Conflict of Interest Declaration
The ILCOR Scientific Advisory Committee 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: Janet Bray and Judith Finn.
CoSTR Citation
Bray J, Cartledge S, Doherty Z, Leary M, Finn J, Bhanji F, Robert Greif on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Basic Life Support Training for likely rescuers of adults and children at high-risk of cardiac arrest. Groups Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2020 November 29. 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 detailed review of the systematic review conducted by Janet Bray and Marion Leary as part of the ILCOR evidence review in 2015 (Finn 2015 e203). Additional scientific literature published after the search end-date in the published systematic review was identified by a subsequent search of the relevant databases, conducted by Janet Bray with involvement of clinical content experts. The totality of this identified evidence was considered by the Education, Implementation and Teams (EIT) task force, and used to create/update bias assessment tables and evidence profile tables. These data were then used to formulate the Consensus on Science and Treatment Recommendations (CoSTR).
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: For Adults and children at high-risk of OHCA
Intervention: Basic Life Support training (BLS) of likely rescuers (e.g. family or care-givers)
Comparators: No training
Outcomes: Patient outcomes: Good neurological outcome at hospital discharge/30-days, Survival at hospital discharge/30-days, Return of spontaneous circulation (ROSC), Rates of bystander CPR (subsequent utilization of skills), Bystander CPR quality during an OHCA (any available CPR metrics), Rates of automated external defibrillator use (subsequent utilization of skills). Educational outcomes: CPR quality and correct AED use at the end of training and within 12 months of training; CPR and AED knowledge at the end of training and within 12 months of training; Confidence and willingness to perform CPR post training at the end of training and within 12 months of training, CPR training of others.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished full studies (including conference abstracts, trial protocols) were excluded.
Timeframe: All years and all languages were included providing there was an English abstract. Literature search updated to October 15 2021.
PROSPERO Registration CRD42021233811
Consensus on Science
For people at high-risk of OHCA (P), does focused training of likely rescuers (e.g. family or care-givers) (I), compared with no training (C), change patient outcomes, education outcomes, the number of people trained in CPR, and willingness to provide CPR (O)?
We defined BLS training as any type of BLS education (e.g. self-directed, video-only, video with manikin practice, instructor-led). In addition to RCTs with control groups, we included studies with a comparator group (e.g. those that measured outcomes before interventions or where data could be compared to guideline standards such as chest compression rate, chest compression depth). We also included studies with patients and relatives but excluded studies that only trained high-risk patients.
The 2015 ILCOR review (Bhanji 2015 S242; Finn 2015 e203) found 32 studies relating to BLS training in likely rescuers (e.g. family or care-givers) of high-risk OHCA groups (Bardy 2008, 1793; Barr 2013, 538; Blewer 2012, 787; Brannon 2009, 133; Dracup 1986, 1757; Dracup 1989, 61; Dracup 1998, 219; Dracup 1998 170; Dracup 1994, 116; Dracup 2000, 3289; Eisenberg 1989, 443; Greenberg 2011, 166; Haugk 2006, 263; Higgins 1989, 1102; Khan 2010, 299; Kliegel 2000, 147; Knight 2013, 9; Komelasky 1990, 387; Komelasky 1993, 96; Long 1992, 30; McDaniel 1988, 2029; McLauchlan 1992, 7; Messmer 1993, 217; Moore 1987, 669; Moser 1999 326; Pane 1989, 15; Pierick 2012, 1140; Sanna 2006, e1; Schneider 2004, 295; Sharieff 2001, 93; Sigsbee 1990, 662; Wright 1989, 37). One study (Pane 1989, 15) from the 2015 review wasn’t relevant for the revised outcomes in this update, and was not included in this updated review.
