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Teaching Life Support Competencies in Health Care –Assessment of

Current Practice and Recommendations

Bentham L, RN1, Lilford L, MD, PhD2, Mohammed M, MD3, Bullock I, MD 5

Bradburn S6, Fawdry R, MD4, Barach Paul, MD, MPH7

1Research Nurse, 2Professor of Clinical Epidemiology, 3Senior Research Fellow, Department

of Public Health and Epidemiology, 4Consultant Obstetrician, The University of

Birmingham, Edgbaston, Birmingham B15 2TT; 5RCN Institute, Radcliffe Infirmary, Oxford

OX2 6HE; 6University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital,

Birmingham; 7 Associate Professor, Department of Anesthesiology, University of Miami,

Florida, USA

Corresponding Author:

Professor R.J.Lilford

Tel: 0121 414 2226

Fax: 0121 414 7878

Email: r.j.lilford@bham.ac.uk

Counts: Total Words = 5997; Abstract word: 368; Tables 2; Figures 3.

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ABSTRACT

Objectives: The study sought: 1) to survey the type of courses teaching adult life support and

pre cardiac arrest management provided by UK hospitals and medical schools and required

by professional bodies; 2) to describe both the curriculum content and applied teaching

methods used the most popular in-hospital adult life support courses; and 3) to examine the

fidelity of adult life support courses and their implementation in England; 4) to stimulate

policy makers in other countries that are examining the utility and effectiveness of life

support courses

Methodology: We surveyed the prevalence, distribution and impact of the resuscitation

training population among UK health trusts. We conducted semi-structured telephone

interviews with a randomised sample (n=30), and then a detailed thematic analysis of written

and online course materials.

Results: We found a large number of both providers and types of life support courses for

health care professions, the public and special groups such as divers. All but one of the thirty

English NHS Hospitals surveyed provided adult life support courses. The Resuscitation

Council UK Advanced Life Support (ALS) course was run by a majority (n=20) of the acute

hospital trusts surveyed. Many hospitals ran ‘in-house’ courses alongside or in addition to the

national (franchised) courses. Our survey revealed that courses aimed at the recognition and

management of pre-arrest deterioration are now widely taught in hospitals (n=25). The survey

of UK medical schools (n=25) revealed that while life support training was provided at all

sites, courses varied and those aimed at the recognition and management of acutely ill

patients were provided by only six sites. Only three professional colleges surveyed (n=16)

required members to provide evidence of life support skill competence. Although many

hospital sites have endeavoured to customize the three most widely provided courses to

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produce ‘in-house’ courses, the franchised course format was followed with meticulous

fidelity.

Conclusions: There are a small number of market leaders for the main franchised

resuscitation courses. The teaching and provision of life support courses is now

institutionalised in the hospital sector. Courses are implemented with great fidelity when

compared by curriculum content. There has been a large increase in uptake of ‘pre-arrest’

courses. More study is needed to assess the impact of these courses on clinical care and

patient outcomes.

Key Words: Education, Resuscitation, Training, Advanced Life Support, patient safety,

simulation

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INTRODUCTION

Cardiopulmonary resuscitation has become an integral part of modern health care.

Cardiac arrest survival rates have been relatively static at around 20%, in recent years (1-3).

CPR is attempted in increasing numbers of patients and many of these patients are unlikely to

benefit from CPR (ref? Perkins/Soar). A United Kingdom (UK) meta-analysis of studies

examining survival rates of adult in-hospital patients after cardiopulmonary resuscitation

reported an immediate survival rate of one in three, with only one in eight patients likely to

survive to discharge (1).

In-hospital cardiac arrest improved survival is associated with rapid recognition of

need, initiation of resuscitation, the experience of the team and a shock-responsive rhythm.

The latter however, is particularly associated with short term survival (4-8). Variables

associated with decreased survival to discharge rates include infection on the day prior to

resuscitation, cancers, dementias, hypovolaemia, coronary artery disease and patient age over

65 years (1). Organisations such as ILCOR (the International Liaison Committee on

Resuscitation), the ERC (European Resuscitation Council) and the Resuscitation Council UK

(9) have developed treatment and education guidelines that form the basis of courses dealing

with the evaluation and management of cardiac arrest (10-12).

This study, commissioned by the National Patient Safety Agency (NPSA) to describe

life support courses currently available, is part of a larger study entitled ‘Teaching life

support and resuscitation competencies in health care – current practice and strategies for

future research’(13). The first section of the report compared and contrasted teaching

methods currently used in life support and resuscitation training against contemporary

educational theories of best practice, and against results of existing comparative studies of

different methods used to teach life support and resuscitation.

