Rapid Cycle Deliberate Practice in Resuscitation Training (EIT6414) TF SR

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

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: Nothing to declare

CoSTR Citation

Abelairas-Gómez C, Sawyer T, Donoghue A, Cortegiani A, Greif R, on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT) Life Support Task Force. Consensus on Science with Treatment Recommendations. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Team Task Force, 2023 Dec 01. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search by Mary-Doug Wright of Rapid Cycle Deliberate Practice in resuscitation training as opposed to other approaches. Evidence was sought and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Publication in progress.

PICOST

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

Population: Learners training in basic or advanced life support.

Intervention: Instruction using Rapid Cycle Deliberate Practice.

Comparators: Compared to traditional instruction or other forms of learning without Rapid Cycle Deliberate Repetition.

Outcomes: Knowledge acquisition and retention, skills acquisition and retention, skill performance in real CPR, attitudes, willingness to help, and patients’ survival.

Study Designs: 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.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded.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 Nov 1st, 2023.

PROSPERO Registration CRD42023468862

Risk of bias

Risk of bias was assessed per article rather than per outcome (Table 1a and 1b).

Consensus on Science

A search of Medline, Embase, Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials on 1st November 2023 identified 4420 references (Figure 1). After de-duplication, 2532 titles and abstracts were reviewed. Full text review was conducted on 65 papers. Eight studies were identified that addressed the PICOST question comparing Rapid Cycle Deliberate Practice (RCDP) with after-event debriefing under simulated conditions.^1-8 Study cohorts were comprised of residents,^1,3,8 interns,^4,5 physicians,⁶ medical students,⁷ and a mix of fellows, nurses and respiratory therapists,² who were involved in adult,^6,7 pediatric^1-3,5,8 and neonatal⁴ simulated scenarios. Most of the studies reported comparisons between RCDP and other approaches after a single session of simulation-based training, lasting 20-60 minutes.^2-4,6-8

Seven were randomized studies^2-8 and one an observational study with a before-after design.¹ In addition, seven of them referred directly to RCDP^1-6,8 and the other one used an “In simulation debriefing” during the clinical scenario meeting the key components of the RCDP.⁷ No studies reported clinical outcomes. Meta-analysis was performed only for one outcome (time to chest compressions) due to the low number of studies per outcome, heterogeneity in the study designs and the reported outcome measures.

Figure 1. PRISMA flow diagram. EIT 6414 PRISMA

Time to chest compressions:

For the important outcome Time to chest compressions, we identified very-low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision) from three randomized studies^3,4,8 enrolling 66 participants tested individually and 41 teams, which showed no benefit from the use of RCDP when compared with after-event debriefing; the estimated standardized mean difference (SMD) for the outcome, using random effects model, was -0.1734 (95% CI: -0.6900 to 0.3431). Therefore, the SMD did not differ significantly from zero (z = -0.6581, p = 0.5105) (Figure 2).

Figure 2. Meta-analysis forest plot – Time to chest compressions.

In addition, in an observational study, participants of the RCDP group spent significantly less time between the onset of pulseless ventricular tachycardia and initiation of chest compressions.¹

Time to recognize cardiac arrest:

One study assessed the time to recognize cardiac arrest with no differences between RCDP and after-event debriefing.⁶

Time to ventilate:

One randomized study assessed time to positive pressure ventilations (from birth),⁴ where participants in the intervention group initiated positive pressure ventilation within 1 minute more frequently than controls. The observational study measured time to use bag-valve mask,¹ with no differences found between groups.

Time to defibrillation:

Four studies, 3 randomized estudies^3,6,8 and 1 observational¹ study assessed time to defibrillation. The 3 randomized studies comprised 82 participants (RCDP: n=41; after-event debriefing: n=41). Two of the randomized studies found that participants from the RCDP group had significantly lower time between recognition of the rhythm and defibrillation.^3,6 In the observational study, participants of the RCDP group spent significantly less time between the onset of pulseless ventricular tachycardia and defibrillation.¹

Time to first epinephrine:

Two randomized studies assessed the time to the administration of epinephrine.^3,4 They comprised 75 participants (RCDP: n=37; after-event debriefing: n=38). One of the studies found that participants of the RCDP group had significantly shorter time to the administration of epinephrine than controls.⁴

Compression fraction / No-flow fraction:

One randomized study evaluated compression fraction⁶ and one observational study no-flow fraction.¹ Both articles found significant differences between groups in favor of RCDP participants.

No-ventilation fraction:

The observational study analyzed the no-ventilation fraction,¹ described as the proportion of time a pulseless patient received no respiratory support, and found significant differences between groups in favor of RCDP participants.

