The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation Quality Improvement Initiative.

OBJECTIVE: To evaluate the effect of implementing real-time audiovisual feedback with and without postevent debriefing on survival and quality of cardiopulmonary resuscitation quality at in-hospital cardiac arrest. DESIGN: A two-phase, multicentre prospective cohort study. SETTING: Three UK hospitals, all part of one National Health Service Acute Trust. PATIENTS: One thousand three hundred and ninety-five adult patients who sustained an in-hospital cardiac arrest at the study hospitals and were treated by hospital emergency teams between November 2009 and May 2013. INTERVENTIONS: During phase 1, quality of cardiopulmonary resuscitation and patient outcomes were measured with no intervention implemented. During phase 2, staff at hospital 1 received real-time audiovisual feedback, whereas staff at hospital 2 received real-time audiovisual feedback supplemented by postevent debriefing. No intervention was implemented at hospital 3 during phase 2. MEASUREMENTS AND MAIN RESULTS: The primary outcome was return of spontaneous circulation. Secondary endpoints included other patient-focused outcomes, such as survival to hospital discharge, and process-focused outcomes, such as chest compression depth. Random-effect logistic and linear regression models, adjusted for baseline patient characteristics, were used to analyze the effect of the interventions on study outcomes. In comparison with no intervention, neither real-time audiovisual feedback (adjusted odds ratio, 0.62; 95% CI, 0.31-1.22; p=0.17) nor real-time audiovisual feedback supplemented by postevent debriefing (adjusted odds ratio, 0.65; 95% CI, 0.35-1.21; p=0.17) was associated with a statistically significant improvement in return of spontaneous circulation or any process-focused outcome. Despite this, there was evidence of a system-wide improvement in phase 2, leading to improvements in return of spontaneous circulation (adjusted odds ratio, 1.87; 95% CI, 1.06-3.30; p=0.03) and process-focused outcomes. CONCLUSIONS: Implementation of real-time audiovisual feedback with or without postevent debriefing did not lead to a measured improvement in patient or process-focused outcomes at individual hospital sites. However, there was an unexplained system-wide improvement in return of spontaneous circulation and process-focused outcomes during the second phase of the study.

Improving the efficiency of advanced life support training: a randomized, controlled trial.

BACKGROUND: Each year, more than 1.5 million health care professionals receive advanced life support (ALS) training. OBJECTIVE: To determine whether a blended approach to ALS training that includes electronic learning (e-learning) produces outcomes similar to those of conventional, instructor-led ALS training. DESIGN: Open-label, noninferiority, randomized trial. Randomization, stratified by site, was generated by Sealed Envelope (Sealed Envelope, London, United Kingdom). (International Standardized Randomized Controlled Trial Number Register: ISCRTN86380392) SETTING: 31 ALS centers in the United Kingdom and Australia. PARTICIPANTS: 3732 health care professionals recruited between December 2008 and October 2010. INTERVENTION: A 1-day course supplemented with e-learning versus a conventional 2-day course. MEASUREMENTS: The primary outcome was performance in a cardiac arrest simulation test at the end of the course. Secondary outcomes comprised knowledge- and skill-based assessments, repeated assessment after remediation training, and resource use. RESULTS: 440 of the 1843 participants randomly assigned to the blended course and 444 of the 1889 participants randomly assigned to conventional training did not attend the courses. Performance in the cardiac arrest simulation test after course attendance was lower in the electronic advanced life support (e-ALS) group compared with the conventional advanced life support (c-ALS) group; 1033 persons (74.5%) in the e-ALS group and 1146 persons (80.2%) in the c-ALS group passed (mean difference, -5.7% [95% CI, -8.8% to -2.7%]). Knowledge- and skill-based assessments were similar between groups, as was the final pass rate after remedial teaching, which was 94.2% in the e-ALS group and 96.7% in the c-ALS group (mean difference, -2.6% [CI, -4.1% to 1.2%]). Faculty, catering, and facility costs were $438 per participant for electronic ALS training and $935 for conventional ALS training. LIMITATIONS: Many professionals (24%) did not attend the courses. The effect on patient outcomes was not evaluated. CONCLUSION: Compared with conventional ALS training, an approach that included e-learning led to a slightly lower pass rate for cardiac arrest simulation tests, similar scores on a knowledge test, and reduced costs. PRIMARY FUNDING SOURCE: National Institute of Health Research and Resuscitation Council (UK).

Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation.

