EIT 6317 Best Practices for In-hospital Cardiac Arrest Team Composition: TF ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. Task Force members and content experts were recused from the decision to include papers and extract data from papers which they had authored. None of the Task Force members declared any conflict of interest to this review apart from Dr. Lauridsen authoring included papers.

Dr. Lauridsen was not involved in assessment of the studies or data extraction. He participated as an expert in the Task Force discussion.

Task Force Synthesis Citation

Lindkvist-Viggers S, Carballo-Fazanes A, Riis DN, Cheng A, Hogeveen M, Kawakami MD, Myburgh M, Lauridsen KG on behalf of the International Liaison Committee on Resuscitation Task Forces on Neonatal Life Support, Pediatric Life Support, and Education, Implementation, and Teams.

Best Practices for In-hospital Cardiac Arrest Team Composition: A Scoping Review. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2025 December X Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review on team compositions for in-hospital cardiac arrest proposed by the ILCOR Education, Implementation, and Teams Task Force and was conducted as a nodal review together with the Neonatal Life Support (NLS) and Pediatric Life Support (PLS) Task Forces. Considerations for neonatal and pediatric setting were specifically reviewed by the NLS and PLS task forces respectively.

This scoping review was conducted and reported in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR).

Relevant literature related to team composition, role allocation or team member characteristics of resuscitation teams was identified from PubMed, EMBASE, and CINAHL databases. After title and full text screening, relevant data were extracted by the writing group and presented to the EIT Task Force for discussion. The final scoping review’s task force insight was discussed and agreed upon during EIT Task Force meetings and approved by the Task forces PLS and NLS, as well as by the ILCOR Science Advisory Committee.

PICOST

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

Population: In-hospital resuscitation teams performing adult, pediatric, or neonatal advanced life support in a simulated or clinical setting.

Intervention: Any specific role allocation (e.g. shared leadership), team composition (e.g. team size), or team member characteristics (e.g. clinical/ training background, experience, seniority).

Comparators: Any other role allocation (e.g. no shared leadership), team composition, or team member characteristics.

Outcomes: Patient survival: Return of spontaneous circulation (ROSC), survival to hospital discharge/30 days, survival to hospital discharge/ 30 days with favorable neurological outcomes, survival beyond discharge/ 30 days, survival with favorable neurological outcomes beyond hospital discharge/ 30 days (critical).

Real life clinical performance: CPR skill performance (critical), adherence to guidelines (critical), teamwork (critical), provider workload (critical).

Performance in simulated setting: CPR skill performance (important), adherence to guidelines (important), teamwork (important), provider workload (important).

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies and case series where n>5) were eligible for inclusion. Included all languages as long as an English abstract was available. Editorials, commentaries, conference abstracts, grey literature, social media, unpublished studies, trial protocols, and non-peer reviewed studies were not eligible for inclusion. Relevant scoping reviews and systematic reviews were screened for relevant original literature.

Timeframe: All years searched from inception until August 19th 2025.

Search Strategies
A comprehensive search strategy was developed and reviewed with assistance from Information Specialist Anne Vils Mead, Aarhus University Librabry, with the involvement of members of the ILCOR Education, Implementation and Teams (EIT), NLS and PLS Task Forces working on this scoping review.

We systematically searched PubMed, EMBASE, and CINAHL from database inception to 19 August 2025. We identified articles using the following key terms: “cardiac arrest”, “heart arrest”, “cardiopulmonary arrest”, “CPR”, “resuscitation”, “team*”, “resuscitation resident”, “Hospital Rapid Response Team”, “role*”, “leader*”, “co-lead*”, “teamwork”, “seniority”, “training”, “experience”, “team composition”, “code reader”, “officer*”, “resident*”. Where appropriate, we used controlled vocabulary (MeSH, Emtree, CINAHL Headings) alongside free-text terms. Boolean operators (AND, OR, NOT) were used to combine and structure the search terms, resulting in the following full search strategy.

Pubmed:

((("Heart Arrest"[MeSH Terms] OR "cardiac arrest"[tiab] OR "heart arrest"[tiab] OR "Resuscitation"[MeSH Terms] OR "Cardiopulmonary Resuscitation"[MeSH Terms] OR CPR[tiab] OR "cardiopulmonary arrest"[tiab] OR resuscitation[tiab]))

AND

(("Hospital Rapid Response Team"[Mesh] OR team*[tiab] OR "resuscitation resident"[tiab])
AND

("Leadership"[Mesh] OR "Professional Role"[Mesh] OR role*[tiab] OR leader*[tiab] OR co-lead*[tiab] OR teamwork[tiab] OR "code reader"[tiab] OR size[tiab] OR training[tiab] OR experience[tiab] OR compos*[tiab] OR seniority[tiab] OR officer*[tiab] OR resident*[tiab] )))