In our updated search, we found 12 new studies published since the 2015 review (Ataiants 2021 328; Blewer 2016 740; Blewer 2020 28; Cartledge 2017 148; Gonzalez-Salvado 2019 795; Han 2018 224; Ikeda 2016 45; Kim 2016 465; Michel 2020 e114; Raaj 2016 142; Tomatis-Souverbielle 2019 e141; Varalakshmi 2016 574). Some of these studies were RCTs comparing different methods of BLS training, but for the purpose of this PICO they are classified as non-RCTs (Blewer 2016 740; Blewer 2020 28; Gonzalez-Salvado 2019 795; Kim 2016 465; Raaj 2016 142). The 12 new studies included likely rescuers of patients with cardiac disease (Blewer 2016 740; Blewer 2020 28; Cartledge 2017 148; Gonzalez-Salvado 2019 795; Han 2018 224; Ikeda 2016 45; Kim 2016 465; Raaj 2016 142; Varalakshmi 2016 574), pulmonary disease (Raaj 2016 142) or who had suffered an acute life-threatening event (Tomatis-Souverbielle 2019 e141). Similar to the 2015 reviewed studies, these new studies used varying methods for BLS training, control groups and assessment of outcomes and were too heterogeneous for meta-analysis for any outcome to be performed.
In brief, following the training of likely rescuers of patients at high-risk of cardiac arrest there is insufficient evidence on trainees subsequent use of BLS skills and OHCA patient outcomes. Existing evidence suggest likely rescuers are unlikely to seek training on their own but are willing to receive training. Most studies assessing educational outcomes demonstrated improvements to BLS skills and knowledge following training. Those trained were also likely to share training with other family members and friends.
For the critical patient outcomes (survival with favorable neurologic outcome at discharge/30 days, survival at discharge/30 days, return of spontaneous circulation), and the important outcomes of subsequent use of skills (bystander CPR and automated external defibrillator), our updated review identified one observational study reporting data for these outcomes to 3-months post-training (Tomatis-Souverbielle 2019 e141). Tomatis-Souverbielle et al. (2019 e141) reported caregivers providing CPR and full recovery in 4 (7%) infants, however this study was subject to high loss to follow-up (79%). Therefore, the certainty of evidence for these outcomes remains very low-to-low (downgraded for risk of bias and imprecision), with too few OHCA events during follow-up to be confident in the direction of effect.
Full details of these outcomes from the previously identified three RCTs (Bardy 2008, 1793; Dracup 1986, 1757; Dracup 2000, 3289) and eight non-RCTs (Dracup 1998, 219; Dracup 1994, 116; Eisenberg 1989, 443; Higgins 1989, 1102; McDaniel 1988, 2029; McLauchlan 1992, 7; Pierick 2012, 1140; Sanna 2006, e1) are reported in the 2015 CoSTR documents, however those studies also reported that there were too few events to be confident in the direction of effect (Bhanji 2015 S242; Finn 2015 e203).
For the important outcomes of BLS skills and knowledge at completion of training we identified eight new studies (non-RCTs: Cartledge 2018 148; Gonzalez-Salvado 2019 795; Han 2018 224; Kim 2016 465; Michel 2020 e114; Raaj 2016 142; Tomatis-Souverbielle 2019 e141; Varalakshmi 2016 574), in addition to the 15 studies identified in the 2015 ILCOR review (Barr 2013, 538; Blewer 2012, 787; Brannon 2009, 133; Dracup 1998, 170; Dracup 1989, 61; Khan 2010, 299; Kliegel 2000, 147; Komelasky 1990, 387; Komelasky 1993, 96; Long 1992, 30; Messmer 1993, 217; Moore 1987, 669; Sharieff 2001, 93; Sigsbee 1990, 662; Wright 1989, 37).
