Community Initiatives to promote BLS implementation: EIT 6306 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 applicable.

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 applicable.

Task Force Synthesis Citation

Tasuku Matsuyama, Andrea Scapigliati, Drieda Zace, Alexander Olaussen, Andrew Lockey, Robert Greif, on behalf of the International Liaison Committee on Resuscitation (ILCOR)

the Education, Implementation and Team (EIT) Task Forces. Community initiatives to promote BLS implementation-Scoping Review.

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review conducted by the ILCOR EIT Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered by the Education Implementation Team Task Force.

Scoping Review

PICOST

Search Strategies

PubMed

(((("Heart Arrest"[Mesh] OR "heart arrest*"[TIAB] OR "cardiac arrest*"[TIAB] OR "cardiovascular arrest*"[TIAB] OR "cardiopulmonary arrest*"[TIAB] OR "cardio-pulmonary arrest*"[TIAB] OR "Out-of-Hospital Cardiac Arrest*"[Mesh] OR OHCA OR "Out of Hospital Cardiac Arrest*"[TIAB] OR "out-of-hospital cardiac arrest*" [TIAB] OR "Outside-of-Hospital Cardiac Arrest"[TIAB]) OR (resuscitation [Mesh] OR resuscitation* [TIAB] OR "cardiopulmonary resuscitation"[Mesh] OR "cardiopulmonary resuscitation"[TIAB] OR "CardioPulmonary Resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR [TIAB] OR "Life Support Care"[Mesh] OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" [TIAB] OR "cardiorespiratory resuscitation"[TIAB] OR "Heart Massage*"[Mesh] OR “heart massage*”[TIAB] OR “cardiac massage*” [TIAB] OR “chest compression*”[TIAB] OR “cardiac compression*”[TIAB]) OR (defibrillators [Mesh] OR defibrillator* [TIAB] OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock [Mesh] OR “Electrical Cardioversion*” [TIAB] OR “Cardiac Electroversion*”))AND (bystander*[TIAB] OR "first responder*"[TIAB] OR "firstresponder*"[ TIAB] OR Layperson*[TIAB] OR “lay people”[TIAB] OR “lay rescuer*”[TIAB] OR “lay public” OR witness*[TIAB] OR “non-healthcare professional” [TIAB] )) AND (((community OR public OR local OR social OR population* OR citizen*) AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR preparation* OR implement* OR project* OR strategy* OR program OR programs OR network* OR training* OR campaign* OR education OR coaching OR information* OR learning OR instruction* OR guidance* OR response* OR responsiveness OR reply OR reaction OR awareness OR alertness OR realization OR sensibility OR sensitivity OR consciousness) OR “community-based initiative*” OR “community-driven initiative*”)) ● Filters: Only humans

Embase

((('heart arrest' OR 'cardiac arrest*' OR 'cardiovascular arrest*' OR 'cardiopulmonary arrest*' OR 'cardio-pulmonary arrest' OR 'out of hospital cardiac arrest' OR ohca OR 'out-of-hospital cardiac arrest*' OR 'outside-of-hospital cardiac arrest') OR ('heart massage OR 'cardiopulmonary resuscitation' OR 'cardiopulmonary resuscitation' OR 'cardio pulmonary resuscitation' OR cpr OR 'basic life support' OR 'cardiorespiratory resuscitation' OR 'heart massage*' OR 'cardiac massage*' OR 'chest compression*' OR 'cardiac compression*' OR defibrillator* OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock OR “Electrical Cardioversion*” OR “Cardiac Electroversion*”)) AND ('layperson' OR bystander* OR 'first responder*' OR 'first-responder*' OR layperson* OR 'lay people' OR 'lay rescuer*' OR 'lay public' OR witness* OR 'nonhealthcare professional')) AND ((community OR public OR population* OR citizen*) AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR implement* OR program OR programs OR network* OR training* OR campaign* OR guidance* OR response* OR responsiveness OR reply OR awareness OR alertness OR sensibility OR sensitivity OR consciousness OR 'community-based initiative*' OR 'community-driven initiative*’)))

