be successful in cases of ventricular fibrillation or pulseless ventricular tachycardia. These are not grounds for complacency, however. Even in countries or areas where emergency services are well developed, most victims of cardiac arrest do not receive bystander CPR, and when it is given, the quality is generally far from ideal. The need, therefore, is not only for more CPR but also for better-quality CPR.Both skills acquisition and skills retention have been shown to be poor after conventional training in CPR for laypersons. The reasons are manifold. The necessary psychomotor skills for current courses are complex and demanding, an issue of particular importance because in many countries the average student is usually older than 50 years of age. Course curricula and instructor training are generally poorly adapted to the needs of course participants, and few instructors have been trained to teach. In addition, instructors frequently digress from the planned script (telling anecdotes and providing other irrelevant material), do not allow sufficient time for practice, and provide poor supervision and feedback. This is not a criticism of individual instructors but rather of the methods that have developed as a response to a perceived need but without consideration or knowledge of educational principles, clear objectives, appropriate formats, or agreed-on methods of evaluation and audit.Unexpected cardiac arrest is a major cause of premature death in industrialized countries.4 The potential value of bystander CPR, which can reduce mortality by one half in appropriate settings,1 is therefore of considerable importance. Yet in most countries, little effort has been given to making CPR a universal skill. The major efforts that have been made have largely come through voluntary organizations rather than government or healthcare agencies.Survival rates for unexpected cardiac arrest depend not only on the quality of the education given to potential caregivers but also on the validity of treatment guidelines and a well-functioning Chain of Survival. These factors interact in such a way that they can be regarded as multiplicands. For example, poor guidelines can affect even good education, whereas a potential rescuer who is poorly trained may not be able to effectively access even a well-functioning emergency medical services system. This is illustrated in the Table, which suggests that even slight imperfections in the quality of guidelines, together with realistic decrements in education and performance of the Chain of Survival, may well cost the lives of 4 of 5 potential survivors. A realistic target for improving the standard of education could have an important impact, irrespective of better techniques, guidelines, and rescue processes.Theoretical Model of Factors in Patient OutcomeGuideline QualityEfficient Education of Patient CaregiversWell-Functioning Chain of Survival at a Local LevelPatient Survival Relative to Theoretical Potential (Factors Multiplied)Utopia111≈1.00Ideal?0.90.90.9≈0.72Actual?0.80.50.5≈0.20Attainable?0.80.90.5≈0.32Universally, there is an urgent need to promote more and better CPR that is complementary to—and does not replace—policies aimed at providing earlier defibrillation. The impediments are formidable. Instruction must be provided on a large scale and must be readily accessible. Fears of infection and litigation must be countered with better information. Skills acquisition and retention, which are poor,5–9 must be improved by simplified procedures and better training methods, and ideally by both. Successful strategies to achieve these aims must therefore be a matter for international debate and concerted action. The potential exists for extending the window of opportunity for successful resuscitation with better survival rates.The need for improvement in the way CPR is taught has received scant attention but should no longer be ignored.Utstein Symposium on Education in ResuscitationAn international debate began at an educational symposium held June 22 to 24, 2001, at Utstein Abbey, on the island of Mosteroy, off the coast of Stavanger, Norway. The name Utstein is already associated with resuscitation because of previous conferences held at the abbey to discuss uniform reporting of out-of-hospital cardiac arrest,10,11 in-hospital cardiac arrest,12,13 and pediatric emergencies.14,15 Other meetings related to trauma16 and laboratory resuscitation research17,18 have also carried the name Utstein to signify international coordinated effort and agreement in these areas. Participants at 4 of these meetings have been active members of the national and international resuscitation organizations that make up the International Liaison Committee on Resuscitation (ILCOR). The Utstein symposium was held under the direct auspices of ILCOR but included independent invited experts in resuscitation education. Participating organizations were the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australia and New Zealand Resuscitation Council, the Resuscitation Council of Southern Africa, and the Consejo Latino-Americano de Resusucitación. The Japanese Resuscitation Council was also represented by an observer.Symposium ProcedureAfter an introductory session and discussion of planned expert presentations, participants divided into 4 panels during each of 2 sessions, making a total of 8 panels. After 1 hour of brief presentations and discussion with 2 moderators, the other panel members moved to other groups so that as many as possible could contribute to each topic. The