Basic Life Support training for specific layperson populations: EIT6108 TF ScR

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: Sebastian Schnaubelt and Robert Greif are authors of one included study.

Task Force Synthesis Citation

Schnaubelt S, Abelairas-Gomez C, Anderson N, Nabecker S, Neymayer M, Snijders E, Veigl C, Greif R.- on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. International facets of the ‘Chain of Survival’. Scoping review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2023 December 1. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

This scoping review was conducted by five experts of the ILCOR EIT Task Force Scoping Review team and three external content experts. Evidence for adult literature was sought and considered by the EIT Task Force; literature on children was excluded by PICOST definition. The EIT task force discussed the evidence and provided insights.

We expect to submit this Scoping Review for publication in January 2024.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Design and Timeframe) was defined as follows:

Population: Specific adult layperson populations and/or groups (defined below) participating in BLS training

Intervention: Tailored BLS training (defined below)

Comparators: Non-tailored BLS training (defined below)

Outcomes:

• Patient outcomes: ROSC, survival to hospital discharge, 30-days survival, 12-months survival, neurological outcome
• Clinical outcomes: Starting CPR in case of real cardiac arrest, performance during real CPR
• Educational outcomes: knowledge and skills acquisition, willingness to perform CPR, barriers towards performing CPR, participant satisfaction and/or knowledge and skills retention at the end of the respective course and later (e.g., 3 months, 1 year), implementation success, resource implications and cost effectiveness

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, controlled before-and-after studies, cohort studies, and case series n ≥ 5), reviews, surveys in respective population groups, with at least an abstract in English were eligble for inclusion. Research aimed at teaching BLS to children; research on CPR training for different healthcare professionals (both sufficiently covered elsewhere) were excluded.

Timeframe: All years. Literature search updated to 10 July, 2023

Definitions:

• “Specific”: We defined “specific population and/or group” as a subgroup of the general population having a specific feature (e.g., a job, an age-group, etc.). We acknowledge that this is a very wide definition.
• “Layperson”: We defined “layperson” as the general adult population excluding qualified-, retired-, or in-training healthcare professionals (e.g., medical students, nursing students, paramedic students, etc.). However, to make the approach more structured, we define two groups of laypersons:
• Duty to respond: Laypersons (non-healthcare professionals) that do have a duty to respond. This includes any type of professional first responders (e.g., law enforcement, firefighters), lifeguards, flight crews, and any other people that would have a duty to attend victims of an emergency.
• No duty to respond: Community laypersons that have no duty (occupational expectation) to respond to a cardiac arrest. This includes anyone else not included in group 1, and also first responders who would respond to an alarm on a smartphone app or similar (as they do not have an occupational duty to respond).
• “Standard BLS training” (“non-tailored BLS courses”): Non-tailored standard BLS training are considered BLS courses that follow current recommendations from the large course developers and organizers like the AHA or the ERC.
• “Tailored training” (or: “tailored courses”): After initial abstract screening and discussions among the Task Force, the definition of “tailored training” was refined to: Tailored courses are altered to serve the special needs of a population (e.g., in duration, frequency, content, assessment, feedback, used material and devices, specific aids, contextualization of the environment, specially trained instructors, etc.).

Search Strategies and Screening

The search strategy was performed by information specialist Mary-Doug Wright (AHA, USA), finalized on 10 July 2023, and peer-reviewed by a second IS (Medical University of Vienna, Austria) on 21 July 2023.

Records from database searches were downloaded and imported into an EndNote database to facilitate removal of duplicates and screening. Databases searched were Embase 1974 to 2023 May 24; MEDLINE(R) ALL 1946 to 1974 to May 24, 2023 (multi-database search via Ovid); Cochrane Central Register of Controlled Trials (Cochrane Library via Wiley Online). Final database searches were conducted July 10, 2023. See Annex I for the full search strategies.

1203 abstracts were imported in Rayyan (rayyan.qcri.org) and screened independently by Sebastian Schnaubelt, Cristian Abelairas-Gomez, Natalie Anderson, Sabine Nabecker, Marco Neymayer, Erwin Snijders, Christoph Veigl, and Robert Greif. 104 additional abstracts which were found as cross citations in the reviewing process were added by the reviewers, leading to a total of 1307 screened abstracts. Conflicting decisions were resolved by agreement. 17 duplicates were deleted, and 74 articles were decided upon for full-text retrieval. After having assessed the full-text content, 66 publications were excluded, leaving 8 full texts to be included in the review.

