Part 14: Education

There remains strikingly low survival rates for both OHCA and IHCA despite scientific advances in the care of cardiac arrest victims. The Formula for Survival suggests that cardiac arrest survival is influenced by high-quality science, education of lay providers and healthcare professionals, and a well-functioning Chain of Survival.1 Considerable opportunities exist for education to close the gap between actual and desired performance of lay providers and healthcare teams. For lay providers, this includes proficient CPR and AED skills and the self-efficacy to use them, along with immediate support such as dispatch-guided CPR. For healthcare providers, the goals remain to recognize and respond to patients at risk of cardiac arrest, deliver high-quality CPR whenever CPR is required, and improve the entire resuscitation process through improved teamwork. Additionally, there needs to be a feedback loop focused on continuous quality improvement that can help the system improve as well as identify needs for targeted learning/performance improvement. Optimizing the knowledge translation of what is known from the science of resuscitation to the victim’s bedside is a key step to potentially saving many more lives.

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 successfully perform resuscitation. “Part 14: Education” provides an overview of the educational principles that the AHA has implemented to maximize learning from its educational programs. It is important to note that the systematic reviews from which the Guidelines were derived assigned a hierarchy of outcomes for educational studies that considered patient-related outcomes as critical and outcomes in educational settings as important.

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Significant New and Updated Recommendations

The key recommendations based on the systematic reviews include the following:

  • The use of high-fidelity manikins for ALS training can be beneficial in programs that have the infrastructure, trained personnel, and resources to maintain the program. Standard manikins continue to be an appropriate choice for organizations that do not have this capacity.

Use of a CPR feedback device is recommended to learn the psychomotor skill of CPR. Devices that provide feedback on performance are preferred to devices that provide only prompts (such as a metronome). Instructors are not accurate at assessment of CPR quality by visual inspection, so an adjunctive tool is necessary to provide accurate guidance to learners developing these critical psychomotor skills. Improved manikins that better reflect patient characteristics may prove important for future training. Use of CPR quality feedback devices during CPR is reviewed in the Adult BLS and CPR Quality Part, “Part 5: Adult Basic Life Support and CPR Quality.”

  • Two-year retraining cycles are not optimal. More frequent training of BLS and advanced life support skills may be helpful for providers likely to encounter a cardiac arrest.
  • Although prior CPR training is not required for potential rescuers to initiate CPR, training helps people learn the skills and develop the self-efficacy to provide CPR when necessary. BLS skills seem to be learned as well through self-instruction (video or computer based) with hands-on practice as with traditional instructor-led courses. The opportunity to train many more individuals to provide CPR while reducing the cost and resources required for training is important when considering the vast population of potential rescuers that should be trained.
  • To reduce the time to defibrillation for cardiac arrest victims, the use of an AED should not be limited to trained individuals only (although training is still recommended). 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.
  • Precourse preparation, including review of appropriate content information, online/precourse testing, and/or practice of pertinent technical skills, may optimize learning from advanced life support courses.
  • 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.
  • Communities may consider training bystanders in compression-only CPR for adult OHCA as an alternative to training in conventional CPR.

Knowledge Gaps

  • Research on resuscitation education needs higher-quality studies that address important educational questions. Outcomes from educational studies should focus on patient outcomes (where feasible), performance in the clinical environment, or at least long-term retention of psychomotor and behavioral skills in the simulated resuscitation environment. Too much of the current focus of educational research is on the immediate end-of-course performance, which may not be representative of participants’ performance when they are faced with a resuscitation event months or years later. Assessment tools that have been empirically studied for evidence of validity and reliability are foundational to high-quality research. Standardizing the use of such tools across studies could potentially allow for meaningful comparisons when analyzing evidence in systematic reviews to more precisely determine the impact of certain interventions. Cost-effectiveness research is needed because many of the AHA education guidelines are developed in the absence of this information.
  • The ideal methodology (ie, instructional design) and frequency of training required to enhance retention of skills and performance in simulated and real resuscitations needs to be determined.


  1. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JP; Utstein Formula for Survival Collaborators. The formula for survival in resuscitation. Resuscitation. 2013;84:1487–1493. doi: 10.1016/j.resuscitation. 2013.07.020.
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Part 14: Education