Pre-course preparation for advanced courses (revised) (EIT #637): Systematic Review

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: Andrew Lockey (co-author of three articles included in the SR).

CoSTR Citation

Breckwoldt J, Beck S, Beckers SK, Bhanji F, Bigham BL, Bray JE, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma M, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn J, Greif R. - on behalf of the International Liaison Committee on Resuscitation Task Force Education, implementation and Teams. ‘Pre-course preparation for advanced courses’ Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Task Force Education, Implementation and Teams, 2020, Jan 3^th. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (PROSPERO submission Dec 2, 2019 ) conducted by Gosteli M (Information specialist, University of Zurich) and Breckwoldt J, Beck S, Beckers SK (clinical content experts). Evidence was sought and considered by the Task Force EIT. These data were taken into account when formulating the Treatment Recommendations.

PICOST

Population: Among students who are taking advanced life support courses in an educational setting

Intervention: Does precourse preparation for advanced courses (e.g. e-learning or pre-testing combined with face to face training)

Comparison: compared with a traditional course (face-to-face training)

Outcomes: change cognitive knowledge, skill performance at course conclusion, skill performance at 1 year, skill performance in actual resuscitations, increase survival rates, skill performance at time between course conclusion and 1 year.

Study Designs: All comparative, human studies (prospective and retrospective) examining the use of pre-course preparation for advanced life support training and reporting knowledge/skills outcomes. Also, patient outcomes and performance in actual resuscitation situations.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to November 20, 2019.

PROSPERO submission [160799]: Dec 2^nd, 2019

Risk of Bias table

The studies addressing the comparison of interest have different risks of bias and are too different to combine.

¹ n=105 participants eligible, only n=65 included; ² high instructor variation, small sample size; ³ assessors not blinded;

⁴ high instructor variation; ⁵ n=3’732 participants randomized, n=2’179 finally analyzed (58.4%); ⁶ reasons of non-participation partly unclear; ⁷ assessors not blinded; ⁸ reasons of non-participation partly unclear; ⁹ participants chose course version; ¹⁰ locally developed measurement, no validation reported; ¹¹ single center study; ¹² low sample size;

¹³ assessors not blinded; ¹⁴ no randomization.

Consensus on Science

A variety of learning formats preceding face to face training was identified by the search including ranging from pure precourse preparation to e-learning formats replacing parts of a face to face course (blended learning approach). To account for these differences, we report the results of the search separately for studies (a) comparing the distribution of precourse learning material to no distribution, and (b) comparing any kind of blended learning format that reduces face to face training to traditional courses.

The question of providing learning resources prior to a face to face course was addressed by two RCTs (Nacca 2014 913, Perkins 2010 877). One study compared the 2-week access to an online advanced cardiovascular life support [ACLS] simulator to no access to such a simulator (Nacca 2014 913), and the other study provided a Microsim CD as precourse material and compared it to no CD distribution (Perkins 2010 877). The heterogeneous nature of the studies prevented pooling of data for any outcome; therefore, no meta-analysis was performed.

Neither of the studies addressed the critical educational outcomes of skill performance 1 year after course conclusion and skill performance between course conclusion and 1 year. Furthermore, neither study addressed the important educational outcomes of quality of performance in actual resuscitations or patient survival with favorable neurologic outcome.

For the important educational outcome of skill performance at course conclusion, we found low-certainty evidence (downgraded for risk of bias and imprecision) from the two RCTs. The first study (Nacca 2014 913), with 65 medical students, found no influence on the time to initiate chest compressions but significant advantages in the intervention group for the time to defibrillate ventricular fibrillation (112 seconds versus 150 seconds; P<0.05) and pacing of symptomatic bradycardia (95 seconds versus 155 seconds; P<0.05). The second RCT, with 572 participants of ALS courses (Perkins 2010 877) distributing a Microsim CD before the course to the intervention group, found no significant differences in performance between intervention and control during a standardized cardiac arrest scenario test at course conclusion (pass rate I: 93.6% versus pass rate C: 91.8%; P=0.4).