OBJECTIVE: This study aims to explore the relationship between team-leadership skills and quality of cardiopulmonary resuscitation in an adult cardiac-arrest simulation. Factors affecting team-leadership skills were also assessed. DESIGN: Forty advanced life-support providers leading a cardiac arrest team in a standardized cardiac-arrest simulation were videotaped. Background data were collected, including age (in yrs), sex, whether they had received any leadership training in the past, whether they were part of a professional group, the most recent advanced life-support course (in months) they had undergone, advanced life-support instructor/provider status, and whether they had led in any cardiac arrest situation in the preceding 6 months. MEASUREMENTS AND MAIN RESULTS: Participants were scored using the Cardiac Arrest Simulation test score and Leadership Behavior Description Questionnaire for leadership skills. Process-focused quality of cardiopulmonary resuscitation data were collected directly from manikin and video recordings. Primary outcomes were complex technical skills (measured as Cardiac Arrest Simulation test score, preshock pause, and hands-off ratio). Secondary outcomes were simple technical skills (chest-compression rate, depth, and ventilation rate). Univariate linear regressions were performed to examine how leadership skills affect quality of cardiopulmonary resuscitation and bivariate correlations elicited factors affecting team-leadership skills.Teams led by leaders with the best leadership skills performed higher quality cardiopulmonary resuscitation with better technical performance (R = 0.75, p < .001), shorter preshock pauses (R = 0.18, p < .001), with lower total hands-off ratio (R = 0.24, p = .01), and shorter time to first shock (R = 0.14, p = .02). Leadership skills were not significantly associated with more simple technical skills such as chest-compression rate, depth, and ventilation rate. Prior training in team leader skills was independently associated with better leadership behavior. CONCLUSIONS: There is an association between team leadership skills and cardiac arrest simulation test score, preshock pause, and hands off ratio. Developing leadership skills should be considered an integral part of resuscitation training.

Advanced life support update.

INTRODUCTION: Cardiac arrest is a common emergency in acute hospitals. The Resuscitation Council (UK) Advanced Life Support Guidelines provide a systematic approach to cardiac arrest recognition, treatment and aftercare. This review provides an update on the current treatment guidelines and identifies areas where these may be strengthened. METHODS: The evidence informing the 2005 Resuscitation Guidelines is reviewed. New evidence since the publication of the guidelines was identified by searching Medline (December 2005-December 2008) with the term heart arrest or advanced life support. RESULTS: Opportunities for strengthening the chain of survival exist for each link. These include better recognition of critically ill patients at risk of cardiac arrest, improved quality of cardiopulmonary resuscitation, defibrillation strategies, which minimize pre- and post-shock pauses and development of post-resuscitation care bundles. CONCLUSION: Emerging evidence suggests opportunities where Resuscitation Guidelines could be strengthened by focusing on specific aspects of the chain of survival.

Compression feedback devices over estimate chest compression depth when performed on a bed.

INTRODUCTION: CPR feedback/prompt devices are being used increasingly to guide CPR performance in clinical practice. A potential limitation of these devices is that they may fail to measure the amount of mattress compression when CPR is performed on a bed. The aim of this study is to quantify the amount of mattress compression compared to chest compression using a commercially available compression sensor (Q-CPR, Laerdal, UK). A secondary aim was to evaluate if placing a backboard beneath the victim would alter the degree of mattress compression. METHODS: CPR was performed on a manikin on the floor and on a bed with a foam or inflatable mattress with and without a backboard. Chest and mattress compression depths were measured by an accelerometer placed on the manikin's chest (total compression depth) and sternal-spinal (chest) compression by manikin sensors. RESULTS: Feedback provided by the accelerometer device led to significant under compression of the chest when CPR was performed on a bed with a foam 26.2 (2.2)mm or inflatable mattress 32.2 (1.16)mm. The use of a narrow backboard increased chest compression depth by 1.9mm (95% CI 0.1-3.7mm; P=0.03) and wide backboard by 2.6mm (95% CI 0.9-4.5mm; P=0.013). Under compression occurred as the device failed to compensate for compression of the underlying mattress, which represented 35-40% of total compression depth. CONCLUSION: The use of CPR feedback devices that do not correct for compression of an underlying mattress may lead to significant under compression of the chest during CPR.

Quality of CPR during advanced resuscitation training.

