Are cardiac arrest patient outcomes improved as a result of a member of the resuscitation team having attended an accredited advanced life support course: EIT 4000

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Andy Lockey is a Trustee of Resuscitation Council UK – who provide NLS training.

CoSTR Citation

Lockey A, Patocka C, Lauridsen K, Finn J, Greif, T on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Are cardiac arrest patient outcomes improved as a result of a member of the resuscitation team attending an accredited advanced life support course Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2022 Jan 24. Available from: http://ilcor.org

Methodological Preamble

The previous (2020) Taskforce Systematic Review to address the PICOST was an adolopment of an existing published systematic review (Lockey, Lin, & Cheng, 2018). It was confined to participants of adult A(C)LS courses only.

This proposed (2021/22) review will consist of updated searches and evidence updates for this type of course, but also expanded the remit to similar accredited advanced life support courses covering newborn, and paediatric patients.

The results from the expanded search strategy (shown below) are presented for three separate contexts, namely

Following consultation with the EIT T/F members, it was decided to deal with the findings of this updated and expanded search(shown below) in the following manner:

(1) Advanced Life Support (ALS): one additional study was identified (Pareek, Parmar, Badheka, & Lodh, 2018) and this was included as an update to a previous systematic review (Lockey et al., 2018)

(2) Neonatal Resuscitation Training (NRT): one systematic review of all NRT approaches (Patel, Khatib, Kurhe, Bhargava, & Bang, 2017) was included as an Adolopment process. No further studies were identified in the search.

(3) Helping Babies Breather (HBB): one systematic review addressing ‘Helping Babies Breathe’ course was included as Adolopment process (Versantvoort et al., 2020). One additional study identified on updated search and included in the appraisal (Innerdal et al., 2020).

Definitions

Accredited advanced life support courses are defined as structured advanced life support courses that have been approved by a professional organization (e.g. national resuscitation council). Basic life support and First Aid courses are excluded from this definition.

Background and Rationale: A previous Worksheet (EIT 4000) recommended the provision of accredited adult ALS training for healthcare providers (weak recommendation, very low-certainty evidence). The purpose of this Worksheet is to expand the search to participants of other advanced life support courses covering patients of all age groups.

Attendance of participants on advanced life support courses comes at a cost – both financial and time – to stakeholders, including participants themselves and their institutions. It is therefore important to show whether this participation has any meaningful impact on patient outcomes.

PICOST

(Population, Intervention, Control, Outcomes, Study design and Timeframe)

Consensus on Science

This review identified 18 studies covering the adult advanced life support course (ALS, n=1), Neonatal Resuscitation Training courses (NRT, n=11) and the Helping Babies Breathe course (HBB, n=6). In addition, two review articles were identified, one of which covered NRT and the other covered HBB.

Adult Advanced Cardiac Life Support (ALS/ACLS)

An update was performed for the previous ILCOR systematic review to include the newly identified study (Pareek et al., 2018). This retrospective descriptive study from India involving an AHA certified course when added to previously identified evidence, confirmed very low-certainty evidence that support the conclusions from the previous ILCOR CoSTR. An updated GRADE table is presented below (Table 1) as an attachment:EIT 4000 Upgraded GRADE table

Neonatal Resuscitation Training (NRT)

One systematic review was identified (Patel et al., 2017) covering all Neonatal Resuscitation Training approaches. No additional studies were identified through our search. This systematic review satisfied the AMSTAR-2 criteria for adolopment as defined by the ILCOR Adolopment Process document (9 January 2021, available at ICOR.org). Data were extracted and analysed for hospital-based studies only, and this is presented in Table 2. These were all pre and post intervention studies from low to middle resource settings. The changes were significant in all the outcomes; except 28-day neonatal mortality. Statistical and clinical heterogeneity was significant in all outcomes except all stillbirths. Despite the heterogeneity of evidence, all analyses show a consistent treatment effect (improved outcomes) for this training with the potential for many lives saved.

