Part 14: Education

    Key Words:
  • cardiopulmonary resuscitation
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1
Introduction

Resuscitation education is primarily focused on ensuring widespread and uniform implementation of the science of resuscitation (eg, the Scientific Statements and Guidelines) into practice by lay and healthcare providers.

Resuscitation education aims to close the gap between actual and desired performance by assisting lay and healthcare providers in mastering CPR skills and the self-efficacy to use them by:

  • supplementing training with in-the-moment support, such as dispatch-assisted CPR;
  • improving healthcare professionals’ ability to recognize and respond to patients at risk for cardiac arrest;
  • improving resuscitation performance (including CPR);
  • ensuring continuous quality improvement activities to optimize future performance through targeted education.

Thousands of lives could potentially be saved every year in the United States through the simple approach of ensuring that cardiac arrest victims receive care consistent with the state of resuscitation evidence.

2
Willingness to Perform

2.1
Barriers to Bystander CPR

Because panic can significantly impair a bystander’s ability to perform in an emergency, it may be reasonable for CPR training to address the possibility of panic and encourage learners to consider how they will overcome it. (Class IIb LOE C) (2010 Part 16)

Interviews with actual bystanders and surveys of the general public report that people more recently trained in CPR techniques expressed greater willingness to attempt resuscitation than those without recent training.

Short, self-directed video instruction is an effective and cost-efficient strategy for training rescuers.

Fear of harming the victim or fear of personal harm (ie, infection or injury) may reduce willingness to undertake basic life support training or to perform CPR.

Educating the public about the low risks to the rescuer and victim may increase willingness to perform CPR.

Some rescuers, including healthcare providers, may be more likely to initiate CPR if they have access to barrier devices.

Despite the low risk of infections, it is reasonable to teach rescuers about the use of barrier devices emphasizing that CPR should not be delayed for their use. (Class IIa, LOE C) (2010 Part 16)

Rescuers who are not willing to perform mouth-to-mouth ventilation may be willing to perform Hands-Only (chest compression-only) CPR.

CPR training programs should teach compression-only CPR as an alternative to conventional CPR for rescuers when they are unwilling or unable to provide conventional CPR. (Class I, LOE B) (2010 Part 16)

Note: Because most cardiac arrests in children are asphyxial in origin, children should receive conventional CPR (ie, compressions with breaths).

Conventional CPR (chest compressions and rescue breaths) should be provided for pediatric cardiac arrests. (Class I, LOE B-NR) (2015 Part 11)

However, because compression-only CPR is effective in [pediatric] patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-only CPR for infants and children in cardiac arrest. (Class I, LOE B-NR) (2015 Part 11)

2.2
Barriers to Recognition of Cardiac Arrest

Gasping is commonly misinterpreted as a sign of life or evidence of breathing that may prevent rescuers from initiating resuscitation.

Rescuers should be taught to initiate CPR if the adult victim is unresponsive and is not breathing or not breathing normally (ie, only gasping). (Class I, LOE B) (2010 Part 16)

Dispatcher CPR instructions substantially increase the likelihood of bystander CPR performance.

We recommend that emergency dispatch centers offer CPR instructions and empower dispatchers to provide such instructions for adult patients in cardiac arrest. (Class I, LOE C-LD) (2019 Systems of Care)

We recommend that emergency medical dispatch centers offer dispatch-assisted CPR instructions for presumed pediatric cardiac arrest. (Class I, LOE C-LD) (2019 PBLS)

Dispatchers should instruct callers to initiate CPR for adults with suspected out-of-hospital cardiac arrest. (Class I, LOE C-LD) (2019 Systems of Care)

We recommend that emergency dispatchers provide CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress. (Class I, LOE C-LD) (2019 PBLS) There is insufficient evidence to make a recommendation for or against dispatch-assisted CPR instructions for pediatric cardiac arrest when bystander CPR is already in progress.

2.3
Barriers to AED Use

Some rescuers may be intimidated by the idea of delivering a shock, but AEDs are safe, and adverse events are rare.