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The aim of this study, which forms the second section of the NPSA commissioned

report (13), was to describe current practice and address key issues by conducting four

separate studies of increasing focus (see Figure 1):

1. To provide a broad survey of all courses teaching life support for clinicians that are

currently available in the UK;

2. To survey courses dealing specifically with adult life support and identification and

management of antecedents to cardiac arrest (we refer to these in the text as ‘pre-

arrest management courses’), provided by UK hospitals and medical schools and to

examine the life support training requirements set by professional bodies;

3. To describe the organisation and teaching methods prescribed by three of the most

widely provided courses; and,

4. To examine the fidelity with which the prescribed courses are implemented in

England.

Deterioration leading to a cardiac arrest is often not sudden. Symptoms indicating

physiological deterioration have been recorded in patient notes around a mean of 6.5 hours

prior to cardiac arrest (14-16). The need for preventative clinical strategies, highlighted in

several studies, has led to the development of courses dealing with the recognition and

treatment of acute life-threatening conditions (15-18). There have been some intriguing data

from Australia and the US suggesting better patient survival with rapid response teams (19),

although Hillman, et al, in a multi-center study failed to show benefit (Hillman et al.

Introduction of the MET system: A cluster randomized controlled trial. Lancet

2005;365:2091-7).

In 2002 a Royal College of Physicians of London Working Party (20) recommended

that medical school postgraduate courses include in their curricula an acute medical

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emergencies course such as the Acute Life-threatening Events – Recognition and Treatment

(ALERT™) course. More recently a multi-agency working group (The Acute Care

Undergraduate Teaching Initiative – ACUTE) has been set up by the Resuscitation Council

UK to develop a module on safe care of acutely ill patients for the national undergraduate

medical curriculum (21).

Figure 1 goes @ here

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Project 1. A broad survey of al l courses teaching l i fe support for cl inicians , special ist groups and the public, that are currently avai lable in the UK

METHODS

This section contains a brief précis of the methodology for each survey in the study. A

more detailed account of the methodology is given in our report - ‘Teaching life support and

resuscitation competencies in health care - current practice and strategies for future

research’(13).

Compilation of UK Life Support courses

The survey compiled a database of courses in the UK that teach resuscitation, ranging

from adult life support and life support for particular groups of patients and courses for the

general public. This was achieved by carrying out expert input, internet searches, and by

conducting telephone inquiries.

A. Survey of adult life support courses and ‘pre-arrest management’ courses Hospital adult life support and ‘pre-arrest management courses’

The survey was undertaken to examine the number and type of courses teaching life

support in English NHS hospital trusts. Because of the considerable number and type of life

support courses currently available, including specialist courses, we focussed the survey on

courses concerned with the recognition and management of the collapsed or deteriorating

adult patient. An independent statistician was employed to make a random selection from a

list of 161 acute NHS hospital trusts obtained from an NHS website (22). Sites were allocated

a sample number (from 1 to 161). A random selection sample interval of 5.367 gave a

sample of 30 sites of 161 sites (first number 4.717). If a Resuscitation Officer could not be

contacted, or did not reply after 5 attempts by telephone interviewers, the next site on the list

of acute hospitals would be contacted.

A semi-structured telephone interview with resuscitation officers and resuscitation

managers was used at randomly selected sites to elicit the following information (13):

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1. The proportion of sites running hospital life support courses with automated external

defibrillation versus the proportion of hospital life support courses with manual

defibrillation;

2. The proportion of advanced life support courses that are ‘formally approved by

national bodies’ (we call these ‘franchised’) versus advanced life support courses, that

are ‘hospital designed, operated and quality assessed’ (we call these ‘in-house’).

3. The difference in the length of ‘franchised’ life support courses versus ‘in-house’ life

support courses.

4. The proportion of candidates attending ‘in-house’ versus ‘franchised’ hospital life

support courses of similar type.

5. The proportion of instructors to candidates in ‘franchised’ courses versus ‘in-house’

courses.

The questionnaire used to obtain this data is included in the main report as Appendix 3(a)

(13) and in this report as Appendix A.

B. Survey of life support training requirements for specialist health practitioners, by

professional accreditation or standard setting bodies

The survey identified life support training required by post-graduate medical

practitioners, professionals allied to medicine, midwives and nurses, in order to qualify for

membership of specialist medical or health colleges in the UK. The survey also identified the

continuing professional development training requirements of specialist medical

practitioners, nurses, midwives and professionals allied to medicine of each UK professional

accreditation or standard setting body.

Data were collected from on-line guidelines and course curricula, expert input, and

by contacting education departments of colleges included: Courses that trainees are required

to attend in order to achieve membership; Continuing Professional Development training

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requirements in order to maintain membership; Courses that trainees are recommended to

attend with no membership consequences.

C. Survey of UK medical school training

The survey identified the life support training offered to medical undergraduates from

a sample of 24 medical schools in the UK (23). Twenty-four medical schools were identified,

with successful data collection from twenty-one sites (87.5%). Information about training

requirements was established by obtaining online undergraduate curriculum (n = 4);

contacting the undergraduate dean or a sub-dean of each medical school (n =16); and by

contacting resuscitation officers (n =1).