Table 2 NRT outcomes from hospital only studies

Helping Babies Breathe (HBB)

One systematic review was identified (Versantvoort et al., 2020) covering the ‘Helping Babies Breathe’ course. This systematic review satisfied the AMSTAR-2 criteria for adolopment as defined by the ILCOR Adolopment Process document (9 January 2021, available at ICOR.org). All of the included studies were from low-resource areas. They concluded that there was moderate evidence for a decrease in intrapartum-related stillbirth and 1-day neonatal mortality rate after implementing the ’Helping Babies Breathe’ training and resuscitation method. One additional study was identified in our search, which concluded that HBB may be effective in a local first-level referral hospital in Mali (Innerdal et al., 2020). An appraisal of this study was made using the same tool used in the Versantvoort systematic review. The conclusion of this appraisal using the McMaster Critical Review form was that the Innerdal study is of moderate quality and that the findings are consistent with the Versantvoort analysis without changing their result. Although the study is of moderate quality based on the McMaster Critical Review Tool, we recognize that within GRADE methodology this ‘before and after’ study would be considered low quality.

Treatment Recommendations:

We recommend the provision of accredited advanced life support training (adult ACLS/ALS) for healthcare providers who provide advanced life support care for adults. (strong recommendation, very low-certainty evidence)

We recommend the provision of accredited courses in Neonatal Resuscitation Training (NRT/NRP) and Helping Babies Breathe (HBB)) for healthcare providers who provide advanced life support care for newborns and babies. (strong recommendation, very low-certainty evidence.

We have made a discordant recommendation (strong recommendation despite very-low certainty evidence) because we have placed a very high value on an uncertain but potentially life preserving benefit, and the intervention is not associated with prohibitive adverse effects

Justification and Evidence to Decision Framework Highlights

In making this recommendation, the EIT task force considered the following:

• We recognize that the evidence in support of this recommendation comes from studies of very low quality and relate to a range of courses run in different resource settings around the world over a large time period.
• Despite this, the studies show a consistent treatment effect for this training with potential for many lives saved
• The provision of NRT and HBB training is feasible in low and middle resource settings

Task Force Knowledge Gaps

We identified several knowledge gaps in the published literature.

• Best combination of settings
• Trainee characteristics and training/recertification frequency to sustain the existing effect on patient outcomes
• Impact of other advanced life support courses on patient outcomes
• Impact of blended learning approaches
• Impact of modifications necessitated by COVID-19 pandemic

Recommended 2022 CoSTR:

We recommend the provision of accredited advanced life support training (adult ACLS/ALS) for healthcare providers who provide advanced life support care for adults (strong recommendation, very low-certainty evidence)

We recommend the provision of accredited courses in Neonatal Resuscitation Training (NRT/NRP) and Helping Babies Breathe (HBB) for healthcare providers who provide advanced life support care for newborns and babies. (strong recommendation, very low-certainty evidence)

• Values and preferences statement: In making this recommendation we recognize that the evidence in support of this recommendation comes from studies of very low quality and relate to a range of courses run in different resource settings around the world over a large time period.
• The provision of NRT and HBB training is feasible in low and middle resource settings.
• Knowledge gaps: best combination of settings, trainee charecteristics and training/recertification frequency to sustain the existing effect on patient outcomes. Impact of other advanced life support courses on patient outcomes. impact of blended learning approaches. impact of modifications necessitated by COVID pandemic

Search Strategy: EIT 4000 Search Strategy

EMBASE.com, CINAHL, Cochrane: Run May 2021 and and re-run October 2021

PRISMA: EIT 4000 PRISMA

Summary of Search findings:

Advanced Life Support (ALS)

• One study identified, to be included as Evidence Update to previous ILCOR COSTR:
  • Pareek M, Parmar V, Badheka J, Lodh N. Study of the impact of training of registered nurses in cardiopulmonary resuscitation in a tertiary care centre on patient mortality. Indian journal of anaesthesia. 2018 May;62(5):381 (3)

Neonatal Resuscitation Training (NRT)

• One systematic review of all NRT approaches (no further studies identified on updated search) to be included in Adolopment process:
  • Patel, A., Khatib, M. N., Kurhe, K., Bhargava, S., & Bang, A. (2017). Impact of neonatal resuscitation trainings on neonatal and perinatal mortality: a systematic review and meta-analysis. BMJ Paediatr Open, 1(1), e000183. doi:10.1136/bmjpo-2017-000183 (4)

Helping Babies Breathe (HBB)

• One systematic review addressing ‘Helping Babies Breathe’ course (one additional study identified on updated search – see below) to be included in Adolopment process:
  • Versantvoort, J. M., Kleinhout, M. Y., Ockhuijsen, H. D., Bloemenkamp, K., de Vries, W. B., & van den Hoogen, A. (2020). Helping Babies Breathe and its effects on intrapartum-related stillbirths and neonatal mortality in low-resource settings: a systematic review. Archives of disease in childhood, 105(2), 127-133. (5)
  • One additional study addressing ‘Helping Babies Breathe’ identified on updated search:
    • Innerdal, M., Simaga, I., Diall, H., Eielsen, M., Niermeyer, S., Eielsen, O., & Saugstad, O. (2020). Reduction in perinatal mortality after implementation of HBB training at a district hospital in Mali. Journal of tropical pediatrics, 66(3), 315-321. (1)

