EIT 6105: Targeted BLS training for likely rescuers of high-risk populations: An Adolopment Systematic Review

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

Nation K, Allan K, Lockey A, Cheng A, Nabecker S on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Targeted BLS training for likely rescuers of high-risk populations – an adolopment systematic review. Consensus on Science with Treatment Recommendations: International Liaison Committee on Resuscitation (ILCOR), 10 December 2025. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

This continuous evidence evaluation process to produce Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review published in 2025.⁽¹⁾ Following this review, the EIT task force conducted a secondary literature search on targeted BLS training for likely rescuers of high-risk populations, supported by an information specialist (MT), 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

Doherty, Z., Bray, J., Finn, J., Cartledge, S. (2025). "Basic life support training targeted to family members or carers of those at high-risk of out-of-hospital cardiac arrest: a systematic review." Resuscitation Plus 25: 101031.

https://doi.org/10.1016/j.resp...

PICOST

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

Population: For adults and children at high-risk of out-of-hospital cardiac arrest (OHCA)

Intervention: does targeted BLS training of likely rescuers (e.g. family or caregivers)

Comparison: compared with no such targeting

Outcomes:

Patient outcomes (Critical)

Survival with favorable neurological outcome at discharge and 30 days

Survival to hospital discharge/30 days

Return of spontaneous circulation

Bystander CPR quality during OHCA (any available CPR metrics)

Process outcomes (Critical)

Rates of bystander CPR (subsequent use of skills)

Rates of AED use (subsequent utilization of skills)

Bystander CPR quality during OHCA (any available CPR metrics)

Education outcomes (Important)

CPR quality and AED competency post training completion and within 12 months of training

CPR and AED knowledge post training completion and within 12 months of training

Confidence to perform CPR post training and within 12 months of training

Willingness to perform CPR post training and within 12 months of training

Secondary training of others

Study Design: 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. All languages are included if there is an English abstract available. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. Review articles will be searched for additional citations.

Timeframe: All years from inception to 20 November 2025.

PROSPERO Registration CRD42021233811

Consensus on Science

Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and a high proportion of OHCA occur in the home. Bystander CPR rates are low. This topic was reviewed by ILCOR in 2015 and again in 2022. An earlier systematic review was published in 2016.⁽²⁾

The 2015 ILCOR review found 32 studies relating to BLS training in likely rescuers of high-risk OHCA groups.⁽³⁾ The 2021 ILCOR updated search found 12 new studies published since the 2015 review.⁽⁴⁾ All the 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.

There continues to be insufficient evidence found on trainees’ use of BLS skills and OHCA patient outcomes following the training of likely rescuers of patients at high-risk of cardiac arrest.

An updated systematic review has been published in 2025.⁽¹⁾ A total of 48 studies (17 new non-randomized studies) were found. These studies targeted training to a variety of high-risk populations. Adult studies included family members of cardiac patients, cardiac arrest survivors and one in women with a history of drug use. Studies of pediatric populations mostly targeted family members of infants in neonatal intensive care units. The consensus on science is an adolopment of this review.⁽¹⁾

We conducted an updated search run on 20 November 2025 and found one additional non-randomized study with moderate risk of bias.⁽⁵⁾ This study aimed to establish an integrated public CPR training system for family members of patients with chronic diseases under community care and evaluate the feasibility of the newly established system. The investigators surveyed participants (n=140) six months following training.⁽⁵⁾

Subsequent use of BLS skills

For the critical patient outcomes including subsequent use of BLS skills, 17 studies (including 3 RCTs) reported at least one critical outcome, with periods of follow-up ranging from 3 months to 10 years and most studies relied on self-reported outcomes.^(6-22) Both the adult (n=919)^{(10-12, 19, 23-31)} and pediatric (n=818)^{(13, 28, 32-34)} studies often reported significant loss to follow-up with few subsequent OHCA events making the effect of the interventions on patient outcomes unclear.⁽¹⁾

