Cognitive Aids used in Resuscitation (EIT 6400) TF SR

Conflict of Interest (COI) 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: Kevin Nation

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: none declared.

CoSTR Citation

Nabecker S, Nation K, Gilfoyle E, Abelairas-Gomez C, Koota E, Greif R on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Cognitive Aids Used in Resuscitation Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 30 November 2023. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process to produce Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of the use of cognitive aids in resuscitation conducted by an information specialist with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were considered when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to PubMed using this format when it is available if published.

Publication in progress

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults, children and neonates in any setting (in-hospital or out-of-hospital) requiring resuscitation or laypersons and health care providers providing resuscitation or learning to provide resuscitation.

Intervention: The use of cognitive aids or checklists during resuscitation or resuscitation training

Comparators: No use of cognitive aids or checklists.

Outcomes: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Quality of performance in actual resuscitations, skill performance 1 year after course conclusion, skill performance between course conclusion and 1 year, skill performance at course conclusion, knowledge at course conclusion were included as important outcomes. Measures of effect outcomes included adherence to resuscitation guidelines, CPR quality and test scores were also included as important outcomes.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included if there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search was updated to January 1990 to 28 October 2023.

PROSPERO Registration CRD42020159162.

Consensus on Science

For the critical outcomes of survival to hospital discharge with good neurological outcome and survival to hospital discharge, we were unable to identify any relevant studies.

Health Care Providers Managing Resuscitation in Neonates (RoB Table 1)

We found 4 studies^(1-4) investigating the effects of cognitive aids used during simulated neonatal resuscitation. Non-interactive aids were used in 2 studies^{(1, 2)}, including a poster ⁽¹⁾, or a tablet with auditory and visual prompts⁽²⁾. Interactive aids were used in 2 studies ^{(3, 4)}, including an audio voice guidance App^(3), or an augmented reality decision support tool^(4).

For the important outcome of adherence to a protocol or process, we identified very low certainty evidence (downgraded for serious indirectness and serious impression) from 4 studies^(1-4) with a total of 89 participants in the intervention groups and 84 participants in the control groups.

• one study⁽⁴⁾, investigating an electronic decision support tool, demonstrated improvement in performance score.
• one study⁽²⁾ investigating an audio visual prompt device, demonstrated fewer deviations from a resuscitation algorithm.
• one study⁽³⁾ investigating an audio visual guidance tool, demonstrated improved adherence to a resuscitation algorithm and performance to a guideline.
• one study⁽¹⁾ investigating a poster of an algorithm demonstrated no difference in performance.

Healthcare Providers Managing Paediatric Resuscitation (RoB Table 2 and 2a)

We found 3 studies^(5-7) investigating the effects of cognitive aids used during simulated paediatric resuscitation. A non-interactive CPR checklist was used in 1 study⁽⁷⁾. Interactive aids were used in 2 studies^{(5, 6)} including a Tablet App⁽⁶⁾ and a Personal Digital Assistant App⁽⁵⁾.

For the important outcome of CPR quality we found low quality evidence from 2 randomised trials^{(6, 7).}

• One study investigating the use of a checklist by 16 individuals in the intervention and control groups found no difference in CPR performance^(7).
• One study investigating a decision support App with 32 teams in the intervention group and 75 teams in the two control arms also showed no difference in CPR quality metrics^(6).

For the important outcome of adherence to a protocol or process we found very low quality evidence (downgraded for very serious risk of bias and serious indirectness) from 2 randomised trials^{(5, 6).}

• one study investigating a computer based resuscitation tool in the intervention group examined the use of a computer based resuscitation tool by an individual, found improvement in the number of tasks completed with the tool compared to the 19 participants in the control group. Other time relevant interventions showed no benefit^(5).
• one study investigating a decision support App found significantly less deviations from guideline recommendations in the intervention groups compared with control ^(6).

Healthcare Providers Managing Adult Advanced Life Support (RoB Table 3)

We found 8 studies^(8-15) investigating the effects of cognitive aids used during adult advanced life support simulated resuscitation. All the studies used interactive aids, a Smartphone App^{(8, 12, 14)}, a Tablet App^{(10, 11, 13)}, or a computer-based clinical decision display system^{(9, 15).}

For the important outcome adherence to a protocol or process, we identified very low quality evidence (downgraded for very serious risk of bias and serious indirectness and very serious imprecision) from 8 randomised trials^(12-19).

