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 EIT Task Force. 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

Three RCTs studied different precourse preparation strategies (2-week access to an online ACLS simulator, precourse material (CD) in addition to the course, eLearning as a substitute for a part of the ALS course) in comparison to traditional courses. {Nacca 2014 913; Perkins 2010 877; Perkins 2012 19}. Two non-RCTs studied different content and amounts of e-learning as a substitute for a part of the ALS course in comparison to the traditional course formats. {Arithra Abdullah 2019, doi.org/10.1177/1024907919857666; Thorne 2015 79}. The heterogeneous nature of the studies prevented pooling of data for any outcome, therefore no meta-analysis was performed.

For the critical educational outcomes of ‘skill performance 1 year after course conclusion’ and ‘skill performance between course conclusion and 1 year’ we did not find any study addressing the outcomes.

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 of evidence (downgraded for risk of bias and imprecision) from three RCTs. One study {Nacca 2014 913}, with 65 medical students found no influence on time to initiate CCs, but significant advantages in the intervention group for the time to defibrillate Ventricular Fibrillation (VF) (112 seconds vs. 149.9 seconds, p<.05) and pacing of symptomatic bradycardia (95.1 seconds vs. 154.9 seconds, p<.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 (CAS) test at course conclusion (I: 93.6% vs. C: 91.8%, p = 0.4). The third study randomizing 3,732 participants of ALS courses to either 6-8 h of eLearning plus 1 day of face-to-face training, or to a traditional 2-day face-to-face ALS course {Perkins 2012 19} found a significantly lower pass rate in the intervention group (C: 80.2% s. I: 74.5%; mean difference, -5.7% [95% CI, -8.8% to -2.7%]).

For the outcome of ‘skill performance at course conclusion’ we also found very low certainty of evidence (downgraded for risk of bias and imprecision) from two Non-RCTs. The first study with 96 ACLS course participants {Arithra Abdullah 2019 doi.org/10.1177/1024907919857666} compared 6 hours of online lectures plus a 1-day face-to-face course to a traditional 2-day face-to-face course, and showed that CAS-test pass rates did not differ statistically (C: 87.5% vs. I: 95.8%; p=0.13). The second study compared 27,170 participants of ALS courses {Thorne 2015 79} who underwent either 6-8 h of e-learning plus 1 day of face-to-face training, or a traditional 2-day face-to-face ALS course. In this study the first attempt CAS-test pass rate was significantly higher in the intervention group (84.6% vs. 83.6%; p = 0.035), however, the absolute educational effect was very low (difference: 1.0% first attempt CAS-test pass rate).

For the important educational outcome of ‘knowledge at course conclusion’ we found low certainty of evidence (downgraded for risk of bias and imprecision) reported by two RCTs. The one RCT with 572 participants of ALS courses {Perkins 2010 877} distributing a Microsim CD to the intervention group before the face-to-face ALS course found no significant differences of post-course MCQ scores between the groups (C: 101.9 (SD 13.8) vs. I: 101.4 (SD 13.9), p = 0.7). The second study randomizing 3,732 participants of ALS courses to either 6-8 h of eLearning 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% vs. C: 89.54%; adjusted difference, 0.55% (CI, -1.11% to +0.02%; p = 0.054).

For the outcome of ‘knowledge at course conclusion’ we also found very low certainty of evidence (downgraded for risk of bias and imprecision) reported by two non-RCTs.

The first study with 96 ACLS course participants {Arithra Abdullah 2019 doi.org/10.1177/1024907919857666} comparing 6 hours of online lectures plus a 1-day face-to-face course to a traditional 2-day face-to-face course, showed that pass rates of MCQ at course conclusion did not differ statistically (C: 85.4% vs. I: 95.8%; p=0.08). The second study including 27,170 participants of ALS courses {Thorne 2015 79} compared 6-8 h of e-learning plus 1 day of face-to-face training to a traditional 2-day face-to-face ALS training. The intervention group scored significantly higher (I: 87.9% vs. C: 87.4%; p < 0.001), however, the absolute difference of 0.5% was not found to represent educational significance.

Treatment Recommendations

We recommend providing the option of precourse e-learning as part of a blended learning approach for participants of ALS courses. (strong recommendation, very low to low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

• Given the higher flexibility for learners and the savings of resources the EIT task force recommends providing the option of such formats for ALS courses (e.g. a 1 day’s equivalent of e-learning plus one day of a face-to-face course). In making this recommendation, the TF 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.
• In making these recommendations, the EIT task force considered the following:

Inclusion of e-learning as a substitute for a part of the ALS course. As the PICOST question left the amount and format of the precourse preparation open we also included e-learning as a substitute for a part 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 and savings of resources.

Knowledge Gaps

• No studies were identified evaluating effects of precourse preparation 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 precourse preparation.
• Evidence is needed for other formats of resuscitation courses (e.g. BLS, PALS)

Attachments

Evidence-to-Decision Table: EIT-637 Precourse preparation Et D

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. doi.org/10.1177/1024907919857666

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.