D. Survey of course pedagogy

Life support courses

We studied the pedagogy of the most frequently provided (nationally approved -

‘franchised’) life support courses and focussed on courses dealing with the following

circumstances: the initial resuscitation of an adult, that has had an acute collapse in the

hospital, but not in the intensive care department or operating room (13). The study focussed

on courses provided by the Resuscitation Council (RCUK), the Advanced Life Support

Group (ALSG), and the Royal College of Surgeons (RCS Eng). Course materials and

instructor’s manuals were examined and senior teachers (typically course co-ordinators or

resuscitation officers) were interviewed in order to confirm our understanding of course

materials and explore the thinking on which the educational methods were predicated. The

number of trainees in 2002 attending each type of life support course developed by course

providers was established through telephone interviews with senior people from these groups

(13).

Courses for the recognition and management of adult acute life-threatening illnesses (‘pre-

arrest management courses’)

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The survey included courses designed to teach health practitioners about the early

identification and management of deteriorating patients. Courses that met the survey criteria

were identified during the telephone interviews with course coordinators of life support

courses, during telephone interviews with staff, while surveying internet sites of professional

accreditation/ standard setting bodies, and using internet search engines. Collection of data

concerning these courses was completed by a semi-structured telephone interview with life

support course coordinators; with organisers of courses with internet sites; and by

examination of course manuals, timetables and guidelines.

E. Detailed analysis of the fidelity with which courses are implemented

We further selected three types of courses – Immediate Life Support (ILS), Advanced

Life Support (ALS) and Advanced Trauma Life Support (ATLS). A survey of Basic Life

Support (BLS) courses has previously been published (24). A list of teaching centres for each

type of course was obtained from the course website or by consulting the provider of each

course. A semi-structured telephone interview was conducted (13) to determine, firstly, the

fidelity with which the course followed the prescribed pattern, and secondly, the reasoning

behind any deviations. The questionnaire used for this survey is included in the main report

as Appendix 3(b) (13). Findings from both the interview and questionnaire were analysed and

compared to increase the validity of data collected.

RESULTS

Narrative summary of results of UK Life Support courses

The search for courses revealed a large number of providers, offering many basic

and advanced life support courses. The courses are aimed at people ranging from hospital

staff to the general public. The type of courses varied from basic life support to specialised

courses. It became apparent from this search that a limited number of courses had become

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‘best of breed’ in their field. Detailed results of this search can be found in Appendix 9 of the

main report (13).

Narrative summary of the survey of adult life support courses at UK hospitals

Comparison of adult life support courses at NHS hospitals

Of the thirty hospitals that responded all but one ran life support courses. The site not

running courses did not have a resuscitation officer in post. The manager of the coronary care

unit (CCU) reported that there were no courses run by the hospital at the time of the survey.

This observation from our study indicates the importance of both training structures and

appropriate personnel to ensure that the essential training is provided. Figure 2 illustrates the

total number of basic life support (BLS), hospital life support with defibrillation (ILS) and

advanced life support (ALS) courses run by each site. It can be seen at once that while all but

one hospital ran courses, the type and number of courses is extremely variable.

Basic Life Support

‘Basic life support’ (BLS) courses in the survey included in-hospital BLS with or

without training in the use of airway adjuncts, and with or without training in practical skills

needed to support a cardiac arrest team. Twenty-one of the thirty sites (70%) described their

BLS courses as a mandatory requirement for all clinical staff, usually a response to the

Clinical Negligence Scheme for Trusts (CNST) that determine levels of insurance premiums.

Twenty-eight out of thirty sites surveyed (93%) ran a BLS course. Eleven (37%) sites ran an

‘out-of-hospital’ BLS course teaching life support without equipment. One site ran an in-

hospital life support course with automated external defibrillation, instead of a BLS course.

The results of the numbers of courses run by each site are detailed in Figure 2.

Immediate life support

Immediate life support (ILS) type courses consist of training in hospital life support

and include training in the use of manual or automated external defibrillation. Twenty-eight

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(93%) out of the thirty sites surveyed ran such courses. The RCUK ILS course was run by

twenty sites. Ten (33%) of the thirty sites ran both RCUK and ‘in-hospital’ courses. Eighteen

of the thirty sites surveyed ran only their own ‘in-hospital’ life support course with automated

external defibrillation or manual defibrillation training. Although the authors recognise that at

the time of data collection, the ILS course was still in its relative infancy (recent figures

demonstrate a large uptake of this course nationally, with 4,700 ILS one day and half day

recertification courses run and more than 40,000 candidates attending during 2004).