For the important educational outcome of knowledge at course conclusion, we found low-certainty evidence (downgraded for risk of bias and imprecision) reported by one RCT. In the study with 572 participants of ALS courses (Perkins 2010 877) a Microsim CD was distributed to the intervention group before the face to face ALS course. The study found no significant differences of post-course MCQ scores between the groups (C: 101.9 [SD 13.8] versus I: 101.4 [SD 13.9]; P=0.7).

The question of analysing blended learning formats to reduce face to face time in ALS courses compared with traditional courses was addressed by one RCT (Perkins 2012 19) and two non-RCTs (Arithra Abdullah 2019 1, Thorne 2015 79). The heterogeneous nature of the studies prevented pooling of data for any outcome; therefore, no meta-analysis was performed.

None of the studies addressed the critical educational outcomes of skill performance 1 year after course conclusion and skill performance between course conclusion and 1 year. Furthermore, no studies addressed the important educational outcomes of quality of performance in actual resuscitations or patient survival with favorable neurologic outcome.

For the important educational outcome of skill performance at course conclusion, we found low-certainty evidence (downgraded for risk of bias and imprecision) from one RCT and two non-RCTs (Perkins 2012 19, Arithra Abdullah 2019 1, Thorne 2015 79). The one RCT randomizing 3732 participants of ALS courses to either 6 to 8 hours of e-learning plus 1 day of face to face training or to a traditional 2-day face to face ALS course (Perkins 2012 19). This study was inconclusive in demonstrating non inferiority in the intervention group (C: 80.2% versus I: 74.5%; mean difference, -5.7%; 95% CI, -8.8% to -2.7%). The first non-RCT, with 96 ACLS course participants (Arithra Abdullah 2019 1), comparing 6 hours of online lectures plus a 1-day face to face training with a traditional 2-day face to face course, showed that cardiac arrest scenario test pass rates did not differ statistically (C: 87.5% versus I: 95.8%; P=0.13). The second non-RCT compared 27170 participants of ALS courses (Thorne 2015 79) who underwent either 6 to 8 hours of eLearning plus 1 day of face-to-face training or a traditional 2-day face to face ALS course. In this study, the first-attempt cardiac arrest scenario test pass rate was significantly higher in the intervention group (84.6% versus 83.6%; P=0.035); however, the absolute educational effect was very low (difference: 1.0% first-attempt cardiac arrest scenario test pass rate).

For the important outcome of knowledge at course conclusion, we found very-low-certainty evidence (downgraded for risk of bias and imprecision) reported by one RCT and two non-RCTs (Perkins 2012 19, Arithra Abdullah 2019 1, Thorne 2015 79). The RCT, randomizing 3732 participants of ALS courses to either 6 to 8 hours of e-learning plus 1 day of face to face training or to a traditional 2-day ALS course (Perkins 2012 19), reported no statistical difference for end-of-course MCQ test scores (I: 88.96% versus C: 89.54%; adjusted difference, 0.55%; CI, –1.11% to 0.02%; P=0.054). The first non-RCT, with 96 ACLS course participants (Arithra Abdullah 2019 1) comparing 6 hours of online lectures plus a 1-day face to face training with a traditional 2-day face to face course, showed that MCQ pass rates at course conclusion did not differ statistically (C: 85.4% versus I: 95.8%; P=0.08). The second non-RCT, including 27170 participants of ALS courses (Thorne 2015 79), compared 6 to 8 hours of e-learning plus 1 day of face to face training with a traditional 2-day face to face ALS training. The intervention group scored significantly higher (I: 87.9% versus C: 87.4%; P<0.001); however, the absolute difference of 0.5% was not found to represent educational significance.

Treatment Recommendations

We recommend distributing precourse learning formats preceding face to face training for participants of ALS courses (based on very-low- to low-certainty evidence). In addition, we strongly recommend providing the option of e-learning as part of a blended learning approach to reduce face to face training time in ALS courses (strong recommendation, very-low- to low-certainty evidence).