Although AEDs can be used effectively with no prior training, even brief training increases the willingness of a bystander to use an AED and improves his or her performance.

To maximize willingness to use an AED, public-access defibrillation training should continue to be encouraged for the lay public. (Class I, LOE B) (2010 Part 16)

3
Educational Design

Evidence-based instructional design is essential to improve training of providers and ultimately improve resuscitation performance and patient outcomes.

The quality of rescuer performance depends on learners integrating, retaining, and applying the cognitive, behavioral, and psychomotor skills required to perform resuscitation successfully

Well-designed resuscitation education informed by adult learning theories and educational science increases the likelihood that learners will develop the self-efficacy to use the skills they learned when faced with a resuscitation scenario.

The development of the AHA courses are guided by core educational principles (see Table 1), including deliberate, hands-on practice, where feedback and debriefing should support participants’ development toward mastery.

Consistent with established methodologies for program evaluation the effectiveness of resuscitation courses should be evaluated. (Class I, LOE C) (2010 Part 16)

Table 1: Core AHA Emergency Cardiovascular Care Educational Concepts

An essential component of resuscitation education is the experiential learning that occurs through simulation and the associated debriefing.

Kolb’s experiential learning cycle provides a framework of 4 stages that are required to consolidate learning (Figure 1). [ from: Kolb DA. Experiential Learning: Experience as the Source of Learning Development. Englewood Cliffs, NJ: Prentice-Hall Inc; 1984]

For most individuals participating in resuscitation courses, clinical resuscitations are rare events, emphasizing the importance of learning from simulated scenarios so that they are able to act when the real-life events occur.

By engaging learners in scenarios and guiding them through a debriefing, instructors can maximize knowledge transfer to real-life events.

Critical to this learning process is the notion that the experience is not enough to promote a change in practice.

Experience needs to be coupled with a constructive debriefing, allowing for guided reflection that can promote change in performance.

AHA courses promote the use of structured and supported debriefing by using the GAS (gather-analyze-summarize) model of debriefing paired with evidence-based scripted debriefing tools.

Figure 1: Experiential learning cycle
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As a part of the educational process, attention to functional task alignment is necessary to ensure that learners take away the appropriate skills.

Realism

  • By aligning the nature and degree of realism with the predetermined learning objectives and/or tasks, the instructor is deliberately targeting realism to the learning need.
  • Greater attention to promoting realism of the simulation scenario with respect to timing, duration, and integration of tasks with accompanying feedback creates a learning environment best suited to improving learning outcomes.

Mastery Learning

  • There is substantial evidence to suggest that mastery learning is the key to skill retention and the prevention of rapid decay in skills and knowledge after simulation-based learning.
  • The goal of mastery learning is to have learners achieve the highest standards for all educational outcomes instead of simply meeting the minimum standard. Flexibility is necessary for mastery learning to occur because the time required for learners to meet this mastery standard may vary.

Assessment

  • Summative assessment (ie, assessment conducted at the end of training that is compared with a standard or benchmark) is required to ensure that intended learning outcomes are met.
  • Formative assessment (ie, low stakes assessment with little to no “point” value in the course) provides clarity to learners about what the important desired outcomes are and provides practical advice to learners on where they can improve and how to do it (so-called assessment for learning).

Early and ongoing faculty development is a priority, as are the development and implementation of appropriate assessment tools with evidence of validity and reliability.

The degree to which a learner masters the material depends on the instructor’s expertise and the debriefing process.

Helping learners understand why the course is important (ie, the relevance) and how it applies to their situation is critical in motivating adult learners.

Familiarity with and respect for learners prior experience and defining how their learning in the course can help them care for loved ones or their patients can be particularly useful.

During debriefing, learners reflect on their performance during the simulation, performance gaps are identified and corrected, and “take-home” messages are generalized to maximize learning.

Without debriefing, learners are unlikely to improve nontechnical skills, decision-making abilities, situational awareness, and team coordination.