moderators subsequently presented key points of the panel discussions to the whole group so that issues could be more widely debated, allowing refinement of conclusions and recommendations. All panel discussions were recorded after amendment during plenary sessions and were distributed for final comments to panel members and then the whole group. These 8 panel proceedings are available on request but have been condensed into this report as the definitive record of the Utstein education symposium. The discussions are presented under 7 major headings, each followed by recommendations that represent a consensus of participants.Subsequent ActionParticipants in the Utstein symposium regarded the meeting as the start of an ongoing process that must continue if its potential benefit is to be realized. If education in basic life support (BLS) is to become even near ideal, evidence-based change is required. Current methods and future developments must be tested by accepted methods. Teaching strategies should be evaluated and compared on the basis of how well learners achieve predefined teaching outcomes (see section 7, “Measurement of Teaching Outcomes”). No single method will be suitable for all circumstances. Thus, evaluation of training methods for purposes of research must be at a higher level than simple assessment of skills acquisition during routine community training. Sophisticated methods of outcome evaluation are warranted. One prototype for assessment discussed at the symposium is presented in Appendix 1 of this report. Scoring is as objective as possible; advanced recording capabilities were used on a manikin with a commercially available PC Skill Reporting System (Laerdal Medical, Norway). Although this has merit and has been validated as reproducible between observers, definitive tools are needed to ensure continuing improvement in the success of education in cardiopulmonary resuscitation.Discussions and Recommendations1. General Objectives in CPR TrainingThe ideal situation—someone attempts to provide BLS in every case of witnessed cardiac arrest in a community—is neither attainable nor even readily measurable. Other more practical objectives are required but have rarely been defined or debated. At present, the number of persons receiving training in any one area has been regarded as the principal measure of success, without measure of quality or benefit. This limited view has now come under scrutiny and is recognized as unsatisfactory.In advanced life support (ALS), limited success has been achieved in measuring the most relevant indicators of the value of CPR training: an increase in the proportion of victims who achieve return of spontaneous circulation, more hospital admissions after out-of-hospital cardiorespiratory arrest, more hospital discharges, and improved 1-year survival.19 Such measures require a highly organized system that is only rarely available, and similar data for BLS are more difficult to obtain. Therefore, more specific and detailed measurements of the quality of training in BLS are required.Symposium participants agreed that objectives in CPR training should be defined, and the best methods of achieving these objectives should be agreed on. Although such ambitious goals could not be achieved during a 2-day symposium, participants believed a start should be made and a mechanism found to continue debate and progress toward global influence. Established adult educational principles that encourage simplification should be adopted in resuscitation training.7 The result should achieve a measurable change in a potential rescuer’s behavior. Although this requires a cognitive element, demonstration of satisfactory performance must be the principal indication of success.8,20–30 Moreover, only improved training outcomes should justify changes in training techniques.22,31 An effective strategy is not necessarily the best strategy, but it can be used as an interim standard for testing new developments to provide continuing beneficial evolution in methodology.32–35The objectives of a training program form a hierarchy of steps toward the ultimate goal of improved outcome:The learner, preferably from a targeted group, will enroll in and complete the training experience in basic or ALS for adults or children.The learner will recognize an emergency and be able to summon help, including the use of an emergency response number.The learner will be able to demonstrate lifesaving CPR (including ALS/advanced cardiovascular life support [ACLS] or pediatric advanced life support [PALS]) on a manikin in a simulated scenario at the end of the training course.The learner will be able to perform the same lifesaving skill adequately 6 months after the training course.The learner will express confidence in his or her ability to act in an emergency.The learner will later be able to perform satisfactory CPR (or ALS/ACLS or PALS) in a real cardiac arrest.Survival rates after cardiac arrest and attempted resuscitation within the community will increase.Summary of Specific RecommendationsA template should be introduced for research on or evaluation of any educational intervention designed to improve resuscitation performance.The template should specify the target population and in particular whether it comprises laypersons, those with a duty to respond, or healthcare professionals.The template should specify which outcome is being tested, preferably with reference to the end points listed above.The template should specify the intervention in sufficient detail to permit replication and