Of the fifty-three ILS type courses at the thirty sites surveyed, the total number of

hospital life support courses with manual defibrillation was twenty (38%), compared with a

total of thirty-three (62%) courses teaching hospital life support with automated external

defibrillation training. Of the fifty-three courses, twenty-three (43%) were franchised

Resuscitation Council UK courses, while the remaining thirty courses (57%) were in-house

designed, and operated.

Advanced Life Support

Advanced life support (ALS) courses consist of ILS plus teaching about team

leadership, drugs and peri-arrest situations and recognition of contributing causes such as

pneumothorax. Twenty (67%) of the thirty sites surveyed ran the Resuscitation Council UK

(RCUK) ALS course. Six of those sites also ran an in-house designed and operated course.

Six sites (20%) surveyed ran only an in-house designed, and operated ALS course. Four

(13%) of the sites surveyed did not run an ALS course.

Some resuscitation officers interviewed for the survey were concerned by not being

able to run more RCUK ALS courses. Reasons cited include: insufficient funding to provide

recommended RCUK life support courses (11 sites); lack of staff cover in order to release

medical and nursing staff attending a 3 day course (9 sites); and inability to employ enough

qualified instructors to run the course as per RCUK guidelines (5 sites). However, other

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resuscitation officers (7 sites) reported that they were sufficiently skilled and experienced in

designing and running courses teaching life support skills and did not require RCUK course

guidance. Our survey found that ‘in-house’ ALS courses are generally shorter than those

prescribed by the RCUK. Figure 3 illustrates this trend. Our survey also revealed that the

proportion of ‘Instructors to Candidates’ on courses was higher on RCUK ALS courses than

with in-house designed and operated ALS courses.

Hospital life support courses teaching manual defibrillation

Safe and effective manual defibrillation skills are required by medical staff that are

required to attend cardiac arrest calls, and those working in specialist fields (e.g.,

anaesthetics, coronary and intensive care), and by nurses working in specialist clinical areas

(e.g., coronary care, intensive treatment units and accident and emergency departments). The

RCUK recommends that staff requiring such training attend either the ILS or ALS course

(12). Where sites were unable, or did not wish to run the RCUK ALS course for these staff,

some reported that they ran the RCUK ILS course with manual defibrillation skills training,

while other sites reported that they ran their own in-house designed course to teach manual

defibrillation skills.

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Table 1 demonstrates the results of the survey question posed by the team as to whether the

in-house designed hospital life support courses with manual defibrillation training may be

taught to a greater number of candidates than ‘nationally formally approved (franchised)’

hospital life support courses with manual defibrillation. Results demonstrate that a greater

number of candidates are taught an ‘in-house manual defibrillation’ course than with the

RCUK manual defibrillation course.

Other ‘Pre-arrest management courses’

Twenty-five (83%) out of thirty sites run a course in the recognition and management

of acutely ill patients. Twenty-three (76%) out of thirty sites run the ALERT™ course. A

course teaching the recognition and treatment of anaphylaxis was offered to clinical staff at

fourteen (47%) of the thirty sites surveyed. Rhythm recognition was taught, as a separate

course, to clinical staff at ten of the sites. A course teaching Altered Airway Resuscitation

was only taught at one of the thirty sites in our sample. None of the thirty sites surveyed

purchased courses from private companies. However five (17%) of the thirty sites ran the

RCSEng Advanced Trauma Life Support (ATLS®) Course.

FIGURE 3 GOES @ HERE

TABLE 1 GOES @ HERe

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Narrative summary of survey of professional requirements

The General Medical Council (GMC), Nursing and Midwifery Council (NMC), nine

specialist medical colleges, ten colleges for Professions Allied to Medicine (PAMs), and four

medical/nursing support and representation bodies were included in this survey. Our detailed

findings are represented in Appendix 8 of the main report (13). Overall we noted an absence

of emphasis on life support training, other than a GMC recommendation on undergraduate

medical education. There were however three notable exceptions – the Royal College of

Anaesthetists and the Royal College of Paediatrics and Child Health, who require members to

be competent in advanced life support skills, and the Royal College of General Practitioners

(RCGP), which requires trainees to provide evidence of successful BLS training in order to

register.

Narrative summary of survey of UK medical schools

Data were successfully collected from associate, vice or sub-deans at twenty-one of

the twenty-four UK medical schools. More detailed results of this survey can be found in

Appendix 7 of the main report (13). An online undergraduate curriculum with information

about life support training was available from five medical schools. Fourteen sites responded

to our request for information, by email. Data were successfully obtained from four sites by

telephone. Life support training was provided at all twenty-one medical schools that

responded. In summary:

1. BLS was taught in 1st year at fifteen medical schools; in 3rd year at two sites and in

4th year at one 1 site.

2. ILS (RCUK) was taught in 3rd year at two sites. BLS and Defibrillation (non-RCUK)

was taught in 3rd year at three sites. ILS (RCUK) was taught in 5th year at seven sites.