• Advanced Life Support (ALS) Updated Systematic Review

Worksheet author(s): Andrew Lockey, Robert Greif, Catherine Patocka, Kasper Lauridsen

Council: ILCOR: Education, Implementation & Teams

This is an evidence update to a previous systematic review. An updated GRADE table is presented below.

The previous Evidence to Decision framework has been updated, and this is presented in Appendix 1.

Last ILCOR Consensus on Science and Treatment Recommendation:

We recommend the provision of accredited adult ALS training for healthcare providers (weak recommendation, very low certainty evidence). [Downgraded for risk of bias, inconsistency, indirectness and imprecision]

2010/2015 Search Strategy: On file

2020 Search Strategy: Same as previous

2021 Search Strategy: expanded to cover all advanced life support formats

Database searched: PubMed, EMBASE, CINAHL

Date Search Completed: 18 October 2021 (last update)

Search Results (Number of articles identified / number identified as relevant): 1 study relevant to ALS shortlisted

Inclusion/Exclusion Criteria:

Included studies: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, and case series where n ≥ 5), studies relating to in-hospital cardiac arrest

Excluded studies: unpublished results (e.g. trial protocols), commentary, editorial, reviews. Studies looking at impact of individual components of courses (e.g. airway, drug thereapy, defibrillation), studies relating to basic life support and first aid courses, ATLS courses (as they address traumatic as opposed to cardiac emergencies), studies relating to out-of-hospital cardiac arrest.

New study identified

Link to Article Titles and Abstracts (if available on PubMed): https://pubmed.ncbi.nlm.nih.gov/29910497/

Pareek, M., Parmar, V., Badheka, J., & Lodh, N. (2018). Study of the impact of training of registered nurses in cardiopulmonary resuscitation in a tertiary care centre on patient mortality. Indian journal of anaesthesia, 62(5), 381. (3)

Background and Aims: Nurses should have cardiopulmonary resuscitation (CPR) knowledge and skills to be able to implement effective interventions during in-hospital cardiac arrest. The aim of this descriptive study was to assess mortality impact after nurses' CPR training with pre-CPR training data at our institute.

Methods: Training regarding CPR was given to nurses, and CPR mortality 1-year before basic life support (BLS) and advanced cardiac life support (ACLS) training were collected and compared with post-training 1-year CPR mortality.

Results: A total of 632 adult patients suffering in-hospital cardiac arrest over the study period. CPR was attempted in 294 patients during the pre-BLS/ACLS training period and in 338 patients in the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 58 patients (19.7%) had return of spontaneous circulation (ROSC), while during the post-BLS/ACLS training period, 102 patients (30.1%) had ROSC (P = 0.003). Sixteen of the 58 patients (27.5%) who achieved ROSC during the pre-BLS/ACLS training period survived to hospital discharge, compared 54 out of 102 patients (52.9%) in the post-BLS/ACLS training period (P < 0.0001). There was no significant association between either the age or sex with the outcomes in the study.

Conclusion: Training nurses in cardiopulmonary resuscitation resulted in a significant improvement in survival to hospital discharge after in-hospital cardiac arrest.

Summary of Evidence Update:

Updated GRADE table for ACLS/ALS-

2022 ACLS/ALS recommendation:

• We recommend the provision of accredited adult ACLS/ALS training for healthcare providers who provide advanced life support care for adults (strong recommendation, very low-certainty evidence)
• Values and preferences statement: in making this recommendation we recognize that the evidence comes from observational studies of very low certainty. However pooling of the available evidence consistently favours ACLS/ALS training.
• The provision of accredited adult ACLS/ALS training may not be feasible or appropriate in some low-resource settings.
• Knowledge gaps: impact of blended learning approaches, ideal recertification intervals, impact of modifications necessitated by COVID pandemic

• Neonatal Resuscitation Training (NRT)

One systematic review was identified by Patel (2017) (4) covering all Neonatal Resuscitation Training approaches. No additional studies were identified through our search. This systematic review satisified the AMSTAR-2 criteria for adolopment as defined by the ILCOR Adolopment Process document (9 January 2021).