INTRODUCTION: Previous studies have documented poor quality CPR during real life resuscitation attempts. This study investigated whether poor quality CPR during advanced life support training could be contributing to poor performance in clinical practice. METHODS: Observational study of quality of CPR during advanced life support training courses before and after the implementation of the European Resuscitation Council Guidelines 2005 into the ALS course. The quality of chest compressions were downloaded from a manikin and direct observations of no-flow time; pre-shock pauses were recorded. RESULTS: 94 cardiac arrest simulations were studied (46 before implementation of Guidelines 2005 and 48 after). Delays in starting CPR, inadequate compression depth, prolonged interruptions of chest compressions and excessive pre-shock pauses were identified. The introduction of Guidelines 2005 resulted in improvements in the number of compressions given per minute and a reduction in no-flow time and duration of pre-shock pauses, but overall the quality of CPR performed during the ALS course remained poor. There was little evidence of performance improving over successive simulations as the course progressed. CONCLUSION: The implementation of Guidelines 2005 into the ALS course appear to have improved the process of CPR by reducing no-flow time during simulated CPR. However, the quality of CPR during ALS training remains sub-optimal. Delays in starting CPR, inadequate compression depth, excessive interruptions in chest compressions and prolonged pre-shock pauses mirror observations from clinical practice. Strategies to improve CPR performance during ALS training should be explored and potentially may result in improvements in clinical practice.

The impact of manual defibrillation technique on no-flow time during simulated cardiopulmonary resuscitation.

INTRODUCTION: Rapid defibrillation is the most effective strategy for establishing return of spontaneous circulation following cardiac arrest due to ventricular fibrillation. The aim of this study is to measure the delay due to of charging the defibrillator during chest compression in an attempt to reduce the duration of the pre-shock pause in between cessation of chest compressions and shock delivery as advocated by the American Heart Association (AHA) guidelines compared to charging the defibrillator immediately following rhythm analysis without resuming chest compressions as recommended by the European Resuscitation Council (ERC). METHODS: This was a randomised controlled cross over trial comparing pre-shock pause times when defibrillation was performed on a manikin according to the AHA and ERC guidelines using paddles and hands free defibrillation systems. RESULTS: The pre-shock pause between cessation of chest compression and shock delivery was significantly different between techniques (Friedman test, P<0.0001). ERC paddles technique had the greatest pre-shock pause (7.4 s [6.7-11.2]) followed by ERC hands free (7.0 s [6.5-8.5]) and AHA paddles (1.6 s [1.1-2.3]). AHA hands free took the least amount of time (1.5 s [0.8-1.5]). Extrapolating these data to older defibrillators with longer charge times saw pre-shock pause intervals of 9 s (Codemaster XL) and 12 s (Lifepak 20) with the ERC approach. CONCLUSION: This study demonstrated clinically significant delays to defibrillation by analysing and charging the defibrillator without performing concurrent chest compressions. In a simulated scenario, charging the defibrillator whilst performing chest compressions was perceived as safe and significantly reduced the pre-shock pause between cessation of chest compression and shock delivery.

Advanced life support cardiac arrest scenario test evaluation.

BACKGROUND: The cardiac arrest scenario test (CASTest) is a central component of the assessment strategy on the Advanced Life Support Course. The aim of this study was to establish equivalence between the four different CASTest scenarios and investigate the impact of profession, candidate order and course centre on the pass rate. MATERIALS AND METHODS: This was a cluster randomised study. CASTest scenarios were randomly allocated to candidates stratified by course centre. Candidate demographics and performance were recorded on the criterion referenced check list along with the final assessment outcome (pass/fail). Differences in pass rates according scenario; profession, course centre and candidate order were examined by Chi-squared and multiple logistic regression. RESULTS: Two thousand, four hundred and forty-nine assessments from 65 course centres were evaluated. There was no difference in pass rate between scenarios (average pass rate 74.4%). Pass rates according to course centre varied widely (40-93%, P<0.0001) as did professional group (42-100%, P<0.0001). The order that candidates took the test did not influence the pass rate. CONCLUSION: The CASTest assessment scenarios used during ALS testing appear equivalent in terms of difficulty. In contrast, the professional background of the candidate and centre at which the assessment is performed do significantly influence the likelihood of passing the assessment. Further evaluation of the reasons for differences between course centres is required.

Recall after cardiac arrest scenario testing.