NOT

(("out-of-hospital"[ti] OR prehospital[ti] OR pre-hospital[ti] OR "pre hospital"[ti]))

Embase:

('heart arrest'/exp OR 'cardiac arrest':ti,ab,kw OR 'heart arrest':ti,ab,kw OR 'resuscitation'/exp OR 'cpr':ti,ab,kw OR 'cardiopulmonary arrest':ti,ab,kw OR 'resuscitation':ti,ab,kw)

AND

('rapid response team'/exp OR 'team*':ti,ab,kw OR 'resuscitation resident':ti,ab,kw) AND ('leadership'/exp OR 'nursing role'/exp OR 'role*':ti,ab,kw OR 'leader*':ti,ab,kw OR 'co-lead*':ti,ab,kw OR 'teamwork':ti,ab,kw OR 'code reader':ti,ab,kw OR 'size':ti,ab,kw OR 'training':ti,ab,kw OR 'experience':ti,ab,kw OR 'compos*':ti,ab,kw OR 'seniority':ti,ab,kw OR 'officer*':ti,ab,kw OR 'resident*':ti,ab,kw)

NOT

('out-of-hospital':ti OR 'prehospital':ti OR 'pre-hospital':ti OR 'pre hospital':ti)

AND

('article'/it OR 'article in press'/it OR 'clinical trial'/it OR 'erratum'/it OR 'preprint'/it OR 'review'/it)

Cinahl:

( ( (MH "Resuscitation+") OR (MH "Heart Arrest+") OR XB ( ("cardiac arrest" OR "heart arrest" OR CPR OR "cardiopulmonary arrest" OR resuscitation) ) ) AND ( ( (MH "Rapid Response Team") OR XB ( (team* OR "resuscitation resident) ) ) AND ( (MH "Leadership") OR (MH "Professional Role+") OR XB ( (role* OR leader* OR co-lead* OR teamwork OR "code reader" OR size OR training OR compos* OR seniority OR officer* OR resident*) ) ) ) ) NOT ( TI (("out-of-hospital" OR prehospital OR pre-hospital OR "pre hospital")) )

Inclusion and Exclusion criteria

Inclusion Criteria:

1. Studies evaluating in-hospital resuscitation teams, defined as clinical resuscitation teams treating cardiac arrest patients in hospitals or teams of healthcare professionals designed to mimic the in-hospital clinical resuscitation teams in a simulated setting. This included studies of teams performing advanced life support on both neonates, children and/ or adults.
2. Studies evaluating role allocation, defined as any particular way of sharing a specific function or task (e.g. use of dedicated leadership vs not, use of shared leadership vs not, use of a time recorder, or whether roles were pre-allocated vs not).
3. Studies evaluating team member characteristics, including clinical experience, gender, previous education, specialty training, other previous training credentials, or seniority.

Exclusion Criteria:

1. Studies with healthcare students only or laypersons as participants.
2. Studies involving prehospital resuscitation teams (e.g. emergency medical technicians or paramedics).
3. Studies involving prospective training interventions for resuscitation teams or team members.
4. Studies not considering life support training of specific team members (i.e. organizational level training).
5. Studies involving CPR coaching (as this was reviewed in a separate ILCOR review).

Data tables: EIT 6317 Data Tables

Task Force Insights

1. Why this topic was reviewed?

In-hospital cardiac arrest (IHCA) remains a significant clinical challenge with high mortality and variable outcomes (39). Despite advancements in cardiopulmonary resuscitation science and derived guidelines, significant gaps persist in optimizing team performance, role allocation and leadership effectiveness(2,8). Current evidence on IHCA resuscitation teams remains limited, with significant knowledge gaps regarding the impact of team composition, leadership structure, and role allocation (16). Previous ILCOR systematic reviews suggest that a CPR coach may help optimize resuscitation performance, although the certainty of this evidence remains very low (40). Additionally, while team leader experience alone does not appear to impact survival in out-of-hospital cardiac arrest (OHCA), exposure to cardiac arrest management may be associated with better outcomes in OHCA (41). However, no contemporary reviews have covered such aspects for IHCA.

Various team factors have been proposed as potential contributors to improved teamwork and resuscitation quality such as shared leadership models, predefined team roles, team size, and structured communication strategies (18,42,43). Despite these hypotheses, the specific best practices for IHCA resuscitation teams remain poorly defined. Understanding the relationship between team composition, leadership strategies, and performance in the IHCA setting is critical to improving resuscitation outcomes. This scoping review aims to systematically map the existing evidence on IHCA team structure, leadership characteristics, and role allocation. And to provide insights that can support the development of optimized resuscitation team models for IHCA management.