assessment of generalizability.2. Training Laypersons in Basic Life SupportCPR training of laypersons should follow an organized plan of implementation that targets 2 ends of the age spectrum. First are persons most likely to encounter someone in cardiac arrest, typically persons 40 years of age and older. Second, as a valuable long-term investment, instruction of schoolchildren is important because they are at an age when knowledge and skills are well retained; they are also relatively immune to social pressures and the fear of involvement that can be a negative influence in later years.36–41 Thus, the symposium participants strongly recommended that instruction in CPR be incorporated as a standard part of the school curriculum.More efficient use of resources is possible if attempts are made to attract volunteers who wish to participate and if programs focus on the learner’s personal objectives rather than on the more standardized objectives of training organizations.42Easy accessibility of training is a fundamental requirement that is often overlooked. Training should take place in a comfortable environment to make CPR appropriate in the familiar settings of everyday life. This implies some differences in the presentation of courses designed for the classroom, the work site, or the home.Most people who complete CPR training will not perform effective basic CPR even immediately after training.* This is because of (1) inadequate training of instructors who devote too much time to presenting information and too little time to hands-on practice and (2) lack of teaching methods appropriate for laypersons, which has a negative effect both on learning and psychosocial willingness to respond. Benefit to the community is also reduced by failure to target persons most likely to encounter someone in prehospital cardiac arrest.Instructors frequently fail to achieve satisfactory results from conventional courses, partly because they lack the necessary skills, but also because they allow insufficient time for practice. This has led to development of strategies that minimize the role of the instructor, who might be more appropriately called the facilitator.49–51 These strategies include video-based techniques: watch-then-practice or watch-while-you-practice (so-called synchronous self-instructional learning).27,41,52–61 Television instruction should also be considered.61 From the outset, immediate hands-on practice meets students’ expectations for training, helps prevent anxiety about skills performance that can be a barrier to learning, and increases the relevance of any necessary verbal information so that answers do not preempt questions. Television and video instruction can be adapted to any setting and both are particularly suitable for the lay student. Video-based self-training at home has been recommended for the general public but is less suitable for families or caregivers of persons at high risk.27,41,52,53,56,62 Whatever the method of instruction, the emphasis must be on a simple explanation of “pump and blow” techniques, but 2 additional skills may be added: control of bleeding and knowledge of when (and how) to move victims. These skills are easy to teach, readily understood, and of value in immediate management of life-threatening emergencies. Initial training must always include specific plans for refresher sessions because even the best instructional techniques are unlikely to impart permanent optimum skills and knowledge.63,64 The first session should therefore be presented as the first phase of a continuing process of learning and not as a once-only event.65,66A training session of 1 to 4 hours is limited as a means of providing sustained motivation for laypersons to act in a cardiac arrest emergency.67 The media can and should be encouraged to help through available contacts and by offering newsworthy stories of successful resuscitations.68,69 Accounts or images of lay people recognizing cardiac emergencies and providing effective interventions can be a powerful motivation to others. Celebrities from all walks of life can act as role models and contribute to the acceptability of CPR in the community. Increased confidence and willingness to respond to an emergency are best achieved by repeated practice in realistic role-playing scenarios with situations and environments students are most likely to encounter, although such a strategy is not always feasible.57,70,71Although there has been sporadic research since the 1960s on how effectively students acquire and retain CPR skills, only recently has attention turned to instructor competence and quality and relevance of courses.* Much more attention should be given to program development, quality of instruction, and evaluation of results.It is appropriate to assess how a lay rescuer responds to an emergency, shouts or phones for help, compresses the chest, and ventilates the lungs adequately. (For children, the order of priority for phoning, ventilation, and compression is different.) More specifically, these skills can be measured by rate of chest compressions, number of compressions given per minute, degree of chest depression or deformation, and ability to make the chest rise with ventilation. More detailed definitions for assessing actions associated with an educational intervention are shown in the draft template (Figure 1). Course development should be evidence based, and educational efficacy should be demonstrated before the course is conducted.73Download figureDownload PowerPointFigure 1. Utstein Education Template. Uniform