The nationwide impact of COVID-19 on life support courses. A retrospective evaluation by Resuscitation Council UK.

Aim: To determine the impact of the COVID-19 pandemic on Resuscitation Council UK Advanced Life Support (ALS) and Immediate Life Support (ILS) course numbers and outcomes. Methods: We conducted a before-after study using course data from the Resuscitation Council UK Learning Management System between January 2018 and December 2021, using 23 March 2020 as the cut-off between pre- and post-pandemic periods. Demographics and outcomes were analysed using chi-squared tests and regression models. Results: There were 90,265 ALS participants (51,464 pre-; 38,801 post-) and 368,140 ILS participants (225,628 pre-; 142,512 post-). There was a sharp decline in participants on ALS/ILS courses due to COVID-19. ALS participant numbers rebounded to exceed pre-pandemic levels, whereas ILS numbers recovered to a lesser degree with increased uptake of e-learning versions. Mean ALS course participants reduced from 20.0 to 14.8 post-pandemic (P < 0.001).Post-pandemic there were small but statistically significant decreases in ALS Cardiac Arrest Simulation Test pass rates (from 82.1 % to 80.1 % (OR = 0.90, 95 % CI = 0.86-0.94, P < 0.001)), ALS MCQ score (from 86.6 % to 86.0 % (mean difference = -0.35, 95 % CI -0.44 to -0.26, P < 0.001)), and overall ALS course results (from 95.2 %to 94.7 %, OR = 0.92, CI = 0.85-0.99, P = 0.023). ILS course outcomes were similar post-pandemic (from 99.4 % to 99.4 %, P = 0.037). Conclusion: COVID-19 caused a sharp decline in the number of participants on ALS/ILS courses and an accelerated uptake of e-learning versions, with the average ALS course size reducing significantly. The small reduction in performance on ALS courses requires further research to clarify the contributing factors.

Blended learning for accredited life support courses - A systematic review.

Aim: To evaluate the effectiveness on educational and resource outcomes of blended compared to non-blended learning approaches for participants undertaking accredited life support courses. Methods: This review was conducted in adherence with PRISMA standards. We searched EMBASE.com (including all journals listed in Medline), CINAHL and Cochrane from 1 January 2000 to 6 August 2021. Randomised and non-randomised studies were eligible for inclusion. Study screening, data extraction, risk of bias assessment (using RoB2 and ROBINS-I tools), and certainty of evidence evaluation (using GRADE) were all independently performed in duplicate. The systematic review was registered with PROSPERO (CRD42022274392). Results: From 2,420 studies, we included data from 23 studies covering fourteen basic life support (BLS) with 2,745 participants, eight advanced cardiac life support (ALS) with 33,579 participants, and one Advanced Trauma Life Support (ATLS) with 92 participants. Blended learning is at least as effective as non-blended learning for participant satisfaction, knowledge, skills, and attitudes. There is potential for cost reduction and eventual net profit in using blended learning despite high set up costs. The certainty of evidence was very low due to a high risk of bias and inconsistency. Heterogeneity across studies precluded any meta-analysis. Conclusion: Blended learning is at least as effective as non-blended learning for accredited BLS, ALS, and ATLS courses. Blended learning is associated with significant long term cost savings and thus provides a more efficient method of teaching. Further research is needed to investigate specific delivery methods and the effect of blended learning on other accredited life support courses.

Characteristics of Restart a Heart 2019 event locations in the UK.

INTRODUCTION: Restart a Heart (RSAH) is an annual CPR mass training initiative delivered predominantly by ambulance services in the UK. The aim of this study was to identify to what extent voluntary participation in the 2019 initiative delivered training to the population with the highest need. METHODS: A cross-sectional observational study of location characteristics for RSAH training events conducted by UK ambulance services. Descriptive statistics were used to analyse event and area characteristics. National cardiac arrest registry data were used to establish proportions of training coverage in "hot spot" areas with above national median incidence of cardiac arrest and below median bystander CPR rates. The significance of observed differences were tested using chi-square for proportions and t-test for means. RESULTS: Twelve of 14 UK ambulance services participated, training 236,318 people. Most of the events (82%) were held in schools, and schoolchildren comprised most participants (81%). RSAH events were held in areas that were less densely populated (p < 0.001), were more common in affluent areas (p < 0.001), and had a significantly lower proportion of black residents (p < 0.05) and higher proportion of white residents (p < 0.05). Events were held in 28% of known "hot spot" areas in England. CONCLUSION: With mandatory CPR training for school children in England, Scotland and Wales there is an opportunity to re-focus RSAH resources to deliver training for all age groups in OHCA "hot spots", communities with higher proportions of black residents, and areas of deprivation. In Northern Ireland, we recommend targeting schools in areas with similar characteristics.