3. ALS (RCUK) was taught in 4th year at three sites and in 5th year at four sites.

Advanced cardiac life support (ACLS/ non RCUK) was taught in 3rd year at one site.

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Survey of the content and pedagogy of life support and ‘pre-arrest management’ courses Life support courses

The survey results are reported in Appendix 4 of our main report (13). The content

and pedagogy of the three well defined, widely accessible courses can be are in table 2. We

contacted the course providers to establish the number of each course type run annually, and

the number of candidates attending courses annually. In summary:

• The RCUK ILS and ALS courses; the Royal College of Surgeons ATLS® course; the

Advanced Life Support Group MedicALS, and ALERT™ were the most widely

taught courses. The most widely provided course of those surveyed was the RCUK

ILS, of which 1833 courses were held in 2002. In the UK a total of 16,880 people

attended ILS courses in 2002. Detailed results of this survey are contained in

Appendix 6 of the main document (13).

‘Pre-arrest management’ courses

Of the five courses identified, six course coordinators were contacted to complete the

telephone interview. Appendix 5 of the main report contains a detailed results table (13). Two

of the six courses surveyed were ALERT™ (18). There was little variation between the two

ALERT™ courses surveyed in pedagogy or content apart from the amount of time spent on

practical skills teaching. There was, however, considerable variation in the pedagogy and

content of the remaining four courses. Trainees on the ALERT, MedicALS and IMPACT

courses spend a large amount of the overall course time in practical skills training, whereas M

& K Update and CB Nursing Updates provide only theoretical/didactic teaching. ALERT™,

MedicALS and IMPACT courses provide a pre-course manual for candidates while M & K

Update and CB Nursing Updates do not.

The ratio of trainee to instructor also varies considerably. MedicALS, IMPACT and

ALERT have ratios of 2 to 4 trainees to 1 instructor, while M & K Update and CB Nursing

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Updates both have ratios of 30 trainees to 1 instructor. Trainees on the MedicALS and the

IMPACT courses are assessed whereas the remaining courses had no assessment. The

ALERT™, M & K Update and CB Nursing Updates courses are aimed at a multidisciplinary

group, whereas the MedicALS and IMPACT courses are intended only for medical

practitioners. Trainees on all courses surveyed are able to claim Continuing Professional

Development points for attendance. It would seem that courses run by independent

commercial companies such as CB Nursing Updates and M & K Nursing Updates are

becoming increasingly popular. In 2002 alone, CB Nursing Updates ran 15 Acute Medical

Nursing Emergencies courses for a total of 600 nursing staff.

Fidelity of the Implementation of Courses

Immediate Life Support Courses (RCUK ILS)

ILS courses are provided and accredited by the RCUK. We surveyed a total of six ILS

courses from different hospital sites. Detailed results of this survey are contained in Appendix

4(a) of the main report (13). One site in the survey ran 2 different ILS courses. All our

sample courses had a pre-course manual, which was sent out to students in advance. Only

two of our sample courses altered their course content from that prescribed by the RCUK.

One course was aimed at final year medical students and the other course had two additional

lectures covering ‘do not attempt resuscitation’ policies, and clinical audit.

All sampled courses used the prescribed 4-stage teaching method (26) centred on

various clinical scenarios. All but one course used a 15-minute “Demonstration” exercise.

Two courses used “individual teaching” at skills stations, i.e., 1 instructor: 1 trainee, although

there was no requirement to do so. There was wide variation in the ratio of manikins to

trainees (1:2 to 1:5). Peer-led education was used in half of the surveyed courses. A formal

assessment process is not prescribed, although three courses incorporated a formal

assessment of skills such as defibrillation.

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Advanced Life Support Courses

We surveyed five ALS courses franchised by the RCUK at 5 different hospital sites.

Detailed results are presented in table form in Appendix 4(b) of the main report (13). All our

sample courses provided a pre-course manual, which was sent out to students in advance. No

variation in course content was seen between prescribed and sampled courses. Some variation

in pedagogy was found. One course simplified the course content and modified the prescribed

RCUK teaching algorithms. Whilst there is no requirement for 1:1 teaching, two courses

adopted 1:1 teaching at skills stations, arguing that this was essential to ensure proper transfer

of skills. Three of our sampled courses took twice as long (30 minutes) with

“Demonstrations”, compared to the prescribed 15 minutes. All courses surveyed used the

prescribed 4-stage teaching methods centred on various clinical scenarios (DETAILS)? Peer-

led education was used in all our surveyed courses. All surveyed courses assessed four basic

skills using a written assessment based on one or more clinical scenarios.

Advanced Trauma Life Support Courses

ATLS® courses are purveyed and prescribed by the Royal College of Surgeons of

England (RCSEng). We surveyed five ATLS® courses from different hospital sites. Detailed

results of this survey are presented in Appendix 4(c) of the main report (13). All courses in

our sample had a pre-course manual sent out to students in advance. None of our sample

courses altered their course content from that prescribed by the RCSEng.