definitions for reporting initial and remote outcomes from adult BLS training.Summary of Specific RecommendationsLearning objectives for training of lay rescuers must include the following: recognition of an emergency, ability to call an emergency response number, competence in compression and ventilation skills, and emotional preparation for the capability to act in an emergency.CPR training of laypersons should follow an organized plan of implementation that targets those most likely to encounter victims of cardiac arrest as well as young persons such as schoolchildren. Access to training courses or self-instruction must be readily available in the community.The definition of specific characteristics and needs of each training group should be an initial step in all curriculum development.Because conventional CPR instruction has not been sufficiently effective in developing skills performance, other instructional methods must be considered, including video-assisted instruction when more effective or appropriate.Certification should be restricted to a statement of course participation.Trainers/facilitators (for courses for laypersons or healthcare professionals) must have received appropriate instruction in facilitation learning and must attend training updates on a regular basis.Training should take place in an environment that is comfortable for learners and should use instructional methods that learners understand and use daily.The media should promote accounts and images of laypersons recognizing cardiac emergencies and intervening positively.Initial training must always include specific plans for refresher training.Research in CPR training must be encouraged and developed. The educational efficacy of new course content or methods should be demonstrated before the course is widely conducted.3. BLS Training of Laypersons With a Duty to RespondUntil recently, 2 broad classes of rescuers were recognized: healthcare professionals and lay bystanders. The increased use of automated external defibrillators (AEDs) in the community has brought to the fore another important class: persons who are not healthcare professionals but whose occupation includes a duty of care that has been expanded to include BLS and defibrillation.Symposium participants agreed on 3 important principles:This group does require a different type of training course.This course should be tailored to a specific occupational role.The evaluation must be competence-based and tailored to the participant’s occupational role.The following are characteristics of laypersons with a “duty to respond”:They have an increased probability of encountering someone in cardiac arrest.They are likely to be well motivated.They are likely to have only limited equipment available to them, ideally a pocket mask and an AED.They require training specific to their needs with particular attention to correct use of equipment.Their resuscitation training must be integrated into their occupational duties.It was agreed that any training program should be developed on the basis of an understanding of the primary occupational role and integrated with it. Resuscitation should not conflict with nor deflect from other occupational duties. Students must understand the integration of training and its implications with their primary occupation, particularly when the 2 aspects of duty have very different connotations, for example, the police officer who may need to use a gun or a pocket mask. The training course should take into account the time constraints of the primary role. A conventional BLS course for laypersons, appropriately modified, would probably provide an adequate basis for training but require additional time for training in the use of pocket masks and AEDs. Any move toward providing a more complex course or teaching ALS/ACLS skills should be strongly resisted: simplicity must be the keynote.Training could start in the classroom but should move quickly to scenario-based training through role playing within the appropriate work-related context. For learners to achieve the required performance, the course must train to a high standard and learners must take refresher courses at regular intervals. All training must be integrated with the learner’s primary occupational role. Training should be conducted by specially trained facilitators with training and resuscitation skills and experience in the learners’ primary occupation. These qualities are essential to motivate the learner, achieve credibility, and understand the learner’s specific occupational role. The learner’s occupation may influence the manner in which conventional CPR must be used, for example, in commercial aircraft. Although employers should cover the time and cost of training, employees should do their part in showing that these expenses will be used well on the job.Well-intentioned but ill-informed advice from bystanders who are healthcare professionals, especially those without experience in emergencies, is a frequent problem that can limit the effectiveness of first-responder interventions and must be addressed during training. Rivalry between professional peer groups is another concern that must be identified and diffused at an early stage if optimum benefit is to be attained. Healthcare professionals need to be aware of local first-responder groups, the type of training they receive, and their effectiveness and availability. Encouragement from healthcare professionals will help motivate lay rescuers who are first responders.Summary of Specific RecommendationsResuscitation