Defibrillation within 2 or 3 minutes:

One randomized study evaluated successful defibrillation within 3 minutes⁸ and the observational study within 2 minutes.¹ In the randomized study, RCDP participants had more than 5 times the odds of defibrillation occurring within 3 minutes.⁸ The observational study, by means of hazard ratio, found that RCDP participants had 1.65 times the odds of defibrillating within 2 minutes.¹

Defibrillation pre-pause:

One randomized study⁶ and the observational study¹ assessed defibrillation pre-pause. Both studies found that RCDP participants registered significantly shorter defibrillation pre-pause.

Quality of performance (adherence to protocol):

Three randomized studies evaluated quality of performance with different tools.^2,4,5 RCDP participants reached higher scores of performance by using the Megacode Assessment Form (MCAF),⁴ but no differences were found with the Simulation Team Assessment Tool² or Pediatric Advance Life Support performance.⁵

Team leader performance:

One randomized study evaluated team leader performance, with significantly higher scores in the RCDP group.⁸

Self-reported confidence:

Two randomized studies evaluated self-reported confidence.^4,7 One did not report specific information about the instrument. ⁴ In the other study, both groups increased their confidence level with no differences between groups.⁷

Participants’ subjective perception of the teaching effectiveness:

One study aimed to analyze teaching effectiveness by means of 8 questions.⁷ In 3 of the 8 questions (help to learn effectively, help to understand the correct actions, effectiveness of the debriefing) the after-event debriefing group had high-median scores compared to the RCDP group.

Retention:

Retention of skills was analyzed in one randomized study (4-month follow-up).⁴ No differences were found between groups in any variable (MCAF scores, time to positive pressure ventilations, time to chest compressions, time to epinephrine administration), although RCPD participants decreased the overall score of the MCAF in a higher proportion than controls.

Treatment Recommendations

Based on the evidence found in this systematic review the Task Force suggests that it may be reasonable to include Rapid Cycle Deliberate Practice as an instructional design feature of basic and advanced life support training (weak recommendation, very low quality of evidence).

Justification and Evidence to Decision Framework Highlights

Simulation-based training for resuscitation is an important approach to acquire knowledge and both technical and non-technical skills. Often times, participants are given limited opportunity to practice and master critical skills (i.e. individual and team-based skills) during training. Within that training plays debriefing a key role in acquiring the learning outcomes.⁹ However, debriefing characteristics are usually inconsistently described in clinical-simulation research.¹⁰ Traditionally, debriefing occurs after trainees finalize the simulated-scenario (after-event debriefing with reflection on action). RCDP addresses these issues by incorporating stop-and-go practice with immediate feedback on the performance and ample time for repetition to improve performance.¹ This approach increases time of practice and aims to enhance training methodologies to produce improvements in clinical outcomes.

Direct evidence of the use of RCDP during resuscitation training were considered in informing the treatment recommendation.

• Although more differences in favor of RCDP were found across the studies, the only meta-analysis performed (time to chest compression) did not show a difference. Two of 4 studies found differences in this variable in favor of intervention group, one randomized³ and one observational study.¹ However, compression fraction was higher in the RDCP group in the two studies analyzed.^1,6
• Different studies showed that RCDP group had shorter time to ventilate,^1,4 to deliver a shock,^1,3,6 and to the administration of epinephrine.⁴
• Two studies found that RCDP group had more odds of reaching defibrillation within 2¹ and 3 min.⁸ Defibrillation pre-pause was also significantly shorter in intervention participants.^1,6
• One study reported differences in one outcome (teaching effectiveness) in favor of controls.⁷ No more differences in favor of controls were found in any outcome in any manuscript.
• Findings were in favor of RCDP across many studies, but the majority of these studies had trainees as participants, thus making it difficult to generalize these findings to other groups such as experienced healthcare providers.

Knowledge Gaps

The following knowledge gaps were identified:

• The use of Rapid Cycle Deliberate Practice in other populations (laypeople, first responders, and experienced healthcare providers).
• The effect of Rapid Cycle Deliberate Practice after a medium/long-term follow-up.
• Resources required and costs of implementation of Rapid Cycle Deliberate Practice in simulation-based training curriculum of health care providers and other populations.
• The effect of the implementation of curriculums based on Rapid Cycle Deliberate Practice on clinical outcomes and patient survival.
• There is heterogeneity in the use of terms and a not standardized definition of Deliberate Practice and Rapid Cycle Deliberate Practice.

Attachments: EIT 6414 Rapid Cycle Deliberate Practice Et D, EIT 6414 Rapid Cycle Deliberate Practice Grade Pro

References

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2. Lemke DS, Fielder EK, Hsu DC, Doughty CB. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing. A Pilot Study. Pediatr Emer Care 2019;35:480–486. doi: http://dx.doi.org/10.1097/PEC....
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