Some variation in pedagogy was found. All but one (citing time constraints) of our

sampled courses used the prescribed 4-stage teaching method centred on various clinical

scenarios. Whilst the franchised course does not prescribe 1:1 teaching, three sites adopted a

1 instructor to 1 candidate ratio, if the instructors thought a candidate would benefit from

additional practical skills training in a skills station. One of the courses surveyed employed

actors to play patient roles, whereas the remainder used a manikin. Four of the courses used

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animal cadavers, but one did not. Education staff at the RCSEng, who were interviewed state

that animal cadavers need not be used, although the ATLS® manual indicates their use.

There was no variation in the mode of assessment and the number of skills assessed in our

sample courses.

DISCUSSION

Our study demonstrated that resuscitation training has become a widespread activity

across the UK hospital trusts, with courses available across a diverse range of situations.

Courses range from BLS for carers of people with heart disease to deep-sea diving courses.

Within hospitals it is now ‘institutionalised’ in the sense that permanent posts exist at most

centres and large numbers of staff attend courses. Indeed the coverage within hospitals is far

more comprehensive than in medical schools or professional colleges, suggesting that the

NHS, far from responding to the educational and standard setting bodies, has led the way. We

have no doubt that organisations such as the RCUK have been very influential in mentoring

this process.

One of our most striking findings is the extent to which ‘pre-arrest’ courses teaching

recognition and management of the deteriorating patient have caught on; the finding that

nearly half of all unexpected cardiac arrests are preceded by clear evidence of deteriorating

physiology to which no response is made, has been taken to heart. Research evidence is

currently being generated to measure the impact this has on mortality and morbidity, with a

real possibility existing that this will help reduce the number of both events and inappropriate

admissions to intensive care (16).

The team interviewed staff from independent commercial companies about the

number of nursing staff taking up places on their courses. One possible reason for the high

uptake of these two courses could be the relatively low cost for course attendance in

comparison to other courses, and that they provide practitioners with Continuing Professional

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Development points for attendance. Our survey revealed that only didactic teaching was used

to teach these courses. Given the emphasis that other course developers and educationalists

place on the use of practical skills training (12) the research team feel that questions remain

about the suitability or effectiveness, of courses offering only large-group lecture-based

teaching (29). Recent direction from one of the main providers (RCUK) demonstrates the

importance of adult learning principles shaping curriculum delivery, with high candidate

participation, experiential tools (standardized patients and simulation) and interactivity.

While the above courses might be insufficiently intensive many other courses may err

in the opposite direction. This applies particularly to the franchised RCUK courses. The

evidence we have presented shows that many hospitals prefer to run in house courses that are

less expensive in direct costs and in staff time. For example the RCUK ALS course, at the

time of the survey, involved 3 days of intensive training. There is some research evidence

(from educational theory) and direct evidence (from randomised trials) (13), casting doubt on

the benefits of such ‘deep immersion’ courses over shorter, modular (spaced) courses.

Although there is a very wide range of pre-existing knowledge and skill of

multidisciplinary staff undertaking some life support courses, it was interesting to note that of

all courses surveyed, only two sites tested the pre-course (baseline) knowledge and skill of

candidates. The recent ILCOR Advisory Statement on Education in Resuscitation (30)

emphasizes the importance of adapting course contents and teaching methods to the needs of

the candidate group being taught. Where there is no prior knowledge of a candidate’s skill

level a short baseline measure, or pre-test, provides instructors with the necessary knowledge

about a candidate’s training needs. Applying the same pre- and post-course test would also

provide useful feedback to instructors and researchers on the effectiveness of the course

contents as indicated by measurable behavioural change, i.e., practical life support skills

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acquisition and retention. Assessing the knowledge, skills and attitudes of the trainees would

help increase the chances of positive outcomes and sustained gains.

Although it was not a primary aim of the study, the research team was interested in

the efforts of course providers to update the life support treatment and management evidence

base of the course contents. ILCOR, the ERC and the RCUK, provide a good example of

groups working to provide a contemporary evidence base for clinicians. This evidence is

disseminated at a clinical level through the work of NHS trust resuscitation officers and

others involved in the teaching of RCUK courses. In a meeting with management staff of the

ALSG, the team discovered that the contents of courses is continually updated as new

evidence emerges. On completing an ALSG course, candidates are advised to log on

regularly to the BestBETS website (31) to update their knowledge.

What should be taught and to whom?

The need for life support skills is an issue faced by all healthcare professionals, not

just those who form emergency teams. Given that most clinicians will seldom be called upon

to do life support and that skills decay, a basic set of ALS skills must be taught to a wide

community while a smaller number receive training in a more extensive advanced skill set. A

recent ILCOR advisory statement on Resuscitation in Education (32) after an extensive

review of life support teaching studies, recommended the development of evidence-based,

educationally sound basic life support courses targeting providers that would be most likely

to attend a cardiac arrest. The idea of organisational training needs assessments also emerges

very strongly in the Salas and Cannon-Bowers review on the science behind training (33).