2. Narrative summary of evidence identified

Study Characteristics

An extensive search of the databases yielded 10872 citations. After removing 3531 duplicates, 7341 articles were screened by reviewing titles and abstracts. Of these, 88 studies were included for full text review, which resulted in 37 eligible studies. Of these 37 studies, 28 were conducted in clinical setting (2–15,17,18,21–25,28,30–35) and eight were simulation-based (16,19,20,26,27,29,36,37). One study had both clinical events and in-situ simulation (38). Six of the studies were RCT’s, and all were simulation studies (20,26,27,29,36,37). Of those only two (26,27) were multicenter studies. Of the clinical studies 26 were single center observational studies (2–6,8–10,12–14,16–19,22–25,28,30–35,38) and 4 multi center observational studies (7,11,15,21). A total of 26 studies involved adult cardiac arrest teams (2,5–9,11–16,18,21–24,26,28,30–35,38). Five studies focused on neonatal resuscitation teams (3,10,29,36,37), and three studies were about pediatric in-hospital cardiac arrest teams (19,20,27). Finally, three studies were about mixed IHCA populations (4,17,25).

Regarding outcomes, the included studies most commonly assessed ROSC, survival to hospital discharge, timing and process measures e.g., time to defibrillation, medication timing, pauses, and team performance such as CPR quality, communication, teamwork ratings, and adherence to resuscitation algorithms.

Evidence was synthesized narratively, as recommended for scoping reviews. Studies were grouped into three thematic domains: team leader characteristics; team size and structure, and role allocation, including telemedicine, to describe patterns in processes and outcomes. According to scoping review guidelines no meta-analysis or strength-of-evidence grading was performed.

Leadership characteristics

A total of 16 studies compared different leadership characteristics(2–17) . Across these studies, ROSC findings were inconsistent. Several studies reported higher ROSC for specific leader types in defined contexts, for example ICU physicians leading arrests outside the ICU (12), cardiologists managing arrests in the cath lab (14), resuscitation-trained residents (8) or specialists compared with technicians or ward staff (4), while other studies found no differences between residents, hospitalists, internal medicine physicians or nurse-led teams (2,3,7,10,17). The studies showing improved ROSC were setting-specific and did not translate into consistent survival benefits in any study. Evidence regarding training and experience was similarly mixed. Leadership-focused or combined ALS/BLS training improved early ROSC or early survival in some studies (5,9,13), whereas ALS certification alone did not ensure effective leadership behaviors or improved outcomes (6,7). Two simulation studies demonstrated that stronger leadership behaviors (16) and recent simulation-based training (15) were associated with improvements in CPR process measures, including shorter pauses and higher compression fraction, but neither study assessed clinical outcomes. Overall, leader profession, seniority and training background influenced CPR process performance variably, but no leadership attribute showed a consistent association with patient centered outcomes.

Team structure and size

We identified 11 studies evaluating team structure and size, including variations in team size, dedicated resuscitation teams, shared leadership models, and telemedicine leadership (18–20,22–29). Dedicated teams achieved higher ROSC in three single-center cohort studies (18,22,25), including one where comparator teams were ALS-trained (18). However, these improved ROSC rates did not consistently extend to survival to discharge or longer-term outcomes. Across studies of team size, larger teams and a greater number of compressors were associated with lower chest compression fraction, while smaller teams experienced higher workload (24,28,29). Interventions aimed at clarifying team structure, such as structured crowd management, explicit role definition, or shared leadership, improved communication, reduced overcrowding, and lowered cognitive load for the primary leader (19,23,26). Telemedicine-supported leadership produced teamwork scores and process metrics comparable to in-person leadership, with no evidence of clinically important differences (20,27). Overall, variations in team size and structural configuration showed limited and inconsistent associations with patient-centered outcomes, and any benefits appeared to arise through effects on teamwork and CPR quality rather than from structural configuration alone.

Role allocation

For the theme role allocation, a total of nine studies were identified (30–38). Across these studies evaluating structured role allocation, including predefined roles, visible role identifiers, dedicated timekeepers, and pharmacist-led medication support, process outcomes consistently improved, while effects on ROSC or survival remained limited or inconsistent. Timekeeper and role-clarity interventions improved algorithm adherence and reduced timing errors without affecting ROSC (30,36). A small pre-post study found that visible role identification and structured allocation was associated with improved teamwork behavior and role clarity but was not significantly associated with ROSC (31). Four studies involving pharmacists found that their involvement was associated with higher adherence to ACLS algorithms, better medication safety with fewer errors, and more complete documentation (32–35). Two of these studies noted higher immediate survival (undefined) or survival to hospital admission(34,35), but none demonstrated improved survival to discharge, and it remains unclear whether observed effects were attributable to pharmacist expertise specifically or to the presence of a dedicated team member responsible for medication-related tasks. One clinical study showed that implementation of clearly assigned roles was associated with a non-significant shorter time-to-defibrillation (38). In simulation, clearly assigned functional roles improved behavioral performance and reduced cognitive load, whereas combining the leader and airway roles increased workload compared with a dedicated leader (37). Overall, structured role allocation improves CPR organization, medication processes, and adherence to ACLS algorithms, with limited and inconsistent evidence for impact on patient-centered outcomes.