COCHRANE

(MeSH descriptor: [Heart Arrest] OR ("cardiac arrest" OR "cardiovascular arrest*" OR "cardiopulmonary arrest*" OR "cardio-pulmonary arrest*"):ti,ab,kw OR MeSH descriptor: [Out-of-Hospital Cardiac Arrest] OR ("cardiopulmonary resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR OR "Life Support Care" OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" OR "cardiorespiratory resuscitation"):ti,ab,kw OR MeSH descriptor: [Heart Massage] OR ("cardiac massage*" OR "chest compression*" OR "cardiac compression"):ti,ab,kw OR defibrillator* OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock OR “Electrical Cardioversion*” OR “Cardiac Electroversion*”):ti,ab,kw) AND ((bystander* OR "first responder*" OR "first-responder*" OR Layperson* OR “lay people” OR “lay rescuer*” OR “lay public” OR witness* OR “non-healthcare professional”):ti,ab,kw) AND (community OR public OR local OR social OR population* OR citizen* OR person OR people):ti,ab,kw AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR preparation* OR implement* OR project* OR strategy* OR program OR programs OR network* OR training* OR campaign* OR education OR coaching OR information* OR learning OR instruction* OR guidance* OR response* OR responsiveness OR reply OR reaction OR awareness OR alertness OR realization OR sensibility OR sensitivity OR consciousness OR “community-based initiative*” OR “community-driven initiative*”):ti,ab,kw

Inclusion and Exclusion criteria

Inclusion Criteria:

1) Studies were eligible if they addressed the research question, reporting the impact of community initiatives (i.e. training, video-based CPR courses, media broadcasts, etc.) involving laypersons on OHCAs outcomes,

2) Peer reviewed journal papers,

3) Written in English

4) Involving human participants and

5) All study designs

Exclusion Criteria:

1) Studies not addressing the research question

2) Abstract only studies,

To avoid overlapping with other PICOs:

3) Public Access Defibrillation (PAD) programs or other AED dissemination and deployment programs including use of drones,

4) Dispatched and/or Telephone CPR including use of Apps for FR dispatch and/or AED localization,

5) Impact of social or economic factors in bystander’s engagement, including geographical areas, neighborhoods differences, ethnic background,

6) Effect of different CPR Techniques or protocols including changes in resuscitation guidelines

Data tables

Please refer to Supplemental Table 1: EIT 6306 Community initiatives to promote BLS implementation Scoping Review supplemental table

Task Force Insights

1. Why this topic was reviewed.

In OHCA, the first three links in the chain of survival—early recognition of cardiac arrest, calling emergency services, and bystander CPR—form the foundation of BLS. Rapid BLS interventions significantly increase survival rates and improve neurological outcomes for OHCA patients. However, there's considerable variability in the implementation of these interventions, with regional differences in the rates of bystander CPR and AED use. To address these discrepancies, various community-based initiatives have emerged, ranging from dispatcher-assisted CPR to public access defibrillation (PAD) programs, AED distribution, simplification of CPR techniques, and applications that help locate first responders and AEDs. While these strategies have been recommended in international guidelines, their impact on BLS implementation is less clear, especially regarding public education and training. Given these uncertainties, this topic was chosen by EIT Task Force to understand better the effectiveness of community-based initiatives in promoting BLS implementation. This review aims to address the knowledge gaps identified in a previous scoping review, providing a comprehensive analysis of these initiatives' impact on BLS implementation and potentially influencing future ILCOR recommendations.

2. Narrative summary of evidence identified

Studies’ characteristics

The scoping review included 21 studies [1-21], primarily conducted in the USA (47.6%) [1,2, 10-16], followed by Denmark (23.8%) [4,17-19], Korea (19.0%) [5-7], Japan (4.8%) [8], Singapore (4.8%) [3], the UK (4.8%) [20], and China (4.8%) [21]. Most studies used a cohort design (42.9%) [2, 8, 10, 12, 13, 17-20], followed by before-after studies (28.6%) [3, 6, 9, 14, 16, 21], cross-sectional studies (23.8%) [4, 5, 7, 15], RCT (4.8%) [1], and one non-randomized controlled trial (4.8%) [11]. Over half were prospective (57.1%) [1, 3, 4-6, 8, 11, 15, 17-19, 21], while the remainder were retrospective (42.9%) [2, 7, 9, 10, 13, 14, 16, 20]. Most studies (81.0%) were published between 2012 and 2019, with two studies (9.5%) published earlier [1, 11] and two (9.5%) published from 2020 onwards [20, 21]. All studies focused on adult OHCA cases, with interventions implemented in workplaces, schools, government offices, public events, and shared community spaces.

Types of interventions and outcomes

The primary community initiatives were grouped into three categories:

Community CPR training programs (n=11) [1-3, 12-19]: instructor-led, self-training, and peer-to-peer

Mass-media campaigns (n=1) [11]: focused on public awareness through media outlets

Bundle interventions (n=9) [4-10, 20, 21]: concurrent efforts that combine CPR training with other community-based strategies such as public awareness campaigns, guideline implementation, legislative changes, and mandatory training for driver’s license applicants.