While the new studies were all non-RCTs, the certainty of evidence was upgraded from ‘very-low’ to ‘low’ for consistency in findings (low certainty of evidence, downgrade for risk of bias and upgraded for consistency). The majority of the additional new studies support the previous findings that providing BLS training improves skills and knowledge in these groups immediately after training (Barr 2013, 538; Blewer 2020 28; Brannon 2009, 133; Cartledge 2018 148; Dracup 1989, 61; Dracup 1998, 170; Gonzalez-Salvado 2019 795; Han 2018 224; Khan 2010, 299; Kim 2016 465; Komelasky 1990, 387; Komelasky 1993, 96; Long 1992, 30; Messmer 1993, 217; Michel 2020 e114; Moore 1987, 669; Raaj 2016 142; Sharieff 2001, 93; Sigsbee 1990, 662; Tomatis-Souverbielle 2019 e141; Varalakshmi 2016 574; Wright 1989, 37). Most of the older studies only reported overall pass rates, and not individual BLS metrics, and reported acceptable pass rates in trained individuals immediately following training (Brannon 2009; Dracup 1989, 61; Dracup 1998; Komelasky 1993; Long 1992, 30; Messmer 1993, 217; Moore 1987, 669; Sharieff 2001, 93; Sigsbee 1990, 662; Wright 1989, 37).
Specific BLS metrics (including older studies reporting these outcomes):
Immediately after training (Barr 2013, 538; Cartledge 2018 148; Gonzalez-Salvado 2019 795; Han 2018 224; Michel 2020 e114):
• Chest compression rate: Four studies reported either an improvement in compression rates from baseline (Han 2018 224) or mean rates at guideline standard (Cartledge 2018 148; Gonzalez-Salvado 2019 795; Michel 2020 e114). One study reported mean compression rates under guideline standard (Blewer 2012, 787).
• Chest compression depth: Five studies reported either an improvement in compression depth from baseline (Gonzalez-Salvado 2019 795; Han 2018 224) or a high proportion at guideline standard (Cartledge 2018 148; Gonzalez-Salvado 2019 795; Michel 2020 e114). One study reported mean compression depths under guideline standard (Blewer 2012, 787).
• Chest compression fraction (CCF): An improvement from baseline was reported by one study (Han 2018 224).
• Full chest recoil: One study reported a high proportion of compressions with full chest recoil (Michel 2020 e114). One non-RCT reported no difference in chest recoil, which was high at baseline (Gonzalez-Salvado 2019 795).
• Hand position during compressions: Three studies reported either an improvement in hand position from baseline (Gonzalez-Salvado 2019 795; Han 2018 224) or a high proportion with correct hand position after training (Michel 2020 e114).
• Ventilation Rate during CPR: Three studies reported an improvement from baseline (Gonzalez-Salvado 2019 795), a ventilation rate at guideline standard (Barr 2013, 538) or a high proportion of successful rescue breaths (Michel 2020 e114).
• Correct AED use: An improvement from baseline for correct AED use was reported by one study (Gonzalez-Salvado 2019 795).
• CPR knowledge: An improvement from baseline CPR knowledge was reported by nine studies (Han 2018 224; Khan 2010, 299; Kim 2016 465; Komelasky 1990, 387; Messmer 1993, 217; Raaj 2016 142; Tomatis-Souverbielle 2019 e141; Varalakshmi 2016 574; Wright 1989, 37).
For the important outcomes of BLS skills and knowledge retention to one-year we identified six new studies which were subject to high risk of bias due to high loss-to-follow-up (very low certainty of evidence, downgraded for risk of bias).
Long term to one-year, overall there was some degradation in some skills compared to post-training but an improvement in skills and knowledge compared to most baseline measurements (all non-RCTs: Blewer 2016 740; Blewer 2020 28; Gonzalez-Salvado 2019 795; Han 2018 224; Kim 2016 465; Tomatis-Souverbielle 2019 e141):
• Chest compression rate: One study reported compression rates at guideline recommended levels at 6-months (Gonzalez-Salvado 2019), and two studies reported rates below guideline recommendations at 6-months (Blewer 2016 740; Blewer 2020 28).
• Chest compression depth: One study reported rates above baseline levels at 6-months (Gonzalez-Salvado 2019). Two studies reported compression depths below guideline recommendations at 6-months (Blewer 2016 740; Blewer 2020 28).
• Chest compression fraction (CCF): No studies were found.
• Full chest recoil: No improvement from baseline was reported by one study (Gonzalez-Salvado 2019).