4
Basic Life Support Training

4.1
CPR Instruction Methods

CPR self-instruction through video- and/or computer-based modules paired with hands-on practice may be a reasonable alternative to instructor-led courses. (Class IIb, LOE C-LD) (2015 Part 14)

This recommendation is based on the absence of differences in learner outcomes, the benefits of increased standardization, the likely reduction of time and resources required for training, and learner preferences.

4.2
Automated External Defibrillator (AED) Training Methods

Allowing the use of automated external defibrillators (AEDs) by untrained bystanders should be encouraged when trained individuals are not immediately available.

Allowing the use of AEDs by untrained bystanders can be beneficial and may be lifesaving. (Class IIa, LOE B) (2010 Part 16)

Although AEDs can be used effectively without prior training, even brief training increases the willingness of a bystander to use an AED and improves individual performance.

A combination of self-instruction and instructor-led teaching with hands-on training can be considered as an alternative to traditional instructor-led courses for lay providers. If instructor-led training is not available, self-directed training may be considered for lay providers learning AED skills. (Class IIb, LOE C-EO) (2015 Part 14)

Self-directed methods can be considered for healthcare professionals learning AED skills. (Class IIb, LOE C-EO) (2015 Part 14)

4.3
CPR Feedback/Prompt Devices in Training

Mastery learning requires accurate assessment of CPR skills and feedback to help learners improve subsequent performance.

Use of feedback devices can be effective in improving CPR performance during training. (Class IIa, LOE A) (2015 Part 14)

If feedback devices are not available, auditory guidance (eg, metronome, music) may be considered to improve adherence to recommendations for chest compression rate only. (Class IIb, LOE B-R) (2015 Part 14)

4.4
Debriefing

Debriefing is a learner-focused, nonthreatening technique to assist individual rescuers or teams to reflect on, and improve, performance.

Debriefing as a technique to facilitate learning should be included in all advanced life support courses. (Class I, LOE B) (2010 Part 16)

4.5
Retraining Intervals for BLS

The standard retraining period for BLS is every 2 years, despite growing evidence that BLS knowledge and skills decay rapidly after initial training.

There is insufficient evidence to determine the optimal method and timing of BLS recertification. Given the rapidity with which BLS skills decay after training, coupled with the observed improvement in skill and confidence among students who train more frequently, it may be reasonable for BLS retraining to be completed more often by individuals who are likely to encounter cardiac arrest. (Class IIb, LOE C-LD) (2015 Part 14)

BLS skill maintenance needs to be appropriately tailored for potential provider groups, based on their setting and experience and the feasibility of more frequent training.

5
Advanced Life Support Training

5.1
Precourse Preparation

To maximize learning from an ALS training program, an adult learner should be well prepared before attending such a program.

Instructors are responsible for providing an optimal learning environment that will assist motivated trainees in acquiring and refining appropriate skills.

Precourse preparation, including review of appropriate content information, online/precourse testing, and practice of pertinent technical skills is reasonable before attending ALS training programs. (Class IIa, LOE C-EO) (2015 Part 14)

5.2
Team and Leadership Training

Effective management of a patient in cardiac arrest requires a team-based approach with providers who have the knowledge, clinical skills, interpersonal communication skills, and leadership skills to perform effectively in a high- stakes environment.

This also requires a team leader who has the ability to provide oversight of the team and guidance for specific tasks, while maintaining a heightened level of situational awareness of the entire resuscitation process.

Given very small risk for harm and the potential benefit of team and leadership training, the inclusion of team and leadership training as part of ALS training is reasonable. (Class IIa, LOE C-LD) (2015 Part 14)

5.3
Manikin Fidelity

The use of high-fidelity manikins for adult and pediatric ALS training can encourage learners to engage physically and emotionally with the manikin and the environment, thus helping to promote teamwork, clinical decision making, and full participant immersion within the experiential learning environment.

High-fidelity manikins are generally defined as manikins that provide physical findings (such as heart and breath sounds, pulses, chest rise and fall, and blinking eyes), display vital signs that correlate with physical findings, and “physiologically” respond to medical intervention through an operator-controlled computer interface.