The challenge facing the training community is in targeting training to reflect the range and

scope of individual clinician’s clinical practice and required competencies.

The number of Resuscitation Officers (ROs or RTOs) has increased over the past 10

years and most hospitals now have a Resuscitation Service. The level and type of life support

24

courses used to train various grades of hospital staff is decided by trust Resuscitation

Committees. These are strongly influenced by the European Council Guidelines on Basic and

Advanced Life Support. BLS forms the major part of the standard level of resuscitation

training in most hospitals (34).

We found that:

1. When a hospital sets out to deliver a package of training they do so in a very

homogeneous way, both with respect to content and pedagogy.

2. There is considerable disagreement over who should receive which package. While

some hospitals (such as hospital 8 in our study) provide over 500 training slots per

year in BLS, but only a handful of slots at a more advanced level. Others, such as

hospital 9, offer many opportunities in immediate life support. Indeed, hospital 9

stopped using BLS and provides only ILS or ALS.

This invites the obvious question – should AED training be incorporated into all BLS

training courses thereby effectively converting them to ILS courses? The idea is supported by

the epidemiology - resuscitation is at least four times more successful when carried out in the

context of a shock-responsive rhythm than in other circumstances. Moreover, standard

monitors contain the ‘intelligence’ to discern such rhythms (35). It seems almost perverse to

install defibrillators in airports, stations, and shopping malls yet not make such equipment

available in acute hospital settings. Even if the proportion of cardiac arrests that have a

shock-responsive rhythm is higher in pre-hospital cases, than in hospital, the absolute

numbers in hospital are likely to be higher. Moreover the outcomes of cardiac arrest on the

wards have improved substantially since the installation of AEDs, and training in their use

was instituted, at the Hammersmith Hospital (36). We feel that all staff should be trained in

ILS pending much more widespread introduction of AED in hospitals. The controversy over

whether attempted defibrillation should be preceded or followed by chest compressions does

25

not need to be resolved in order to reach the conclusion that AED should be part of the most

basic life support training repertoire.

Historical precedent should no longer be allowed to dictate the provision of facilities

for defibrillation in hospitals. While defibrillation programmes have traditionally been

limited to critical care areas where nurses and physicians work together in recognising and

treating ventricular defibrillation, we think that defibrillators should now be more widely

available. These decisions should be informed by a detailed process mapping of needs

coupled with cost-effectiveness modelling. Early indications from the Department of Health

National Defibrillation Programme suggest that such a widespread provision would be cost

effective. Further work in this area is needed. The traditional idea that staff outside the

critical care area would be trained only to maintain the circulation until the arrival of the

resuscitation team is no longer defensible. Given that the success of defibrillation depends

more on the duration of ‘downtime’ than on the expertise of the practitioner (especially with

modern devices) it would seem sensible to make defibrillators more widely available.

A larger question is whether all clinical staff could be trained to provide such

widespread defibrillation cost effectively. Kaye and colleagues (37) have demonstrated that

staff located outside the critical care wards can easily be trained to use AEDs. Indeed staff

that had already been trained in BLS whether qualified or not can be trained to use AEDs in a

2-hour class. In short, little more is required than political will to modify existing courses

which staff are expected to take. Would it be cost effective to follow the policy explicated

here? We have argued that including defibrillation training in the repertoire of BLS would be

inexpensive, and the price of AEDs has fallen rapidly in recent years. Such modelling would

require an estimate of the frequency with which defibrillation is required on the general

wards along with estimates of the marginal gains in survival through the availability of local

AEDs. A single study in Italy (38) reports that 24 patients required resuscitation in the first 9

26

months following implementation of a first responder AED program. Nine of these patients

were in ventricular defibrillation and three survived to discharge. The research team

recommended that the NPSA convene a series of stakeholder meetings to develop a national

policy on this issue (13). We have recommended that a formal cost-effectiveness model be

commissioned to inform this point.

Conclusions

A large cottage industry has grown around the provision of life support courses.

Individual hospitals provide many original in-house courses and also purchase training via

external providers who franchise a smaller number of validated courses, e.g., RCUK ALS

and ILS courses. Most courses are associated with high opportunity costs such as requiring

staff to attend during work hours. As educational interventions, these courses have limited

evaluation in the same way as many other services for either effectiveness or cost

effectiveness.

Studies evaluating courses to teach life support have found that the effect on patient

mortality has not been measured with great precision. Any improvement appears to be

modest perhaps as a result of the well-documented decay in acquired skills. Inappropriate

cardiac arrest interventions in an ageing population in the absence of clear resuscitation status

decisions may also be a contributory factor. Recent trends are far more encouraging

following the emergence of the AED, supported by the wide spread training provision

discussed in this paper. Finally, having national courses based on accepted published

standards with defined regulations and assessments allows healthcare professionals to have

transferable skills between and across organizations.