• Four studies^{(8, 10, 12, 14)} investigated the use of interactive telephone Apps. Two studies reported improved performance scores^{(8, 14).} Two studies^{(10, 12)} demonstrated significantly improved adherence to correct sequences and reduced errors of commission.
• One study using an interactive computer prompt device demonstrated little difference in performance between the intervention group and control group in managing familiar algorithms but improved performance in the intervention group when managing less familiar protocols^(15).
• Another study using an interactive large screen clinical decision display system seen by the team demonstrated a number of interventions performed closer to ACLS recommendations⁽⁹⁾.
• Two studies^{(11, 13)} investigated the use of interactive Tablet Apps. One study⁽¹¹⁾ showed improved performance scores in the intervention group. One study⁽¹³⁾ showed variable results between the intervention and control groups.

Healthcare Providers Managing Other Emergencies (RoB Table 4 and 4a)

We found 5 studies^(16-20) investigating the effects of cognitive aids used by healthcare providers managing other emergencies in simulated events. All of the studies used non-interactive checklists^(16-20).

For the important outcome adherence to a protocol or process, we identified very low-quality evidence (downgraded for very serious risk of bias and serious imprecision) from 3 randomised trials^{(16, 18, 19).}

• Two studies^{(16, 18)} with a total of 79 participants in each of the intervention and control groups demonstrated highly significant increases in average performance scores⁽¹⁸⁾ and reduced failure to adhere to critical steps^(16).
• Two studies^{(17, 19)} with 607 participants in 85 teams in the intervention and 95 teams in control groups demonstrated that using a medical emergency checklist resulted in 9% absolute and 15% relative risk reduction of failure to adhere to guideline-adherent critical process steps. All teams had a lower failure rate for adherence to key processes with the intervention^(19). With a checklist, the intervention groups had significantly shorter time to adequate administration of glucose in the hypoglycaemic coma scenario (median times 632s with checklist, 756s without checklist, p=0.03) but did not shorten time to performance of the other nine emergency interventions. Access to crisis checklists had no impact on whether emergency interventions were carried out or not^(17).

For the important outcome CPR performance and retention, we identified very low quality evidence (downgraded for very serious risk of bias, serious indirectness and serious imprecision) from 1 randomised trial⁽²⁰⁾ indicating long checklists superior to short checklists or no checklist for overall performance on procedural variables but not for CPR quality.

Laypersons Delivering Resuscitation (RoB Table 5 and 5a)

We found 9 studies, 7 randomised trials ^(21-27) and 2 observational studies⁽²⁸⁾, investigating the effects of cognitive aids used by lay rescuers during simulated resuscitation. Non-interactive aids were used in 4 studies^{(21, 24, 25, 27)}, Smartphone Apps^{(21, 24)}, a flowchart⁽²⁵⁾, or an instruction card⁽²⁷⁾. Interactive aids were used in 5 studies^{(22, 23, 26, 28, 29)}, Smartphone Apps^{(22, 26)}, Personal Digital Assistant Apps^{(23, 28)}, or a Chatbot⁽²⁹⁾.

For the important outcome of adherence to a protocol or process assessed by a performance score, we identified very low-quality evidence (downgraded for very serious risk of bias, serious inconsistency and very serious impression) from 5 randomised trials ^{(21, 22, 24, 26, 27)}.

• Three studies^{(21, 22, 24)} investigating the use of mobile phone applications, demonstrated improved adherence to a process measured using a checklist or performance score. One study⁽²⁶⁾ investigating a mobile phone application using yes/no questions found no significant improvement.
• One study investigating the use of an instruction card by individuals found improved adherence to the sequence of AED use and improved time to shock⁽²⁷⁾.

For the important outcome of adherence to a protocol or process (assessed with an Objective Structured Clinical Examination (OSCE) score), we found low quality evidence (downgraded for very serious indirectness) from one observational study⁽²⁸⁾. Investigating the use of speech recognition software on a personal digital assistant device the study demonstrated improved OSCE points scores.

For the important outcome of quality of CPR we identified very low quality evidence (downgraded for very serious risk of bias, serious inconsistency and serious indirectness) from 2 randomised trials^{(23, 25)}.