Important note: The original PICOST only allowed for studies to be included if they reported on tailored courses for specific populations and also compared these tailored courses to standard courses. Four publications only reported on adapted courses comparing them to standard courses or other adaptations in a specific population but were never meant to be tailored TO that specific population (a specific population, for instance university students, being at hand and testing a new course approach within this “format”). After a Task Force discussion, we decided NOT to include these but instead broadening the field again to any reports on courses specifically tailored to specific populations, leaving the eight publications presented in this Scoping Review.

Inclusion and Exclusion criteria

Inclusion Criteria: Publications reporting on BLS courses that were adapted/ tailored specifically for a population group.

The original PICOST aimed to compare tailored courses to standard courses. However, we didn’t find any studies meeting these criteria. Thus, we broadened the inclusion criteria to any reports on tailored courses for specific populations.

Exclusion criteria:

• Studies only assessing CPR knowledge and/ or skills in a specific population without a tailoring/ adaptation of the course at all.
• Comparisons of different instructional designs not being tailored to a specific population. Example: Comparing video-based and instructor-based CPR education in university students, and nothing was specifically tailored to university students.
• Publications only describing ideas about tailoring but not having performed an investigation.
• Studies on participants <18 years.
• Studies on high-risk patients and/ or their relatives, as this topic is already covered by another ILCOR review (EIT_6105).
• Studies reporting on chest-compression only CPR as the sole adaptation in their courses, as this is often already regarded as standard in layperson training.

Data Tables: EIT 6109 Data tables

Task Force Insights

1. Why this topic was reviewed

The EIT Task Force reviewed this topic because of two reasons: 1) Growing reports on course adaptations grew, for instance for individuals with a disability, [9] and 2) more and more specific population groups in the communities might potentially require special attention with course format that differ from standard courses. With an expanding system to save lives including first responders, AED networks, and increasing bystander CPR rates, ways to further enhance survival outcomes are sought. Specific populations who are not health care providers may warrant specific BLS training due to their individual backgrounds (e.g., working in a special environment, someone with special needs or impairments). [10,11] To give two examples, police or firefighters are often already a standard part of the chain of survival, and the fraction of elderly persons in society is steadily growing. However, to date, such groups either receive standard BLS courses or none at all.

A one-size-fits-all approach of BLS courses might not suit certain populations, and it is unclear which specific populations exactly could benefit from adapted tailored teaching. However, if certain populations would benefit from tailored training, this would have an impact on-, and should be emphasized by future guidelines, and respective curricula should be developed.

2. Narrative summary of evidence identified

The eight included publications originated from diverse geographical areas (Table 1); most from Europe (n=7), only one from India. The majority (n=7, 87.5%) came from high-income countries, and none from low-income countries (as per definition of the World Bank, see Table 1). With one exception [5], all studies were published within the last ten years.

Table 2 summarizes the included studies and respective findings. Seven (87.5%) studies [1] [2] [3] [4] [5] [7] [8] investigated courses that had been provided for individuals with a disability, and only one study [6] covered another specific population group (refugees). The addressed disabilities were Down syndrome [1] [4], blindness [2] [3], and deafness or hearing impairment [5] [7] [8]. No studies with tailored courses for specific populations compared their tailored approach to standard courses (even if they compared two different populations). However, as only a limited number of studies on tailored courses was found at all, we decided to also include ones without this comparison into this scoping review.

