Blended learning approach for life support education

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 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 blended and non-blended life support training.

CoSTR Citation

Lockey A, Breckwoldt J, Cheng A, Pellogrino J, Schnaubelt S, Elgohary M, Palazzo F, Finn J, Greif, T on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Are participant educational outcomes improved as a result of a blended learning approach for life support education. 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 (and Link to Published Systematic Review if applicable)

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of blended learning as opposed to non-blended learning approaches to life support course delivery conducted by an information specialist with involvement of clinical content experts. Evidence for all accredited life support courses from the literature was sought and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

PICOST

Consensus on Science

The majority of studies used face-to-face only as the control group, with only two BLS studies having online learning only as a control group {Reder 2006 443; Yeung 2017 138}.

There was a mix of interventions in the BLS group with some adding online content to standardised face-to-face courses {Reder 2006 443; Brannon 2009 133; Shavit 2010 979; Nord 2017 1; Yeung 2017 138}, and some substituting didactic content with online content leaving an amended face-to-face element {Nishiyama 2008 90; Sopka 2012 1; Serwetnyk 2015 E1; Nakanishi 2017 430; Castillo 2018 232; Chien 2020 1; de Balanzó Fernández 2020 45}. In the ALS group, all except one study {Perkins 2010 877} looked at online learning as a substitute for didactic elements. The ATLS study looked at online learning as a substitute for didactic elements.

Basic Life Support

The review included 14 studies {Reder 2006 443; Nishiyama 2008 90; Brannon 2009 133; Shavit 2010 979; Sopka 2012 1; Serwetnyk 2015 E1; Nakanishi 2017 430; Nord 2017 1; Yeung 2017 138; Castillo 2018 232; Castillo 2019 127; Chien 2020 1; de Balanzó Fernández 2020 45; Szyld 2021 1}. For the outcome of BLS knowledge (post intervention), one study found a statistically significant benefit for blended learning {Reder 2006 443}, one study found a statistically significant benefit for face-to-face only {de Balanzó Fernández 2020 45}, one study found increased requirements for knowledge remediation in the blended learning group {Serwetnyk 2015 E1}, and two studies found no significant difference between the blended learning and control groups {Castillo 2018 232; Chien 2020 1}. There was no significant difference between the groups at any time point between 2 and 12 months {Reder 2006 443; Castillo 2018 232; Chien 2020 1; de Balanzó Fernández 2020 45}. All studies were of adult BLS courses.

For the outcome of BLS skills (post intervention), three studies found a statistically significant benefit for blended learning {Nakanishi 2017 430; Yeung 2017 138; Castillo 2018 232}. One of these studies also found a statistically significant benefit for face-to-face only for total number of chest compressions {Nakanishi 2017 430}. One study of infant BLS found better performance with blended learning in a range of BLS components, but no analysis was performed for statistical significance {Shavit 2010 979}. The remaining eight studies (including one of infant BLS) found no significant difference between the intervention and control groups {Reder 2006 443; Nishiyama 2008 90; Brannon 2009 133; Sopka 2012 1; Serwetnyk 2015 E1; Nord 2017 1; Chien 2020 1; de Balanzó Fernández 2020 45}. For BLS skills retention, one study found no significant difference between the groups at 2 months {Reder 2006 443}. One study found a statistically significant benefit for blended learning at 3 months when compared to online learning only for compression depth, but the opposite for compression rate {Yeung 2017 138}. Two studies found a statistically significant benefit for blended learning at 6 months {Yeung 2017 138; Castillo 2018 232}. The remaining four studies found no significant difference between the intervention and control groups {Sopka 2012 1; Nakanishi 2017 430; Nord 2017 1; Chien 2020 1}. There was no significant difference between groups for one study at 9 months {de Balanzó Fernández 2020 45} and one study at 12 months {Chien 2020 1}.

For the outcome of attitudes, there was evidence of positive attitudes to all forms of training {Sopka 2012 1; Serwetnyk 2015 E1; Nord 2017 1; Yeung 2017 138}.

For the outcome of costs, the single cost analysis study found a notable financial benefit for teaching BLS via a blended learning approach {Castillo 2019 127}.