Most studies (52.3%) examined community CPR training programs as the primary intervention type, followed by bundle interventions (42.9%), and a single study focusing solely on mass-media campaigns (4.8%).

1. Community Training Programs

A total of eleven studies [1–3, 12–19] evaluated the impact of CPR training (± media) on OHCA outcomes.

Bystander CPR rate was reported in ten studies, with positive results in seven studies [2, 3, 13–15, 17, 18]. Three studies reported no improvement in bystander CPR rate [1, 16, 19].

Proportion of population trained was evaluated in three studies, all of which reported an increase [13, 15, 19].

ROSC was reported in two studies [3, 16], with one showing a positive outcome [3].

Survival to hospital discharge was reported in six studies, with positive outcomes in two studies following instructor-led training [3, 12]. Four studies showed no improvement in this outcome [14, 16-18].

Survival with good neurological outcome was reported in three studies using instructor-led training. Only one study showed a positive result overall [2], while other showed no significant improvement [12, 16].

Time to first compressions was not reported as an outcome in any study.

1. Mass-Media Campaigns

One study [11] assessed mass media's effect as the primary intervention, reporting an increase in bystander CPR rates following television public service announcements.

1. Bundled Interventions

Nine studies evaluated the impact of bundled interventions on OHCA outcomes, with heterogeneous components within the bundles [4-10, 20, 21].

Bystander CPR rate was the most frequently reported outcome, appearing in all nine studies [4–10, 20, 21]. Positive results were observed in six studies, where bystander CPR rates increased through combinations of instructor-led training, guideline implementation, and public initiatives [4-7, 20, 21]. Three studies reported no significant improvement in bystander CPR rates [8–10].

Proportion of population trained was reported in three studies, with all showing positive impacts [6, 8, 21].

ROSC was reported in one study, with a positive outcome following a bundled intervention [21].

Survival to hospital discharge was reported in two studies, with one study showing a positive effect [21] and another showing no significant improvement [8].

Survival with good neurological outcome was reported in one study, with no significant improvement noted [8].

Time to first compressions was not reported as an outcome in any of these studies.

3. Narrative Reporting of the task force discussions

At the initial stages of the search strategy, the Task Force discussed and refined the inclusion and exclusion criteria. To avoid overlap, it was decided to exclude studies that focused on Public Access Defibrillator (PAD) programs or other AED dissemination, dispatched and/or telephone CPR/apps, the impact of social or economic factors on bystander engagement, and the effect of different CPR techniques or protocols, including guideline changes. This decision was made because these areas are covered by other PICOST reviews specifically designed to address these topics.

The Task Force also deliberated on the appropriate type of review (i.e., scoping vs. systematic). Because of the heterogeneity among included studies, a scoping review was selected as the best approach to narratively summarize findings from starting date to ending date. The only outcome consistently evaluated across nearly all included studies was the bystander CPR rate, and most studies reported improvements in this outcome following community initiatives [2-7, 11-15, 17, 18, 20, 21]. For the proportion of trained individuals, only six studies evaluated this outcome, and all reported an increase in the number of people trained [6, 8, 13, 15, 19, 21]. These findings strongly suggest that community initiatives are effective in increasing both the bystander CPR rate and the proportion of trained individuals, highlighting their value in enhancing community readiness to respond to OHCA. However, for patient outcomes such as survival and neurological outcome, the results were mixed. To better assess the effectiveness of community initiatives, well-designed RCTs will be essential in providing a clearer understanding of the impact as evidence in this field continues to grow.

Knowledge Gaps

• Current research is limited to only a few countries, highlighting the need for broader geographic evidence including low resource settings.
• More well designed RCTs are needed to report key patient outcomes, as current evidence remains insufficient.
• The effect of public campaigns such as WRAH (World Restart A Heart) needs assessment in regions beyond the UK.
• No studies have addressed the impact of interventions on neonatal and pediatric resuscitations.
• The influence of specific legal regulations on CPR uptake in countries other than China requires investigation.
• There is a need to investigate and review how specific laws and regulations can affect community response to cardiac arrest.
• Identifying the specific impact of each intervention in multi-component studies is challenging.
• Studies are needed to evaluate the cost-effectiveness of each intervention and its specific impact on clinical outcomes.

References

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2. Hansen CM, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010-2013. JAMA. 2015;314(3):255-64. doi:10.1001/jama.2015.7938.
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