After BLS courses tailored to individuals with Down syndrome, participants were able to perform BLS including AED use, but with low quality. However, these performances were not worse than seen in other laypersons’ BLS courses. Tailoring for this special group of providers meant paying special attention to shorter sessions due to a potentially reduced attention span, and introducing “lightweight” educational material such as videos with comic elements. Both studies used chest-compression only CPR. [1] [4]

Two studies from one author group assessed CPR education for the blind: The first study was a “training adapted to the participants’ needs” combined with chest-compression only CPR, with results comparable to other BLS providers. [2]. Two years later, the “tailoring” was refined and included supervisors with special pedagogic training, and a very “tactile approach”. The measured CPR scenarios were performed successfully, except for low chest compression quality. This approach also included rescue breaths. [3]

There were three studies on hearing impairment [5] [7] [8], and the basic tenor was that tailored courses led to the participants being able to conduct basic CPR scenarios. All three study groups incorporated a sign language interpreter in their tailoring approaches, and all three did not alter the classic 30:2 approach, thus also teaching rescue breaths. Activating the EMS and following the voice prompts of the AED were seen as the most challenging points. [5] [7] [8] Strnad et al. also tailored the BLS approach in general, incorporating slight adaptations like sending a text message to a respective emergency service for people with a hearing impairment. [7]

One further study addressed BLS education for refugees, deeming them feasible, tailoring the courses by having translators for the respective native languages on site, having a special focus on general health literacy, and additionally teaching chest-compression only CPR. [6]

Overall, the quality of included studies tended to be low as the comparative studies did not compare tailored vs. non-tailored approaches, and the other studies were observational or pre-post designed. That also included research letters [1] [2] [8] which provided limited information.

3. Narrative Reporting of the task force discussions

It is noteworthy to address that no studies were found comparing tailored courses to standard BLS courses, which was the intention of the original PICOST question. Thus, it remains unanswered if tailored BLS education for specific population groups compared to standard approaches produce different results. However, summarizing the data found without such a comparison allowed a current overview of tailored courses for specific populations.

The studies reported only limited details about how the courses were tailored for the needs of the specific groups. Rather, somewhat adapted courses were conducted to show the feasibility of CPR education in the respective groups. Also, none of the studies provided a detailed insight into the development process of their tailored course, and even less so into a potential participation of members of the addressed groups in the specific content development.

Moreover, we acknowledge that educators will often make small adaptations in courses to meet individual needs of students without a proper high quality educational study. This will most likely not be called tailoring and rarely reported in scientific publication. However, “real” tailoring needs to address the needs of the special learners and potential barriers of teaching, as well as enablers towards optimal performance in such specific population groups. All that should be embedded in a structured approach and validated to ensure a beneficial effect for the learners. To judge that, comparative studies (to standard BLS courses) are needed.

The definition of a “standard”, non-tailored, BLS course is not easy, especially from the views of lower resource settings. For this review, we used as “standard” an instructor-led manikin-based course based on current guidelines from the ERC or AHA. However, modern blended learning formats [45], have the potential to develop specific tailored courses within the frame of current teaching approaches from regional resuscitation councils.

We also acknowledge that any benefit in tailored courses could stem from being educated together with peer members of a specific population group – a potential source of bias that needs to be kept in mind for future research.

Despite the studies found for this scoping review, several other specific populations could potentially benefit from tailored training (not an exhaustive list):