Justification and Evidence to Decision Framework Highlights

• Given the higher flexibility for learners and the savings of resources the EIT task force strongly recommends providing the option of such formats for ALS courses (eg, a 1 day’s equivalent of e-learning plus one day of a face-to-face course). In making this recommendation, the Task Force takes into account that learning styles may differ substantially and that face-to-face courses may be more effective for some groups of learners.
• Implementation considerations: Return of investment of e-learning will be more pronounced if materials can be used by larger groups of learners. It should therefore be considered to develop materials collectively by several providers to save resources (i.e. on a national level). However, it should also be taken into account that learners will profit most if the material is produced in the learners’ native cultural context.
• Monitoring and evaluation: Close monitoring and evaluation within accredited courses is recommended and appears feasible.
• This topic was prioritized by the EIT task force based on the recent dynamic development of online learning (blended learning) as an innovative educational strategy with the aim of reducing face to face training.
• In making these recommendations, the EIT task force considered the following:

Inclusion of e-learning as a part of the ALS course with the aim to reduce face to face training time: As the PICOST question left the amount and format of the precourse preparation open we also included e-learning replacing parts of the ALS course. This decision was based on the consideration that the final goal of providing pre course material was to realize an increase of learner flexibility, savings of resources, and a reduction of face to face learning time.

In 2015, the EIT Task Force estimated the effect so low that a specific recommendation for or against precourse preparation in ALS courses was too speculative. In 2020, the evidence for an effects of precourse preparation is still limited. The TF task force nonetheless recommends providing learning formats as precourse preparation for advanced courses, as desirable consequences probably outweigh undesirable consequences in most settings. For the case of learning formats replacing parts of the face to face training, the Task Force strongly recommends providing the option of e-learning as part of a blended learning approach.

Knowledge Gaps

• No studies were identified evaluating effects of learning formats preceding face to face training on long term retention or on outcomes related to real-life (performance in resuscitations, or patient survival).
• Also, no studies addressed different formats of delivery (e.g. invested time for preparation, educational involvement of learners, linkage to face-to-face training), or the content covered by the learning formats preceding face to face training.
• Evidence is needed for other formats of resuscitation courses (e.g. BLS, PALS)

Attachments

Evidence-to-Decision Table: EIT_637_TFSR_precourse_prep-ALS_Et D_table_Updated-20_05_05

References

Arithra Abdullah A, Nor J, Baladas J, Tg Hamzah TMA, Tuan Kamauzaman TH, Md Noh AY, Rahman A. E-learning in advanced cardiac life support: Outcome and attitude among healthcare professionals. Hong Kong Journal of Emergency Medicine 2019:e1024907919857666.

Nacca N, Holliday J, Ko PY. Randomized trial of a novel ACLS teaching tool: does it improve student performance? West J Emerg Med. 2014;15:913-918.

Perkins GD, Fullerton JN, Davis-Gomez N, Davies RP, Baldock C, Stevens H, Bullock I, Lockey AS. The effect of pre-course e-learning prior to advanced life support training: a randomised controlled trial. Resuscitation. 2010 Jul;81:877-881.

Perkins GD, Kimani PK, Bullock I, Clutton-Brock T, Davies RP, Gale M, Lam J, Lockey A, Stallard N; Electronic Advanced Life Support Collaborators. Improving the efficiency of advanced life support training: a randomized, controlled trial. Ann Intern Med. 2012;157:19-28.

Thorne CJ, Lockey AS, Bullock I, Hampshire S, Begum-Ali S, Perkins GD; Advanced Life Support Subcommittee of the Resuscitation Council (UK). E-learning in advanced life support--an evaluation by the Resuscitation Council (UK). Resuscitation. 2015;90:79-84.EIT_637_TFSR_precourse_prep-ALS_Et D_table_Updated-20_05_05