The Resuscitation Council (UK) Advanced Life Support (ALS) Course is a multidisciplinary training course which teaches participants how to manage the resuscitation of a patient at risk of or in cardiac arrest. To reduce variability in assessments, four standardised patient scenarios have been developed with common performance criteria. The aim of the study was to establish how much candidates remembered about their test in order to assess the potential for collusion. Eighty-nine candidates were asked immediately after testing what they remembered about their ALS scenario. Recall of the underlying problem with the simulated patient was good (85 [96%]). Forty-two [47%] correctly remembered the initial cardiac arrest rhythm and 55 [61%] the subsequent cardiac arrest rhythm. Fifty-nine [60%] candidates passed the assessment. Candidates who passed the assessment were significantly more likely to correctly recall the initial and subsequent cardiac arrest rhythms than those who did not. However, even in this group, the overall recall of all elements of the scenario was correct in only 49% of instances. This study demonstrated that immediately after testing candidates had good recall of the initial clinical scenario with which they were presented, but poor recall of cardiac arrest rhythms during the simulated resuscitation attempt. These findings provide some reassurance that the likelihood of successful collusion improving subsequent candidates performance is likely to be small as recall of the scenario progression is limited.

An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary resuscitation debriefing study.

BACKGROUND: The use of cardiac arrest educational debriefing has been associated with improvements in cardiopulmonary resuscitation (CPR) quality and patient outcome. The practical challenges associated with delivering some debriefing approaches may not be generalisable to the UK health setting. The aim of this study was to evaluate the deliverability and effectiveness of three cardiac arrest debriefing approaches that were tailored to UK working practice. METHODS: We undertook a before/after study at three hospital sites. During the post-intervention period of the study, three cardiac arrest educational debriefing models were implemented at study hospitals (one model per hospital). To evaluate the effectiveness of the interventions, CPR quality and patient outcome data were collected from consecutive adult cardiac arrest events attended by the hospital cardiac arrest team. The primary outcome was chest compression depth. RESULTS: Between November 2011 and July 2014, 1198 cardiac arrest events were eligible for study inclusion (782 pre-intervention; 416 post-intervention). The quality of CPR was high at baseline. During the post-intervention period, cardiac arrest debriefing interventions were delivered to 191 clinicians on 344 occasions. Debriefing interventions were deliverable in practice, but were not associated with a clinically important improvement in CPR quality. The interventions had no effect on patient outcome. CONCLUSION: The delivery of these cardiac arrest educational debriefing strategies was feasible, but did not have a large effect on CPR quality. This may be attributable to the high-quality of CPR being delivered in study hospitals at baseline. TRIAL REGISTRATION: ISRCTN39758339.

Electronic learning in advanced resuscitation training: The perspective of the candidate.

BACKGROUND: Studies have shown that blended approaches combining e-learning with face-to-face training reduces costs whilst maintaining similar learning outcomes. The preferences in learning approach for healthcare providers to this new style of learning have not been comprehensively studied. The aim of this study is to evaluate the acceptability of blended learning to advanced resuscitation training. METHODS: Participants taking part in the traditional and blended electronic advanced life support (e-ALS) courses were invited to complete a written evaluation of the course. Participants' views were captured on a 6-point Likert scale and in free text written comments covering the content, delivery and organisation of the course. Proportional-odds cumulative logit models were used to compare quantitative responses. Thematic analysis was used to synthesise qualitative feedback. RESULTS: 2848 participants from 31 course centres took part in the study (2008-2010). Candidates consistently scored content delivered face-to-face over the same content delivered over the e-learning platform. Candidates valued practical hands on training which included simulation highly. Within the e-ALS group, a common theme was a feeling of "time pressure" and they "preferred the face-to-face teaching". However, others felt that e-ALS "suited their learning style", was "good for those recertifying", and allowed candidates to "use the learning materials at their own pace". CONCLUSIONS: The e-ALS course was well received by most, but not all participants. The majority felt the e-learning module was beneficial. There was universal agreement that the face-to-face training was invaluable. Individual learning styles of the candidates affected their reaction to the course materials.

A simple solution for improving reliability of cardiac arrest equipment provision in hospital.

INTRODUCTION: Effective and safe cardiac arrest care in the hospital setting is reliant on the immediate availability of emergency equipment. The patient safety literature highlights deficiencies in current approaches to resuscitation equipment provision, highlighting the need for innovative solutions to this problem. METHODS: We conducted a before-after study at a large NHS trust to evaluate the effect of a sealed tray system and database on resuscitation equipment provision. The system was evaluated by a series of unannounced inspections to assess resuscitation trolley compliance with local policy prior to and following system implementation. The time taken to check trolleys was assessed by timing clinicians checking both types of trolley in a simulation setting. RESULTS: The sealed tray system was implemented in 2010, and led to a significant increase in the number of resuscitation trolleys without missing, surplus, or expired items (2009: n=1 (4.76%) vs 2011: n=37 (100%), p<0.001). It also significantly reduced the time required to check each resuscitation trolley in the simulation setting (12.86 (95% CI: 10.02-15.71) vs 3.15 (95% CI: 1.19-4.51)min, p<0.001), but had no effect on the number of resuscitation trolleys checked every day over the previous month (2009: n=8 (38.10%) vs 2011: n=11 (29.73%), p=0.514). CONCLUSION: The implementation of a sealed tray system led to a significant and sustained improvement in resuscitation equipment provision, but had no effect on resuscitation trolley checking frequency.