3. Narrative Reporting of the task force discussions

The Task Force noted that the evidence base is heterogeneous and largely observational, which limits the ability to identify a single optimal model for team composition in in-hospital cardiac arrest. Although several studies compared leadership performance across professions and experience levels, no specific clinical background or seniority consistently performed better than others. The clearest signal across the evidence was the association between leadership performance and life support training, suggesting that training may be more influential than profession.

The Task Force also discussed studies involving nurse-physician co-leadership, which demonstrated reductions in cognitive load for the primary leader and improved correction of CPR quality deficits. These findings support the broader view that leadership roles can be shared, and that any adequately trained healthcare professional may serve as team leader when supported by clear role structures.

Evidence on the integration of pharmacists into resuscitation teams was also considered. While several cohort studies demonstrated improvements in medication accuracy, documentation and adherence to guidelines, the Task Force highlighted that the key factor may be the presence of a dedicated individual responsible for medication-related tasks, rather than the pharmacist profession specifically.

Discussions further emphasized that the evidence on team size and role allocation remains limited. Although structured role allocation consistently improved organization and adherence to resuscitation processes, only two cohort studies compared dedicated versus ad-hoc teams, and their mixed results likely reflect partial implementation of dedicated structures. Across themes, most studies measured process outcomes rather than survival or neurological endpoints, which constrains interpretation. Finally, the Task Force noted that considerations for neonatal and pediatric resuscitation may differ from adult settings due to distinct team structures and task distribution.

In summary, Task Force discussions support the idea that resuscitation teams benefit from adequate life support training, clear role allocation, and dedicated or well-structured team models. Adaptations in team structure, leadership and/or roles may be required for specific clinical contexts such as pediatric, neonatal or other unique clinical environments (e.g. cardiac catheterization laboratory and emergency room).

Knowledge Gaps

• Across all themes, important uncertainties remain regarding how in-hospital resuscitation teams should be structured.
• The ideal team size for different clinical settings is unknown, and it is unclear how variations in size influence CPR quality, workload, or team coordination.
• Evidence is also insufficient to determine how leadership responsibilities are best arranged or shared, and the most effective ways to train and sustain resuscitation leadership remain undefined.
• Similarly, the optimal allocation of roles, including responsibilities for medications, documentation, airway management and timing tasks has not been established. It remains uncertain whether benefits observed with pharmacists or dedicated time-recorders reflect professional expertise or simply the presence of a clearly assigned team member.
• Most clinical studies assessed team composition at the level of hospital practices rather than at the individual case level, which may have introduced information bias in how team structure was classified.
• Most available studies focus on high-resource adult settings, leaving limited evidence to guide team composition in pediatric or neonatal environments or in low-resource hospitals where staffing, equipment and professional roles differ substantially.
• Finally, because most studies evaluate process measures rather than survival or neurological outcomes, the relationship between team configuration and patient-centered outcomes remains largely undetermined.

Acknowledgement

The authors acknowledge the assistance provided by Information Specialist Anne Vils Mead, Aarhus University Hospital Library, in designing the final search strategy.

The following ILCOR EIT Taskforce Members are acknowledged as collaborators on this scoping review: Aaron Donoghue, Alexander Olaussen, Barbara Farquharson, Chih-Wei Yang, Cristian Abelairas-Gomez, Kathryn Eastwood, Kevin Nation, Andrea Cortegiani, Andrew Lockey, Joyce Yeung, Ming-Ju Hsieh, Sabine Nabecker, Sebastian Schnaubelt, Tasuku Matsuyama, Taylor Sawyer, Ying-Chih Ko, Yiquin (Jeffrey) Lin, Katherine Allan, Adam Boulton, Tracy Kidd, Jan Breckwoldt, and Robert Greif. We would like to thank Judith Finn (ILCOR Science Advisory Committee) for her valuable contributions.

The following ILCOR NLS Taskforce Members are acknowledged as collaborators on this scoping review: Helen Liley

The following ILCOR PLS Taskforce Members are acknowledged as collaborators on this scoping review: Jason Acworth, Barney Scholefield

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