Spaced learning versus massed learning in resuscitation - A systematic review.

AIM: Skill decay is a recognised problem in resuscitation training. Spaced learning has been proposed as an intervention to optimise resuscitation skill performance compared to traditional massed learning. A systematic review was performed to answer 'In learners taking resuscitation courses, does spaced learning compared to massed learning improve educational outcomes and clinical outcomes?' METHODS: This systematic review followed the PRISMA guidelines. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 2 December 2019. Randomised controlled trials and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using RoB, ROBINS-I tool and GRADEpro respectively. Educational outcomes studied were skill retention and performance 1 year after completion of training; skill performance between completion of training and 1 year; and knowledge at course conclusion. Clinical outcomes were skill performance at actual resuscitation, patient survival to discharge with favourable neurological outcome. This systematic review was registered in PROSPERO (CRD42019150358). RESULTS: From 2,042 references, we included data from 17 studies (13 randomised studies, 4 cohort studies) in courses with manikins and simulation in the narrative synthesis. Eight studies reported results from basic life support training (with or without automatic external defibrillator); three studies reported from paediatric life support training; five were in neonatal resuscitation and one study reported results from a bespoke emergency medicine course which included resuscitation teaching. Fifteen out of seventeen studies reported improved performance with the use of spaced learning. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Heterogeneity across studies precluded any meta-analyses. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. There was also insufficient data to examine the effectiveness of spaced learning on laypeople compared to healthcare providers. CONCLUSIONS: Despite the very low certainty of evidence this systematic review suggests that spaced learning can improve skill performance at 1 year post course conclusion and skill performance between course conclusion and 1 year. There is a lack of data from this educational intervention on skill performance in clinical resuscitation and patient survival at discharge with favourable neurological outcomes.

"All citizens of the world can save a life" - The World Restart a Heart (WRAH) initiative starts in 2018.

"All citizens of the world can save a life". With these words, the International Liaison Committee on Resuscitation (ILCOR) is launching the first global initiative - World Restart a Heart (WRAH) - to increase public awareness and therefore the rates of bystander cardiopulmonary resuscitation (CPR) for victims of cardiac arrest. In most of the cases, it takes too long for the emergency services to arrive on scene after the victim's collapse. Thus, the most effective way to increase survival and favourable outcome in cardiac arrest by two- to fourfold is early CPR by lay bystanders and by "first responders". Lay bystander resuscitation rates, however, differ significantly across the world, ranging from 5 to 80%. If all countries could have high lay bystander resuscitation rates, this would help to save hundreds of thousands of lives every year. In order to achieve this goal, all seven ILCOR councils have agreed to participate in WRAH 2018. Besides schoolchildren education in CPR ("KIDS SAVE LIVES"), many other initiatives have already been developed in different parts of the world. ILCOR is keen for the WRAH initiative to be as inclusive as possible, and that it should happen every year on 16 October or as close to that day as possible. Besides recommending CPR training for children and adults, it is hoped that a unified global message will enable our policy makers to take action to address the inequalities in patient survival around the world.

e-Learning in Advanced Life Support-What factors influence assessment outcome?

AIM: To establish variables which are associated with favourable Advanced Life Support (ALS) course assessment outcomes, maximising learning effect. METHOD: Between 1 January 2013 and 30 June 2014, 8218 individuals participated in a Resuscitation Council (UK) e-learning Advanced Life Support (e-ALS) course. Participants completed 5-8h of online e-learning prior to attending a one day face-to-face course. e-Learning access data were collected through the Learning Management System (LMS). All participants were assessed by a multiple choice questionnaire (MCQ) before and after the face-to-face aspect alongside a practical cardiac arrest simulation (CAS-Test). Participant demographics and assessment outcomes were analysed. RESULTS: The mean post e-learning MCQ score was 83.7 (SD 7.3) and the mean post-course MCQ score was 87.7 (SD 7.9). The first attempt CAS-Test pass rate was 84.6% and overall pass rate 96.6%. Participants with previous ALS experience, ILS experience, or who were a core member of the resuscitation team performed better in the post-course MCQ, CAS-Test and overall assessment. Median time spent on the e-learning was 5.2h (IQR 3.7-7.1). There was a large range in the degree of access to e-learning content. Increased time spent accessing e-learning had no effect on the overall result (OR 0.98, P=0.367) on simulated learning outcome. CONCLUSION: Clinical experience through membership of cardiac arrest teams and previous ILS or ALS training were independent predictors of performance on the ALS course whilst time spent accessing e-learning materials did not affect course outcomes. This supports the blended approach to e-ALS which allows participants to tailor their e-learning experience to their specific needs.

E-learning in advanced life support--an evaluation by the Resuscitation Council (UK).