Adult advanced cardiac life support:

The review included eight studies {Perkins 2010 877; Ko 2011 324; Perkins 2012 19; Lockey 2015 48; Thorne 2015 79; George 2018 234; Arithra Abdullah 2019 1024907919857666; Chaves 2020 7681}. For the outcome of ALS knowledge (post intervention), two studies found significantly higher scores in the blended learning group {Thorne 2015 79; Arithra Abdullah 2019 1024907919857666}, whilst the remainder of the studies found no significant difference between the groups {Perkins 2010 877; Perkins 2012 19; Chaves 2020 7681}. There was no significant difference between groups for one study at 7 months {Chaves 2020 7681}.

For the outcome of ALS skills (post intervention), one pilot study {Perkins 2012 19} found significantly higher scores in the control group however a subsequent study of the revised version of the same course found significantly higher scores in the blended learning group {Thorne 2015 79}. The remainder of the studies found no significant difference between the groups {Perkins 2010 877; Ko 2011 324; Arithra Abdullah 2019 1024907919857666; Chaves 2020 7681}.

There was a diversity of attitudes with three studies finding a preference for blended learning {Perkins 2010 877; Ko 2011 324; Arithra Abdullah 2019 1024907919857666} and two studies finding a preference for face-to-face learning {Lockey 2015 48; Chaves 2020 7681}.

For the outcome of costs, two studies found a notable financial benefit for teaching ALS via a blended learning approach {Perkins 2012 19; George 2018 234}.

Adult trauma life support:

One study found that a blended learning approach involving substitution of didactic elements with online learning for Advanced Trauma Life Support is better than face-to-face only in terms of knowledge outcomes {Dyer 2021 }. Overall pass rates were better but there was no specific description of the breakdown of skills performance as opposed to knowledge outcomes in determining the final result so a conclusion about skills training cannot be made.

Treatment Recommendations

We recommend a blended learning as opposed to non-blended approach for life support training where resources and accessibility permit its implementation (strong recommendation, very low quality of evidence).

Justification and Evidence to Decision Framework Highlights

In making this recommendation, the EIT Taskforce considered the following:

• A blended learning approach is grounded in a strong framework from educational theory
• Blended learning approaches result in similar or better educational outcomes for participants
• A blended learning approach can enable ongoing training of life support skills for those in remote locations, lower resource settings, and in times of pandemic
• A blended learning approach may not be feasible in areas where access to online learning is limited or unavailable
• Non-blended learning approaches (i.e., face-to-face only or online only) are an acceptable alternative where resources or accessibility do not permit the implementation of a blended learning approach.
• Most of the research evidence used ‘face-to-face’ only as the control group, with very limited evidence for ‘online only’ as the control group
• Blended learning enables consistent messaging regarding content which can be particularly beneficial for pre-course preparation.
• Participant and stakeholder costs are reduced with a blended learning approach
• Duration of face-to-face training is reduced, although time is still needed to complete the online component

Knowledge Gaps

• The elements of instructional delivery that are associated with better educational outcomes
• Are certain levels of blended learning (i.e., how much, what exactly, when used) more beneficial than other when compared with each other;
• Is there a difference in outcomes between approaches where online learning is added to established face-to-face content or where it substitutes elements of the face-to-face contact
• Does blended learning life support educational lead to better patient outcomes
• Do certain sub-groups of participants (e.g. first time vs recertificating) have better educational outcomes from a blended learning approach?
• Further studies are needed for blended learning compared with online only learning

Attachments

Evidence-to-Decision table

References

Arithra Abdullah, A., J. Nor, J. Baladas, T. M. A. Tg Hamzah, T. H. Tuan Kamauzaman, A. Y. Md Noh and A. Rahman (2019). "E-learning in advanced cardiac life support: Outcome and attitude among healthcare professionals." Hong Kong Journal of Emergency Medicine: 1024907919857666.

Brannon, T. S., L. A. White, J. N. Kilcrease, L. D. Richard, J. G. Spillers and C. L. Phelps (2009). Use of instructional video to prepare parents for learning infant cardiopulmonary resuscitation. Baylor University Medical Center Proceedings, Taylor & Francis.

Castillo, J., A. Gallart, E. Rodríguez, J. Castillo and C. Gomar (2018). "Basic life support and external defibrillation competences after instruction and at 6 months comparing face-to-face and blended training. Randomised trial." Nurse education today 65: 232.

Castillo, J., C. Gomar, E. Rodriguez, M. Trapero and A. Gallart (2019). "Cost minimization analysis for basic life support." Resuscitation 134: 127.