Before and after studies show that knowledge improves and participants enjoy the

courses. Traditionally courses have been based on Basic, Immediate and Advanced skills.

Epidemiology shows that defibrillation is the most effective life support skill so this needs to

27

be introduced at the most basic level, along with increasing availability of AEDs. Individual

trusts, based on national minimum published standards should define the level of

defibrillation competency expected. Of the provision in the UK: there are a small number of

market leaders for the main externally franchised courses. These are implemented with great

fidelity when compared with the written curriculum description. Nationally, simulation

centres have been established to provide training and research opportunities. There has been a

large (and we think welcome) increase in uptake of ‘pre-arrest’ courses.

Overall, the courses are consistent with theory but there are still some unanswered

questions, for example: What is the optimum intensity and duration of courses? How well do

skills in the lab translate into actual clinical practice? What is the role of experiential learning

tools? How best to sustain this knowledge? How best to train teams of providers?

28

Acknowledgements

We would like to acknowledge and thank the following individuals for their significant

contribution to this project:

o Members of The Resuscitation Council UK in London - Sarah Mitchell, Jerry Nolan

o Members of The Advanced Life Support Group in Manchester – Sue Wieteska, Mike

Davis - assisted the research team by meeting to describe the organisation and

function of the ALSG, and by providing a matrix of course details.

o Representatives of the Royal College of Surgeons of England – Samantha Dilgert,

ATLS/PHTLS Coordinator; Judy Murfitt, BST Course Manager met with members of

the research team to provide details of the courses run by the RCSEng and to describe

the function and organisation of their education department.

o Gary Smith Consultant in Intensive Care Medicine, Honorary Senior Lecturer in

Critical Care, Portsmouth Hospitals NHS Trust & School of Postgraduate Medicine &

Director of the ALERT Course

o Above all, we thank the National Patient Safety Agency (NPSA) who sponsored the

study.

29

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35

TABLES AND FIGURES

Table 1. Comparison of Franchised (RCUK) manual defibrillation candidate numbers with

In-house candidate numbers

Site Number

Candidate Numbers (02-03)(Franchised)

Site Number

Candidate Numbers (02-03 )(In-house)

1 210 1 180 2 72 2 84 3 48 4 330 4 96 6 90 6 120 5 120 7 180 8 1248 8 120 9 175 9 432 10 180 11 48 11 250 12 384 13 36 13 288 14 36 14 240 15 72 15 72 16 96 16 336 17 20 17 32 18 120 18 210 19 144 20 48 22 192 21 180 23 282 22 150 24 36 30 84 27 180

Total 3350 (46.39%) Total 3871 (53.60%)

36

Course Key

Features Candidates Instructor:

Student ratio Duration Theory:

practical training

Assessment

RC ILS Ambu bag AED Role Play Teamwork

30 1:6 1 day

1:5 Written

RC ALS

ILS plus Leadership, drugs, arrthymias Simulation Peer-led education

30 1:3 3 day 1:4 Written 4 skills

RCS ATLS

ALS plus teamwork

20 1:2 3 day 1:4 Written Oral on 12 key tasks

Table 2—Comparison of the 3 main resuscitation courses

37

Figure 1. Schematic representation of the increasing focus of this research programme, beginning with a general summary of all courses and working toward a survey of pedagogic detail of particular courses

Project 1. A broad survey of all courses teaching life support for clinicians, specialist

groups and the public, currently

available in the UK.

Project 2. A survey of adult life support courses offered in UK hospitals

and medical schools, and of the life support training requirements set by

professional bodies. Summary of ‘pre-arrest management courses’.

Project 3. Detailed analysis of the contents and pedagogic methods of

the most widely purveyed adult life support courses in

England.

Project 4. A study of the

fidelity with which the

prescribed courses are

implemented in

England.

38

Figure 2. Survey of Adult Life Support Courses provided by NHS hospitals

-50

50

150

250

350

450

550

Sites surveyed

Num

ber

of C

ours

es fr

om D

ec 2

002

to D

ec 2

003

Basic Life Support 348 104 340 10 348 100 216 520 0 159 312 362 48 26 96 120 126 156 200 100 100 404 260 213 0 350 50 220 349 16

Immediate Life Support 48 167 24 18 40 114 67 12 276 70 60 24 25 29 12 24 6 22 0 24 69 72 41 53 0 30 15 260 12 15

Advanced Life Support 7 3 2 14 12 4 6 108 7 30 2 8 2 11 15 4 2 3 12 2 4 5 12 18 0 0 2 0 4 2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

39

0

5

10

15

20

25

30

RCUK Courses In-House Courses

Figure 3: Comparison of Length of RCUK: In-house ALS Courses

Legend?