The impact of chest compression rates on quality of chest compressions - a manikin study.

PURPOSE: Chest compressions are often performed at a variable rate during cardiopulmonary resuscitation (CPR). The effect of compression rate on other chest compression quality variables (compression depth, duty-cycle, leaning, performance decay over time) is unknown. This randomised controlled cross-over manikin study examined the effect of different compression rates on the other chest compression quality variables. METHODS: Twenty healthcare professionals performed 2 min of continuous compressions on an instrumented manikin at rates of 80, 100, 120, 140 and 160 min(-1) in a random order. An electronic metronome was used to guide compression rate. Compression data were analysed by repeated measures ANOVA and are presented as mean (SD). Non-parametric data was analysed by Friedman test. RESULTS: At faster compression rates there were significant improvements in the number of compressions delivered (160(2) at 80 min(-1) vs. 312(13) compressions at 160 min(-1), P<0.001); and compression duty-cycle (43(6)% at 80 min(-1) vs. 50(7)% at 160 min(-1), P<0.001). This was at the cost of a significant reduction in compression depth (39.5(10)mm at 80 min(-1) vs. 34.5(11)mm at 160 min(-1), P<0.001); and earlier decay in compression quality (median decay point 120 s at 80 min(-1) vs. 40s at 160 min(-1), P<0.001). Additionally not all participants achieved the target rate (100% at 80 min(-1) vs. 70% at 160 min(-1)). Rates above 120 min(-1) had the greatest impact on reducing chest compression quality. CONCLUSIONS: For Guidelines 2005 trained rescuers, a chest compression rate of 100-120 min(-1) for 2 min is feasible whilst maintaining adequate chest compression quality in terms of depth, duty-cycle, leaning, and decay in compression performance. Further studies are needed to assess the impact of the Guidelines 2010 recommendation for deeper and faster chest compressions.

Quality of in-hospital cardiac arrest calls: a prospective observational study.

OBJECTIVE: To determine the quality and diagnostic accuracy of in-hospital adult clinical emergency calls. DESIGN: Prospective observational study. SETTING: Three National Health Service acute hospitals in England. PARTICIPANTS: Adult patients sustaining an in-hospital cardiac arrest (CA) or medical emergency (ME) which required activation of the hospital resuscitation team between 1 December 2009 and 30 April 2010. MAIN OUTCOME MEASURES: Emergency call duration, emergency team dispatch time, diagnostic accuracy of emergency call (sensitivity/specificity), thematic analysis of emergency call, patient outcomes (return of spontaneous circulation and survival to hospital discharge). RESULTS: There were 426 adult resuscitation team activations. There was variability in emergency call duration ranging from 6 to 92 s (median 15 s; IQR 12-19). The sensitivity and specificity of calls for a CA was 91% (86.4-94.6%) and 62% (55.5-68.7%), respectively. Sensitivity did not change with call duration but specificity increased from 38% (25.8-51.0%) for the shortest calls to 82% (69.5-89.6%) for longer calls; p=0.03. The return of spontaneous circulation rate was 38% for calls when the patient was confirmed as in CA upon arrival of the resuscitation team. Survival to hospital discharge rates was higher in patients with shorter call durations (26%) than calls with longer call duration (12%); p=0.028. Five themes emerged identifying reasons for the increased call delay. CONCLUSION: There is variability in duration and diagnostic accuracy of in-hospital emergency calls. This is associated with delayed activation of the emergency response. The attempt to differentiate between ME and CA is a source of confusion. A single clinical emergency response for CA and ME calls may provide a more focused and timely emergency response.

The effect of real-time CPR feedback and post event debriefing on patient and processes focused outcomes: a cohort study: trial protocol.