• Hand position during compressions: A sustained improvement from baseline was reported by one study (Gonzalez-Salvado 2019 795).
• Ventilation Rate during CPR: An improvement from baseline was reported by one study at 6-months (Gonzalez-Salvado 2019 795).
• Correct AED use: An improvement from baseline was reported by one study, but this was lower than immediately after training (Gonzalez-Salvado 2019 795).
• CPR knowledge: An improvement from baseline was reported by three studies (Han 2018 224; Kim 2016 465; Tomatis-Souverbielle 2019 e141).
For the important outcome of willingness to provide CPR we identified two new non-RCTS (Cartledge 2018 148; Han 2018 224). These two studies, and all eight studies from the previous review, showed an increase in willingness to provide CPR in those trained (moderate-certainty evidence, downgraded for risk of bias, from 2 RCTs [Blewer 2012, 787; Haugk 2006, 263] and low-certainty evidence, downgraded for risk of bias and upgraded for consistency, from eight non-RCTs [Cartledge 2018 148; Dracup 1994, 116; Han 2018 224; Komelasky 1990, 387; Kliegal 2000, 147; Knight 2013, 9; Moser 1999 326; Schneider 2004, 295]).
For the new important outcome of confidence to perform CPR we identified five new non-RCTs (Cartledge 2018 148; Gonzalez-Salvado 2019 795; Han 2018 224; Kim 2016 465; Macken 2017 572). A low certainty of evidence (downgraded for risk of bias, upgraded for consistency) from all five studies, plus one study from the previous review, suggests those trained have an increased confidence to perform CPR after training (Barr 2013, 538; Cartledge 2018 148; Gonzalez-Salvado 2019 795; Han 2018 224; Kim 2016 465; Macken 2017 572). One study reported a decrease in confidence at 6-months (Macken 2017 572).
For the important outcome of secondary training we identified new evidence from four new studies (Blewer 2020 28; Cartledge 2018 148; Han 2018 224; Ikeda 2016 45), with five studies reporting this from the 2015 ILCOR review (Barr 2013, 538; Blewer 2012, 787; Greenberg 2011, 166; Kligel 2000, 147; Knight 2013, 9;). Overall, a low certainty of evidence (downgraded for risk of bias, upgraded for consistency) suggests those trained are likely to share the training materials (e.g. CPR training kits with videos and a manikin) with others (Barr 2013, 538; Blewer 2012, 787; Blewer 2020 28; Cartledge 2018 148; Han 2018 224; Ikeda 2016 45; Kligel 2000, 147; Knight 2013, 9).
Treatment Recommendations
We recommend BLS training for likely rescuers of populations at high-risk of out-of-hospital cardiac arrest (strong recommendation, low-to-moderate certainty of evidence).
We recommend health care professionals encourage and direct likely rescuers of populations at high-risk of cardiac arrest to attend BLS training (ungraded, good practice statement).
Justification and Evidence to Decision Framework Highlights
In making this recommendation, the EIT Task Force placed higher value on:
• the improvements or competency in BLS skills and confidence when compared to baseline data or guideline standards;
• the improvements in confidence to perform BLS;
• the multiplier effect of trained individuals training others.
• the high proportion of OHCA that occur in the home and the potential benefits of patients receiving BLS by a family-member or caregiver in the case of OHCA;
• the willingness of this group to be trained and to use skills if required;
• BLS training doesn’t increase anxiety in trainees; and
• that these groups are unlikely to undertake training on their own.
Given these facts we considered it important to recommend that health care professionals encourage and direct these groups to attend BLS training even though they may not take up training (Greenberg 2011, 166).
We placed lesser value on the associated costs, and the potential that performance of some skills may not be to guideline standard and may not be retained without refresher CPR training.
Knowledge Gaps
• New methods, such as cardiac arrest registries, are needed to study the long-term impact of on patient outcomes.
• Best methods for training and retraining to achieve high attendance and skill retention.
• Whether health care providers suggesting the need for BLS training influences likely rescuers to seek training.
Attachments
References
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