• Low socioeconomic background: Certain resource settings might lack minimum BLS standards, and location-specific solutions could be developed together with local experts. [12,13] A one-size-fits-all approach may not be sufficient to promote 'CPR readiness' in deprived communities, and future approaches to working with disadvantaged communities could be tailored to the local community. [14–17] For instance, the location of publicly available training plays an important role [18], and targeted CPR training for low-education and low-income neighborhoods may increase bystander CPR and improve OHCA outcomes. [19,20] As often there is a lack of courses at all in certain areas, maybe shortened, cheaper courses might attract more participants. [21]
• Police or Firefighters: Time to defibrillation decreased and survival from out-of-hospital cardiac arrests increased with the implementation of police and firefighter BLS programs [22–26], chest-compression only BLS training may be more suitable for police as first responders [27], and the call received to arrival on scene interval should be reduced by improvements in communication. [28] However, it is entirely unclear if a more tailored training (than just chest-compression only CPR) might bring additional benefits.
• First responders with no “duty to respond”: First responders do not always have to have cardiac arrest response as part of their jobs; rather, there could also be those just having a first aid certificate and have registered in a first responder app. Literature on this is very heterogenous (because it basically comprises all publications including first responders, ever). Tailored courses could serve as an in-between CPR education.
• Lifeguards and/ or boat crews: Lifeguards may need specific course topics and more regular follow-up training. [29,30] Boat crews may or may not benefit from courses with less emphasis on AED use. [31,32]
• Elderly People: Specific first aid courses including BLS training may improve educational outcomes in elderly individuals, willingness to perform CPR, and potentially also patient outcomes. [16,33–35]
• Sex/ Gender: The impact of gender on BLS attitudes and performance shows contradicting results in the literature, and it is unclear whether specific approaches and/ or specially tailored programs should be considered. [13,34]
• Individuals with various kinds of impairments/ disabilities: Individuals with disabilities cannot just be excluded from various activities of social life, including CPR training. Various subgroups might benefit from tailored training. [9]
• Migrants and Refugees: Novel population groups in society comprised of migrants and/ or refugees coming from different cultural backgrounds and speaking various foreign languages comprise a considerable fraction of today’s general population in many countries. BLS courses for these groups could need tailoring. [6,36]
• Specific Sports Groups: For instance, surfers [37] or football players could benefit from tailored BLS training. Sports groups are also potentially highly influential as ambassadors to get the message of saving lives across to a large population. [38,39]
• Volunteers at long-distance races (e.g., running, cycling, triathlon…): Although there is a low overall risk of cardiac arrest during running races, the number of participants in marathon and half-marathon races is increasing annually, and there are numerous reports of race-related cardiac arrest. However, there are often thousands of spectators and helping volunteers at such events which offers the opportunity of mass training with special tailored BLS courses. [40]
• Flight crews: Flight crews are regularly exposed to a very heterogenous group of passengers. Guidelines on in-flight cardiac arrest have been developed, but data on tailored training programs are scarce. Also, in the unlikely event of cardiac arrest in space, special circumstances presented by microgravity and spaceflight must be considered concerning central points, such as rescuer position and methods for the performance of chest compressions, airway management, and defibrillation. Also here, literature lacks suggestions for tailored training. [41,42]
• Higher-education Students: Tertiary students (>18 years old) who are not training to become health professionals are an important specific target group for BLS courses. Whether their learning needs may be better met through tailored courses is unclear. However, they form a quite large and important population group in almost every country worldwide and are potentially young and eager to act in case of emergency. Also, they are potentially easy to reach, associated with tertiary institutions. [43]
• Other specific groups: Prisoners may be open to CPR training. [44]

This opens a wide field of curriculum development and research as no evidence was found in current literature on resuscitation courses for the above-mentioned populations.

In summary, the Task Force came to the following conclusion:

• Tailored BLS education for specific populations is probably feasible and can include such groups into the pool of potential bystander CPR providers that may otherwise have been left out (e.g., individuals with disabilities).
• Studies should explore tailored courses for first responders with and without a duty to respond, including, but not limited to, police, firefighters, or lifeguards.
• Research should be undertaken to address knowledge gaps identified, especially studies between comparing standard vs. tailored courses in specific populations which are best conducted as randomized controlled trials.
• Research needs to address how BLS could be adapted for those with special needs, and how best to involve members of the respective specific populations in its development. I

Our review has limitations: Firstly, we could not meet the original PICOST question as no studies were found that met these criteria. Several of these studies were included in a Scoping Review on BLS education for individuals with disabilities. However, its aim was not the tailored training, but rather a depiction of the feasibility of CPR training for disabled individuals. [9] This (non-ILCOR) review was published after our search and abstract screening were already finished.

In addition, we did not have the opportunity to search grey literature, which might have provided additional insights. Moreover, we did not assess the whole body of literature on chest-compression only CPR. Lastly, even though this Scoping Review covers a topic on specific population groups, we recognize that none of the involved Task Force members or content experts are members of the groups we reported on.

Knowledge Gaps

The EIT Task Force identified the following knowledge:

• There is too little evidence on the topic of tailored BLS training for specific population groups to perform a systematic review.
• It is unclear which specific population groups can benefit from tailored BLS training.
• It is unclear what the cost-benefit ratio is for tailored BLS training.
• It is unknown what type and amount of tailoring in BLS training is optimal.

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Annex I – Search strategies

Search Strategies

Embase 1974 to 2023 July 07, Ovid MEDLINE(R) ALL 1946 to July 06, 2023

Cochrane Central Register of Controlled Trials via Cochrane Library Wiley Online

Issue 7 of 12, July 2023