• One study⁽²³⁾ investigating the use of a voice-activated visual and auditory-assisted decision device, demonstrated improved adherence to a 30:2 CPR ratio.
• One study⁽²⁵⁾ investigating the use of a flowchart demonstrated reduced hands-off time during CPR.

We also identified moderate quality evidence (downgraded for serious indirectness) from one observational study⁽²⁹⁾ investigating the feasibility of Chatbot guidance which demonstrated thirty-three percent of participants achieved high-quality CPR, 86% achieved quality chest release, 38% did so in depth of compressions and only 5% in compression rate. 24% achieved a mean depth between 50 and 60 mm and 62% achieved a mean rate between 100 and 120 c/min.

We found very low-quality evidence from 3 studies^(23-25) involving laypersons with a total of 255 participants that demonstrated potentially undesirable effects. Two studies^{(23, 25)} identified significant increase in time to commencing chest compressions. One study⁽²⁴⁾ found delays in calling emergency services and delays in commencing chest compressions

Treatment Recommendations

• We suggest the use of cognitive aids by health care providers in resuscitation (weak recommendation, very low certainty of evidence).
• We do not recommend the use of cognitive aids for lay providers initiating CPR (weak recommendation, low certainty of evidence).
• We did not examine the use of cognitive aids in health professional or lay rescuer training in resuscitation so no recommendation for or against can be issued.

Justification and Evidence to Decision Framework Highlights

In making this recommendation we recognise that:

• The EIT Task Force continues to prioritise this topic because international resuscitation councils commonly provide cognitive aids to resuscitation course participants and healthcare organizations (algorithms, pocket cards, flowcharts, infographics, etc.). However, it has not been determined if they are effective in improving patient outcomes or provider performance during actual resuscitation, as no evidence was found for the use of cognitive aids by trained healthcare providers during actual resuscitation events.
• In 2021 our evidence update focused on outcomes associated with CPR quality. In the review outcomes have been associated more towards improved team performance through adherence to protocol and process.
• Our recommendation has been issued differentiating health care professionals and laypersons as well as for routine use of cognitive aids during resuscitation and during training for these providers, as the conditions between training and clinical resuscitation differ substantially.
• For lay providers, there is consistent evidence that there are potentially clinically important delays in initiating CPR when using a cognitive aid; however, the evidence for impact on CPR quality metrics (e.g. rate, depth, chest compression fraction) is less consistent. We found insufficient evidence to issue a recommendation for the use of cognitive aids in layperson training.
• For health care professionals sufficient new studies provided the evidence to issue a recommendation for the use of cognitive aids during resuscitation. As no study reported the use of cognitive aids during patient resuscitation, the simulation study results might be used as a surrogate to justify the use of cognitive aids as these have been used over decades by all resuscitation councils.
• Due to no studies being found in resuscitation in the review in 2019, the Task Force has previously considered the trauma resuscitation environment sufficiently similar to the cardiopulmonary resuscitation environment to extrapolate evidence that shows that trauma resuscitation teams generally adhere to resuscitation guidelines better, make fewer errors and perform key clinical tasks more frequently if they use cognitive aids. Over the last few years sufficient new studies addressed the use of cognitive aids in resuscitation (however only in a simulated environment) the Task Force decided to exclude trauma studies from this review, as there may be important differences between cardiac arrest and trauma resuscitation clinical environments.
• There were several studies that used composite scores as their primary outcome (e.g. score calculated based on the completion of several clinical tasks). We included these studies for this systematic review however, given their heterogeneity, comparing and consolidating the results was not possible.
• We did not examine the use of cognitive aids in healthcare professionals or lay rescuer training in resuscitation and this needs to be examined in our next review.

Knowledge Gaps

We identified several knowledge gaps in the literature:

• There is an urgent need for adequately powered studies investigating the impact of cognitive aids in the real-world cardiac arrest environment and on patient survival.
• Further studies are also required to investigate effective implementation strategies of cognitive aid during training and real-life resuscitation for healthcare providers.
• Cost-effectiveness studies on the use of cognitive aids during resuscitation and training and which cognitive aids are more effective than others are needed.
• High-quality studies are also required on the use of cognitive aids during healthcare professional and layperson training.

Attachment:

EIT 6400 Cognitive Aids SR 2023 Evidence to Decision Table

EIT 6400 2023 Cognitive Aids SR Ro B Assessments

EIT 6400 2023 Cognitive Aids Summary of findings Tables

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