Among the studies examining patient outcomes, there were two large RCTs.^{(7, 8)} The largest, the Home Automated External Defibrillator Trial (HAT) randomized 7001 adult patients with acute myocardial infarction to have an AED with BLS training compared to CPR training alone.⁽⁸⁾ In this study, with 100% follow-up, 160 OHCAs occurred over a median follow-up of 37 months, but only 58 (36%) arrests were witnessed by trained family members. It is unclear how many received CPR, but 29 (50%) patients had an AED applied. Notably, in this study, there were seven instances of study AEDs being used for individuals not included in the study (e.g. neighbors). There was no difference in mortality between the 2 study groups (n=228/3506 (6.5%) in the control group vs n=222/3495 (6.4%) in the AED group (hazard ratio, 0.97; 95% CI, 0.81 to 1.17; P=0.77)

The largest pediatric RCT, which trained parents of 462 infants discharged from a neonatal intensive care unit, compared three methods of CPR training in addition to a control group with no training.⁽⁶⁾ At one year, only 58% were followed up, with parents of these infants reporting 13 OHCA events in the home. All these children were successfully resuscitated (not defined), and all had received CPR training, with no events reported in the control group.

We found moderate certainty evidence (downgraded for risk of bias) from one additional non-RCT that surveyed family members of patients with chronic diseases six months after training, 10 individuals (7.1%) had performed CPR.⁽⁵⁾ Two cases of CPR were successful (not defined).

CPR Quality and AED competency

For the important educational outcome of CPR Quality and AED competency 19 studies (1 RCT, 18 non-RCTs) were found.^{(15, 25, 26, 28, 29, 31-43)} For non-RCTs the certainty of evidence was upgraded from very low to low for consistency in findings and RCT certainty of evidence remained as moderate, downgraded for risk of bias. Studies that reported an overall quality or competency metric (and not specific measures) generally found improvements post-training. Beyond training completion, 7 non-RCTs reported on CPR quality and AED competency.^{(10, 23, 24, 29, 32, 40, 44)} The time points of follow-up varied from 2 months to 1-year after the initial training. Recent studies (2012 – 2020) were able to measure and report on each aspect of CPR skills.^{(23-25, 29, 31, 32, 42, 45)} Most studies reported an improvement in compression rate/depth or rates being at guidelines standard from baseline skills or immediately post-training. Correct use of an AED was assessed in one study and showed an improvement from baseline immediately after training.⁽³²⁾ One study reported retention over time by comparing skills at different time points, they identified that refresher training resulted in less decay of skills (rate, depth, hand position and recoil) over time compared to once-off training.⁽²⁹⁾

CPR and AED knowledge

For the important educational outcomes of CPR and AED knowledge, 13 studies (1 RCT, 12 non-RCTs) were found.^{(7, 22, 26, 35, 37, 40, 41, 43, 44, 46-49)} Knowledge was often reported using a test created by the study authors. Most studies found an increase in knowledge immediately post-training. Only two non-RCTs examined knowledge beyond training completion, one at two months and one at 12 months.^{(40, 44)} The 12-month study⁽⁴⁴⁾ examined the impact of reminders to refresh training, and showed CPR knowledge at 12-months was significantly higher in the two intervention groups (audio-visual and audio-visual-practice training with reminders) compared to control (booklet and DVD with no reminders). No initial post-training assessment was done to assess retention over time.⁽⁴⁴⁾

Confidence to perform CPR

For the important outcome of confidence to perform CPR, five non-RCTs with a low certainty of evidence (downgraded for risk of bias, upgraded for consistency) were found.^{(25, 29, 31, 32, 41)} All five studies identified increased confidence following any type of CPR training. However, for studies with ongoing follow-up, a decay in confidence over time was identified.^{(32, 41)}

We found moderate certainty evidence (downgraded for risk of bias) from one additional non-RCT that surveyed family members of patients with chronic diseases, six months after training, to evaluate their confidence to perform CPR. 43.6% expressed confidence in their ability to perform CPR, 45.7% had moderate confidence, 10.7% lacked confidence.⁽⁵⁾