Many high-fidelity manikins also allow participants to actually perform some critical care procedures, including bag-mask ventilation, intubation, intraosseous needle insertion, and/or chest tube insertion.

The use of high-fidelity manikins for ALS training can be beneficial for improving skills performance at course conclusion. (Class IIa, LOE B-R) (2015 Part 14)

The usefulness of high-fidelity manikins for improving knowledge at course conclusion and skills performance beyond course conclusion is uncertain. Given the increased cost associated with high-fidelity training, the use of high-fidelity manikins is particularly appropriate in programs where existing resources (ie, human and financial resources) are already in place.

6
Retraining Intervals for ACLS

Given the potential educational benefits of short, frequent retraining sessions coupled with the potential for cost savings from reduced training time and removal of staff from the clinical environment for standard refresher training, it is reasonable that individuals who are likely to encounter a cardiac arrest victim perform more frequent manikin-based retraining. (Class IIa, LOE C-LD) (2015 Part 14)

There is insufficient evidence to recommend the optimum time interval for retraining of ACLS providers. (2015 Part 14)

7
Checklists/Cognitive Aids

The impact of cognitive aids or checklists on patient outcomes is unknown.

Checklists or cognitive aids, such as the AHA algorithms, may be considered for use during actual resuscitation. (Class IIb, LOE C) (2010 Part 16)

When checklists are used, providers are encouraged to evaluate specific checklists and cognitive aids to determine if they achieve the desired effect and do not result in negative consequences such as delayed actions.

8
Special Considerations

8.1
Compression-Only CPR Training in Communities

Compression-only (Hands-OnlyTM) CPR has been advocated as a method of training laypeople that is simpler to learn and may increase bystander willingness to provide CPR.

Communities may consider training bystanders in compression-only CPR for adult out-of-hospital cardiac arrest as an alternative to training in conventional CPR. (Class IIb, LOE C-LD) (2015 Part 14)

Communities should consider existing bystander CPR rates and other factors, such as local epidemiology of out-of-hospital cardiac arrest and cultural preferences, when deciding on the optimal strategy for community CPR training.

8.2
CPR Training in Resource-Limited Environments

It may be reasonable to use alternative instructional modalities for BLS and/or ALS teaching in resource- limited environments. (Class IIb, LOE C-LD) (2015 Part 14)

8.3
CPR for High-Risk Populations

Training primary caregivers and/or family members of high-risk patients may be reasonable, (Class IIb, LOE C-LD) although further work needs to help define which groups to preferentially target. (2015 Part 14)

8.4
Resuscitation Training in Limited-Resource Communities

Many AHA instructors are involved in training in limited-resource environments in the United States and throughout the world.

The vast majority of participants reportedly enjoy training and feel more comfortable after educational programs, regardless of the type of training provided.

Improvements in provider performance and patient outcomes are inconsistent following training in resource-limited environments.

Resuscitation training, when appropriately adapted to the local providers’ clinical environment and resources, has significantly reduced mortality in developing countries.

There is no strong evidence to support any specific instruction method as preferable for all clinical environments and types of training.

9
Authorship and Disclosures

9.1
2015 Writing Team

Farhan Bhanji, Chair; Aaron J. Donoghue; Margaret S. Wolff; Gustavo E. Flores; Louis P. Halamek; Jeffrey M. Berman; Elizabeth H. Sinz; Adam Cheng

Table 2: Part 14: Education: 2015 Guidelines Update Writing Group Disclosures

9.2
2010 Writing Team

Farhan Bhanji, Chair; Mary E. Mancini; Elizabeth Sinz; David L. Rodgers; Mary Ann McNeil; Theresa A. Hoadley; Reylon A. Meeks; Melinda Fiedor Hamilton; Peter A. Meaney; Elizabeth A. Hunt; Vinay M. Nadkarni; Mary Fran Hazinski

Table 3: 2010 - Guidelines Part 16: Education Implementation and Teams Writing Group Disclosures

10
Footnotes

The American Heart Association requests that this document be cited as follows:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 14: Education. ECCguidelines.heart.org.

© Copyright 2015 American Heart Association, Inc.

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References