Abstract

Background: Training of birth attendants in neonatal resuscitation is likely to reduce birth asphyxia and neonatal mortality. We performed a systematic review and metaanalysis to assess the impact of neonatal resuscitation training (NRT) programme in reducing stillbirths, neonatal mortality, and perinatal mortality

Methods: We considered studies where any NRT was provided to healthcare personnel involved in delivery process and handling of newborns. We searched MEDLINE, CENTRAL, ERIC and other electronic databases. We also searched ongoing trials and bibliographies of the retrieved articles, and contacted experts for unpublished work. We undertook screening of studies and assessment of risk of bias in duplicates. We performed review according to Cochrane Handbook. We assessed the quality of evidence using the GRADE approach.

Results: We included 20 trials with 1 653 805 births in this meta-analysis. The meta-analysis of NRT versus control shows that NRT decreases the risk of all stillbirths by 21% (RR 0.79, 95% CI 0.44 to 1.41), 7-day neonatal mortality by 47% (RR 0.53, 95% CI 0.38 to 0.73), 28-day neonatal mortality by 50% (RR 0.50, 95% CI 0.37 to 0.68) and perinatal mortality by 37% (RR 0.63, 95% CI 0.42 to 0.94). The meta-analysis of pre-NRT versus post-NRT showed that post-NRT decreased the risk of all stillbirths by 12% (RR 0.88, 95% CI 0.83 to 0.94), fresh stillbirths by 26% (RR 0.74, 95% CI 0.61 to 0.90), 1-day neonatal mortality by 42% (RR 0.58, 95% CI 0.42 to 0.82), 7-day neonatal mortality by 18% (RR 0.82, 95% CI 0.73 to 0.93), 28-day neonatal mortality by 14% (RR 0.86, 95% CI 0.65 to 1.13) and perinatal mortality by 18% (RR 0.82, 95% CI 0.74 to 0.91).

Conclusions: Findings of this review show that implementation of NRT improves neonatal and perinatal mortality. Further good quality randomised controlled trials addressing the role of NRT for improving

An Evidence to Decision framework was completed, and this is presented in Appendix 2 in attachments.

2022 NRT recommendation:

We recommend the provision of accredited NRT courses for health care professionals who provide advanced life support care for newborns and babies (strong recommendation, very low-certainty evidence).

Values and preferences statement: In making this recommendation we recognize that the evidence in support of this recommendation comes from studies of very low quality and relate to a range of NRT courses run in different low and middle resource settings around the world over a large time period.

The provision of accredited NRT courses is feasible in low and middle resource settings.

• Helping Babies Breathe (HBB)

One systematic review was identified by Versantvoort (2020) covering ‘Helping Babies Breathe’. This systematic review satisified the AMSTAR-2 criteria for adolopment as defined by the ILCOR Adolopment Process document (9 January 2021). (5)

Abstract

Background: An important factor in worldwide neonatal mortality is the deficiency in neonatal resuscitation skills among trained professionals. ’Helping Babies Breathe’ (HBB) is a simulation-based training course designed to train healthcare professionals in the initial steps of neonatal resuscitation in low-resource areas. The aim of this systematic review is to provide an overview of the available evidence regarding intrapartum-related stillbirths and neonatal mortality related to the HBB training and resuscitation method.

Data sources: Cochrane, CINAHL, Embase, PubMed and Scopus.

Study eligibility criteria: Conducted in low-resource settings focusing on the effects of HBB on intrapartum-related stillbirths and neonatal mortality. Study appraisal Included studies were reviewed independently by two researchers in terms of methodological quality.

Data extraction: Data were extracted by two independent reviewers and crosschecked by one additional reviewer.

Results: Seven studies were included in this systematic review; the selected studies included a total of 230.797 neonates. Significant decreases were found after the implementation of HBB in one of two studies describing perinatal mortality (n=25 108, rate ratio (RR) 0.75; p<0.001), four out of six studies related to intrapartum-related stillbirths (n=125.720, RR 0.31–0.76), in four out of five studies focusing on 1 day neonatal mortality (n=111.289, RR 0.37–0.67), and one out of three studies regarding 7 day neonatal mortality (n=4.390, RR 0.32). No changes were seen in late neonatal mortality after HBB training and resuscitation method.

Limitations: Included studies in were predominantly of moderate quality, therefore no strong recommendations can be made.