Chaves, J., A. A. Lorca-Marín and E. J. Delgado-Algarra (2020). "Methodology of Specialist Physicians Training: From Traditional to e-Learning." International Journal of Environmental Research and Public Health 17(20): 7681.

Chien, C.-Y., S.-Y. Fang, L.-H. Tsai, S.-L. Tsai, C.-B. Chen, C.-J. Seak, Y.-M. Weng, C.-C. Lin, W.-C. Chien and C.-H. Huang (2020). "Traditional versus blended CPR training program: A randomized controlled non-inferiority study." Scientific reports 10(1): 1.

de Balanzó Fernández, X. and E. Ferrés-Amat (2020). "Standard basic life support training of the European Resuscitation Council versus blended training: a randomized trial of a new teaching method." Emergencias: revista de la Sociedad Espanola de Medicina de Emergencias 32(1): 45.

Dyer, L., L. Llerena, M. Brannick, J. R. Lunde and F. Whitaker (2021). "Advanced Trauma Life Support Course Delivery: Comparison of Outcomes From Modifications During Covid-19." Cureus 13(8).

George, P. P., C. K. Ooi, E. Leong, K. Jarbrink, J. Car and C. Lockwood (2018). "Return on investment in blended advanced cardiac life support training compared to face-to-face training in Singapore." Proceedings of Singapore Healthcare 27(4): 234.

Ko, P. Y., J. M. Scott, A. Mihai and W. D. Grant (2011). "Comparison of a modified longitudinal simulation-based advanced cardiovascular life support to a traditional advanced cardiovascular life support curriculum in third-year medical students." Teaching and learning in medicine 23(4): 324.

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Nord, A., L. Svensson, A. Claesson, J. Herlitz, H. Hult, S. Kreitz-Sandberg and L. Nilsson (2017). "The effect of a national web course “Help-Brain-Heart” as a supplemental learning tool before CPR training: a cluster randomised trial." Scandinavian journal of trauma, resuscitation and emergency medicine 25(1): 1.

Perkins, G. D., J. N. Fullerton, N. Davis-Gomez, R. P. Davies, C. Baldock, H. Stevens, I. Bullock and A. S. Lockey (2010). "The effect of pre-course e-learning prior to advanced life support training: a randomised controlled trial." Resuscitation 81(7): 877.

Perkins, G. D., P. K. Kimani, I. Bullock, T. Clutton-Brock, R. P. Davies, M. Gale, J. Lam, A. Lockey, N. Stallard and E. A. L. S. Collaborators (2012). "Improving the efficiency of advanced life support training: a randomized, controlled trial." Annals of internal medicine 157(1): 19.

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Serwetnyk, T. M., K. Filmore, S. VonBacho, R. Cole, C. Miterko, C. Smith and C. M. Smith (2015). "Comparison of online and traditional basic life support renewal training methods for registered professional nurses." Journal for nurses in professional development 31(6): E1.

Shavit, I., S. Peled, I. P. Steiner, D. D. Harley, S. Ross, E. Tal‐Or and A. Lemire (2010). "Comparison of Outcomes of Two Skills‐teaching Methods on Lay‐rescuers’ Acquisition of Infant Basic Life Support Skills." Academic Emergency Medicine 17(9): 979.

Sopka, S., H. Biermann, R. Rossaint, S. Knott, M. Skorning, J. C. Brokmann, N. Heussen and S. K. Beckers (2012). "Evaluation of a newly developed media-supported 4-step approach for basic life support training." Scandinavian journal of trauma, resuscitation and emergency medicine 20(1): 1.

Szyld, E. G., A. Aguilar, S. P. Lloret, A. Pardo, J. Fabres, A. Castro, D. Dannaway, P. V. Desai, C. Capelli and C. H. Song (2021). "Self-directed video versus instructor-based neonatal resuscitation training: a randomized controlled blinded non-inferiority multicenter international study." Journal of Perinatology: 1.

Thorne, C., A. Lockey, I. Bullock, S. Hampshire, S. Begum-Ali and G. Perkins (2015). "E-learning in advanced life support–an evaluation by the Resuscitation Council (UK)." Resuscitation 90: 79.

Yeung, J., I. Kovic, M. Vidacic, E. Skilton, D. Higgins, T. Melody and A. Lockey (2017). "The school Lifesavers study-A randomised controlled trial comparing the impact of Lifesaver only, face-to-face training only, and Lifesaver with face-to-face training on CPR knowledge, skills and attitudes in UK school children." Resuscitation 120: 138.