AIM: To descriptively analyse the outcomes following the national roll out of an e-Learning advanced life support course (e-ALS) compared to a conventional 2-day ALS course (c-ALS). METHOD: Between 1st January 2013 and 30th June 2014, 27,170 candidates attended one of the 1350 Resuscitation Council (UK) ALS courses across the UK. 18,952 candidates were enrolled on a c-ALS course and 8218 on an e-ALS course. Candidates participating in the e-ALS course completed 6-8h of online e-Learning prior to attending the 1 day modified face-to-face course. Candidates participating in the c-ALS course undertook the Resuscitation Council (UK) 2-day face-to-face course. All candidates were assessed by a pre- and post-course MCQ and a practical cardiac arrest simulation (CAS-test). Demographic data were collected in addition to assessment outcomes. RESULTS: Candidates on the e-ALS course had higher scores on the pre-course MCQ (83.7%, SD 7.3) compared to those on the c-ALS course (81.3%, SD 8.2, P<0.001). Similarly, they had slightly higher scores on the post-course MCQ (e-ALS 87.9%, SD 6.4 vs. c-ALS 87.4%, SD 6.5; P<0.001). The first attempt CAS-test pass rate on the e-ALS course was higher than the pass rate on the c-ALS course (84.6% vs. 83.6%; P=0.035). The overall pass rate was 96.6% on both the e-ALS and c-ALS courses (P=0.776). CONCLUSION: The e-ALS course demonstrates equivalence to traditional face-to-face learning in equipping candidates with ALS skills when compared to the c-ALS course. Value is added when considering benefits such as increased candidate autonomy, cost-effectiveness, decreased instructor burden and improved standardisation of course material. Further dissemination of the e-ALS course should be encouraged.

Management of minor head injuries according to NICE guidelines and changes in the number of patients requiring computerised tomography imaging in a district general hospital: a retrospective study.

The objective of this study was to investigate how many patients with minor head injury would have required computerised tomography (CT) imaging if they were to be managed according to the National Institute of Clinical Excellence (NICE) guidelines (June 2003) and the difference in workload for patients presenting out of hours at Calderdale Royal Hospital, Halifax. The study was a retrospective cohort analysis of patient's notes presenting with head injury at Calderdale Royal Hospital, Halifax. The data set comprised case notes of 844 patients with head injuries, 400 adults and 444 children attending the Accident and Emergency department from January to June 2003. The case notes were evaluated according to the NICE guidelines for the indications for CT imaging for the time that they presented to the Accident and Emergency department, and how many of them actually underwent CT imaging. The number of patients who required CT imaging and how many of them presented out of hours (between 17:00 and 21:00 hours on weekdays and at any time on weekends). Ten patients underwent CT imaging for minor head injuries from January to June 2003. Eighty-eight patients required CT imaging if they were to be managed according to the NICE guidelines. Sixty-three per cent of these patients presented out of hours when a radiologist was not available in the hospital. Adhering to the NICE guidelines would significantly increase the number of patients requiring CT imaging. A significant proportion of these patients would present out of hours.

Recognition of death and termination of cardiac resuscitation attempts by UK ambulance personnel.

OBJECTIVES: To identify whether the practice of the UK ambulance trusts comply with national recommendations with respect to when ambulance personnel are allowed to recognise death and/or terminate resuscitation attempts in the adult, normothermic, non-traumatic cardiac arrest. METHODS: Questionnaire study of 39 ambulance trusts. RESULTS: At the time of the study (summer 2000), 23 trusts operated separate policies for recognition of death and termination of resuscitation, two had policies for recognition of death alone, two had policies for termination of resuscitation alone, five operated a policy purely for termination of resuscitation attempts after a limited period of CPR, and seven had no protocols other than "the presence of rigor mortis, postmortem staining or injuries incompatible with life". Only eight trusts conformed to the protocols for both recognition of death and termination of resuscitation attempts recommended by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). CONCLUSION: The JRCALC has proposed guidelines for recognition of death and terminating resuscitation attempts in the adult normothermic non-traumatic cardiac arrest. Despite this, there was still considerable variance in the practice of the UK ambulance trusts.

Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital.

OBJECTIVE: To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce 'life extinct' in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management. DESIGN: Qualitative study involving semi structured interviews and a focus group. SETTING: Accident & Emergency (A&E) departments in the Yorkshire region. PARTICIPANTS: Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region. RESULTS: Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues. CONCLUSION: The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.

'Clearance' of cervical spine injury in the obtunded patient.

The need to exclude cervical spine injury ('clearance') in an obtunded patient poses a dilemma. The purpose of this study was to find out the current practices for tackling this situation around the country. A questionnaire was sent to all Intensive Care Units who accept injured patients. There is a great diversity in the management and investigation of these patients. There is clearly a need for a recognised protocol for dealing with this difficult situation. Such a protocol is suggested.