Conclusions and implications of key findings: Due to the heterogeneous quality of the studies, this systematic review showed moderate evidence for a decrease in intrapartum-related stillbirth and 1-day neonatal mortality rate after implementing the ’Helping Babies Breathe’ training and resuscitation method. Further research is required to address the effects of simulation-based team training on morbidity and mortality beyond the initial neonatal period.

One additional study by Innerdal (2020) (1) was identified in our search.

Abstract

Background: Mali has a high neonatal mortality rate of 38/1000 live births; in addition the fresh stillbirth rate (FSR) is 23/1000 births and of these one-third are caused by intrapartum events.

Objectives: The aims are to evaluate the effect of helping babies breathe (HBB) on mortality rate at a district hospital in Kati district, Mali.

Methods: HBB first edition was implemented in April 2016. One year later the birth attendants were trained in HBB second edition and started frequent repetition training. This is a before and after study comparing the perinatal mortality during the period before HBB training with the period after HBB training, the period after HBB first edition and the period after HBB second edition. Perinatal mortality is defined as FSR plus neonatal deaths in the first 24 h of life.

Results: There was a significant reduction in perinatal mortality rate (PMR) between the period before and after HBB training, from 21.7/1000 births to 6.0/1000 live births; RR 0.27, (95% CI 0.19–0.41; p < 0.0001). Very early neonatal mortality rate (24 h) decreased significantly from 6.3/1000 to 0.8/1000 live births; RR 0.12 (95% CI 0.05–0.33; p . 0.0006). FSR decreased from 15.7/1000 to 5.3/1000, RR 0.33 (95% CI 0.22–0.52; p < 0.0001). No further reduction occurred after introducing the HBB second edition.

Conclusion: HBB may be effective in a local first-level referral hospital in Mali.

An appraisal of the Innerdal 2020 study (1) was made using the McMaster Critical Review form. The conclusion of this appraisal was that the Innerdal 2020 study is of moderate quality and that the findings are consistent with the Versantvoort 2002 analysis (5) without changing their result. Although the study is of moderate quality based on the McMaster Critical Review Tool, we recognize that within GRADE methodology this ‘before and after’ study would be considered low quality.

An Evidence to Decision framework was completed, and this is presented in Appendix 3 in attachments.

2022 HBB recommendation:

• We recommend the provision of Helping Babies Breath support training for healthcare providers who provide advanced life support care for newborns and babies (strong recommendation, very low-certainty evidence).

Values and preferences statement: In making this recommendation we recognize that the evidence in support of this recommendation comes from studies of very low quality and relate to a range of HBB implementations run in different low resource settings around the world over a large time period.

The provision of HBB training is feasible in low resource settings.

Knowledge gaps: best combination of settings, trainee charecteristics and training frequency to sustain the existing effect on perinatal mortality reduction.

Recommended 2022 CoSTR:

We recommend the provision of accredited advanced life support training (adult ACLS/ALS) for healthcare providers who provide advanced life support care for adults. (strong recommendation, very low-certainty evidence)

We recommend the provision of accredited courses in Neonatal Resuscitation Training (NRT/NRP) and Helping Babies Breathe (HBB)) for healthcare providers who provide advanced life support care for newborns and babies. (strong recommendation, very low-certainty evidence)

• Values and preferences statement: In making this recommendation we recognize that the evidence in support of this recommendation comes from studies of very low quality and relate to a range of courses run in different resource settings around the world over a large time period.
• The provision of NRT and HBB training is feasible in low and middle resource settings.
• Knowledge gaps: best combination of settings, trainee characteristics and training/recertification frequency to sustain the existing effect on patient outcomes. Impact of other advanced life support courses on patient outcomes. impact of blended learning approaches. impact of modifications necessitated by COVID pandemic

Attachments: EIT 4000 Et D Outcomes

References

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Patel, A., Khatib, M. N., Kurhe, K., Bhargava, S., & Bang, A. (2017). Impact of neonatal resuscitation trainings on neonatal and perinatal mortality: a systematic review and meta-analysis. BMJ Paediatr Open, 1(1), e000183. doi:10.1136/bmjpo-2017-000183

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Versantvoort, J. M., Kleinhout, M. Y., Ockhuijsen, H. D., Bloemenkamp, K., de Vries, W. B., & van den Hoogen, A. (2020). Helping Babies Breathe and its effects on intrapartum-related stillbirths and neonatal mortality in low-resource settings: a systematic review. Archives of disease in childhood, 105(2), 127-133.