training programs for those with a duty to respond must be developed and integrated with an understanding of the learners’ primary occupational roles.The training course should take into account the time constraints of the learners’ primary role and can be based on a conventional BLS course for laypersons with additional time for special requirements related to automated external defibrillation and role-related issues.Training must be conducted to a high standard; regular refresher courses are required.Certification of participation is likely to be appropriate, but any statement on competence will depend on the circumstances and must be decided locally.Training should be conducted by facilitators with skills in training and resuscitation and experience in the learners’ primary occupational roles.Trainers/facilitators must receive training in facilitating learning and must also be competent in assessment. This principle is applicable regardless of the level of the learners.The content and format of training needs frequent reevaluation.Quality control should be defined and scrupulously applied.The possibility of inappropriate advice from other healthcare professionals must be addressed during training, and rivalry between professional groups must be identified and countered.Good performance in real situations must be recognized and rewarded with positive feedback.Healthcare professionals must be aware of local first-responder groups.4. Training Healthcare Professionals in Basic Life SupportHealthcare professionals are reluctant to attend BLS courses, although numerous studies have shown that they are not uniformly proficient in BLS skills.74 Their level of skills retention is variable and generally poor.56,75–79 Requirements for BLS training for healthcare professionals vary significantly between countries. Some require certification or appropriate credentials, whereas others do not require certification or formal training.Training of healthcare professionals should be tailored to learners’ settings (prehospital versus in-hospital), individual roles (lone rescuer, team member, team leader), and educational background (doctor, nurse, paramedic). Specific work roles must also receive appropriate consideration. For example, the role, experience, expectations, and motivation of an emergency department nurse are likely to be different from those of a ward nurse; similar considerations should be given to an emergency department physician, whose responsibilities differ from those of a physician with an office-based practice. The elements of a course for healthcare professionals will therefore vary in format, content, and style, but the course objectives and cognitive and psychomotor evaluation should remain the same.All healthcare professionals should be able to demonstrate competency in the skills of BLS.77,78 Healthcare professionals should receive their initial training in BLS as students. In some environments the use of peer instruction (for example, doctor to doctor or nurse to nurse) may increase acceptance of BLS training.79 Self-instruction is acceptable, provided competence is achieved. Uniform evaluation of BLS competencies is required to assess the knowledge and skills of healthcare professionals.80Course design and training should adopt validated educational principles.7 Course content and educational messages should be tailored to each group, with simplicity as an acceptable goal,7 but training should include skills that the healthcare professional would generally need, including the use of adjunctive equipment. Examples of these special requirements are 2-person CPR; special resuscitation situations, such as trauma, drowning, and pregnancy; and adjuncts such as bag masks and AEDs. Use of realistic scenarios is important for contextual learning and relevance. Additional evaluation of different educational methods for use with healthcare professionals is needed.Summary of Specific RecommendationsAll healthcare professionals should be able to demonstrate competency in the skills of BLS.All healthcare professionals should also demonstrate their skills on a regular basis. Evidence is needed about the frequency of such demonstrations for a particular situation; currently a detailed general statement on frequency cannot be made.Courses and educational format should be based on validated educational principles.Content and messages should be tailored to each group, with simplicity as an acceptable goal.Certification of participation is likely to be appropriate, but a statement on competence will depend on circumstances and must be a matter for local decision.Healthcare professionals must receive their initial training in BLS while students.Use of peer instruction (eg, doctor to doctor or nurse to nurse) may improve acceptance of BLS training in some settings. Self-instruction is also acceptable. Competence should be demonstrated, regardless of the method of training used.5. Training Healthcare Professionals in Advanced SkillsCourses in advanced resuscitation skills are now well established in many countries.81 When these courses were first introduced, much instruction was didactic and lecture based. Although the emphasis has changed to action-oriented learning, even more responsibility should be placed on learners themselves. To promote this change, the term instructor should be changed to facilitator or another term compatible with peer-directed education.Evidence is still needed to demonstrate conclusively the benefits of advanced training in terms of educational and patient outco