BACKGROUND: Cardiac arrest affects 30-35, 000 hospitalised patients in the UK every year. For these patients to be given the best chance of survival, high quality cardiopulmonary resuscitation (CPR) must be delivered, however the quality of CPR in real-life is often suboptimal. CPR feedback devices have been shown to improve CPR quality in the pre-hospital setting and post-event debriefing can improve adherence to guidelines and CPR quality. However, the evidence for use of these improvement methods in hospital remains unclear. The CPR quality improvement initiative is a prospective cohort study of the Q-CPR real-time feedback device combined with post-event debriefing in hospitalised adult patients who sustain a cardiac arrest. METHODS/DESIGN: The primary objective of this trial is to assess whether a CPR quality improvement initiative will improve rate of return of sustained spontaneous circulation in in-hospital-cardiac-arrest patients. The study is set in one NHS trust operating three hospital sites. Secondary objectives will evaluate: any return of spontaneous circulation; survival to hospital discharge and patient cerebral performance category at discharge; quality of CPR variables and cardiac arrest team factors. METHODS: All three sites will have an initial control phase before any improvements are implemented; site 1 will implement audiovisual feedback combined with post event debriefing, site 2 will implement audiovisual feedback only and site 3 will remain as a control site to measure any changes in outcome due to any other trust-wide changes in resuscitation practice. All adult patients sustaining a cardiac arrest and receiving resuscitation from the hospital cardiac arrest team will be included. Patients will be excluded if; they have a Do-not-attempt resuscitation order written and documented in their medical records, the cardiac arrest is not attended by a resuscitation team, the arrest occurs out-of-hospital or the patient has previously participated in this study. The trial will recruit a total of 912 patients from the three hospital sites. CONCLUSION: This trial will evaluate patient and process focussed outcomes following the implementation of a CPR quality improvement initiative using real-time audiovisual feedback and post event debriefing. TRIAL REGISTRATION: ISRCTN56583860.

The effect of pre-course e-learning prior to advanced life support training: a randomised controlled trial.

BACKGROUND: The role of e-learning in contemporary healthcare education is quickly developing. The aim of this study was to examine the relationship between the use of an e-learning simulation programme (Microsim, Laerdal, UK) prior to attending an Advanced Life Support (ALS) course and the subsequent relationship to candidate performance. METHODS: An open label, multi-centre randomised controlled study was conducted. The control group received a course manual and pre-course MCQ four weeks prior to the face to face course. The intervention group in addition received the Microsim programme on a CD. The primary outcome was performance during a simulated cardiac arrest at the end of the course. Secondary outcomes were performance during multiple choice exams, resuscitation skills assessments and feedback to Microsim programme. RESULTS: 572 participants were randomised (287 Microsim, 285 control). There were no significant differences in the primary outcome (performance during a standard cardiac arrest simulation) or secondary outcomes. User evaluations were favorable. 79% would recommend it to colleagues. 9% stated Microsim could replace the entire ALS course, 25% parts. Over 70% of participants' perceived that Microsim improved their understanding of the key learning domains of the ALS course. CONCLUSION: Distributing Microsim to healthcare providers prior to attending an ALS courses did not improve either cognitive or psychomotor skills performance during cardiac arrest simulation testing. The challenge that lies ahead is to identify the optimal way to use e-learning as part of a blended approach to learning for this type of training programme.

Validation for a scoring system of the ALS cardiac arrest simulation test (CASTest).

AIM: The cardiac arrest simulation test (CASTest) assesses resuscitation knowledge and skills during a simulated cardiac arrest. The aim of this study is to validate an alternative scoring system for measuring individual candidate performance during research involving the CASTest. METHODS: The performance of 537 participants was measured using the new scoring system. Evidence of internal structure was sought by comparing the score with global rating of performance and pass/fail decision; identification of participants with instructor potential, skill tests and MCQ scores. Relationships between CASTest score, profession and seniority were also examined. RESULTS: Global assessment of performance identified 413 passes (76.9%) and 124 fails (23.1%). CASTest score was significantly higher in those that passed than in those that failed (median 77 vs 62.5, P<0.0001). There were no differences between professions. Senior staff performed slightly better than junior staff (median 74 and 72 respectively, P=0.01). Excellent participants (identified as having instructor potential) scored significantly higher than the other participants (median 94 and 72 respectively, P<0.0001). A strong correlation was demonstrated between domains in the CASTest (rho 0.72-0.82, P<0.01). Other assessment outcomes for the ALS course correlated poorly with CASTest scores (rho 0.27-0.37, P<0.01). CONCLUSION: This new simple scoring system can be used to better characterise performance on the ALS course CASTest than the current binary pass-fail outcome.