Willingness to provide CPR

For the important outcome of willingness to provide CPR, moderate certainty of evidence from one RCT and a low certainty of evidence from nine non-RCTs was found.^{(10, 12, 15, 25, 34, 35, 45, 47, 50, 51)} Evidence from the RCT was downgraded to moderate for risk of bias and evidence from non-RCTs was rated as low after being downgraded for risk of bias but upgraded for consistency.⁽¹⁾ Three studies reported a significant increase in willingness to provide CPR after training compared to before training.^{(12, 25, 50)} Willingness based on the relationship to the patient was described in two studies, with lower rates as the example theoretical patient (i.e. imagine the patient was your father) became less “known” to the participant.^{(10, 50)} The method of CPR training was examined in two studies, with one finding slight increases in willingness to perform continuous compression CPR compared to standard CPR⁽⁴⁵⁾, and the other identified traditional “didactic” training to be superior to other forms such as video training.⁽⁵²⁾

Secondary training

For the important outcome of secondary training, we found a low certainty of evidence from one RCT (downgraded for risk of bias)⁽⁴⁵⁾ and eight non-RCTs (downgraded for risk of bias but upgraded for consistency).^{(17, 24, 25, 30-32, 50, 52)} These studies describe participants sharing of CPR training and/or teaching materials with others. Of these studies, five reported the proportion of participants providing secondary training with rates varying between 22% to 72%.^{(24, 25, 31, 32, 45)} One study reported 96% of participants had an intention to teach others, but ultimately only 42% of participants did with one patient-spouse pair training multiple peers.⁽²⁵⁾

Treatment Recommendations and Good Practice Statement

• We recommend BLS training for likely rescuers of adults and children 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 adults and children 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 several factors:

• Training demonstrated measurable improvements in BLS skills and confidence compared to baseline data and guideline standards.
• Improvements in confidence directly influences willingness to act during out-of-hospital cardiac arrest (OHCA) events.
• The multiplier effect of trained individuals sharing their knowledge and training others.
• A high proportion of OHCA occurring in the home and the potential benefits of patients receiving BLS from a family member or caregiver.
• The willingness of this group to undergo training and apply skills when required.
• BLS training does not increase anxiety among trainees
• Low likelihood of self-initiated training

These factors underscore the need for proactive engagement of this group by healthcare professionals.

EtD: EIT 6105 High Risk Populations Adolopment Et D

Attachments: EIT 6105 High Risk Populations Adolopment AMSTAR 2 Assessment; EIT 6105 BLS training high risk populations Adolopment checklist; EIT 6105 Co STR Checklist Targeted BLS training; EIT 6105 High Risk Populations Adolopment Tables and PRISMA

Knowledge Gaps

Research should focus on reporting objective measurements when reporting skill performance and standardised assessment tools when reporting knowledge to allow inter-study comparisons.

Gaps include:

• New methods, such as cardiac arrest registries, are needed to study the long-term impact on patient outcomes.
• Best methods for training and retraining to achieve high attendance and long-term skill retention.
• Whether health care providers suggesting the need for BLS training influences likely rescuers to seek training.
• Strategies to enhance secondary training where trained individuals share their knowledge and train others.

Acknowledgement

The authors acknowledge the assistance provided by information specialist Marisa Tutt, Alberta Children's Hospital Acute Care Alberta, Canada.

The following ILCOR EIT Taskforce Members are acknowledged as collaborators on this adolopment: Aaron Donoghue, Alexander Olaussen, Barbara Farquharson, Chih-Wei Yang, Cristian Abelairas-Gomez, Kathryn Eastwood, Andrea Cortegiani, Sebastian Schnaubelt, Tasuku Matsuyama, Taylor Sawyer, Ying-Chih Ko, Yiquin (Jeffrey) Lin, Adam Boulton, Tracy Kidd, Sandra Lindkvist-Viggers, Aida Carballo-Fazanes, Kasper G. Lauridsen, Robert Greif, We would like to thank Judith Finn (ILCOR Science Advisory Committee) for her valuable contributions.

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