Self-directed digital BLS training: EIT 647 TF Systematic Review

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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: Andrew Lockey, Joyce Yeung, Koen Monsieurs and Robert Greif.

CoSTR Citation

Bray JE, Eastwood K, Bhanji F, Breckwoldt J, Cheng A, Duff J, Gilfoyle E, Hsieh M, Lauridsen K, Lockey A, Matsyuama T, Monsieurs K, Patocka C, Pellegrino J, Sawyer TL, Schnaubelt S, Yeung J, Finn J, Greif R, on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Self-directed digitally-based basic life support (BLS) education and training in adults and Children [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2021 February 1. Available from: http://ilcor.org.

Methodological Preamble (and Link to Published Systematic Review if applicable)

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (Eastwood K, Howell S, Nguyen A, Han C, Seneviratne J, Bray J. A systematic review of digital-based basic life support training. PROSPERO 2020 CRD42020199176) conducted by Kathryn Eastwood and Janet Bray with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Education, Implementation and Teams Task Force. These data were taken into account when formulating the Treatment Recommendations.

We defined self-directed digital-based BLS training as any form of digital (e.g. video, phone application-based, internet-based, game-based learning, virtual reality, augmented reality) education or training for BLS that can be completed without an instructor, except for mass media campaigns (e.g. television and social media education). We defined instructor-led training as education or training (e.g. lecture, skills demonstration, skills feedback) that occurred in the presence of a BLS instructor.

We excluded studies if: the digital training arm included instructor-led practice or feedback; studies without an instructor-led control group or comparing different methods of digital training; the training was specifically designed for health care professionals (e.g. computer training for nursing students to use over the course of a semester); the intervention was designed for refreshment of BLS skills; the sample included a high proportion of health care students who were already CPR certified; or training included advanced life support skills. Some of the included studies examined additional interventions; in these studies, we excluded data from these arms (e.g. blended-training or a no training control group). We used data from no training arms as supporting evidence when the available evidence was conflicting or insufficient. One study included self-directed CPR training and instructor-led AED training, in this study the AED data was excluded (Roppolo 2007 276).

PICOST

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

Population: Adults and children undertaking BLS training.

Intervention: Self-directed digitally-based BLS training.

Comparators: Instructor-led BLS training.

Outcomes: Patient outcomes: Good neurological outcome at hospital discharge/30-days; Survival at hospital discharge/30-days; Return of spontaneous circulation (ROSC); Rates of bystander CPR; Bystander CPR quality during an OHCA (any available CPR metrics); Rates of automated external defibrillator (AED) use. Educational outcomes at the end of training and within 12 months: CPR quality (chest compression depth and rate; chest compression fraction; full chest recoil, ventilation rate, overall CPR competency) and AED competency; CPR and AED knowledge; Confidence and willingness to perform CPR.

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 are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) commentary and editorial papers, reviews and animal studies were excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to July 1, 2020.

PROSPERO Registration CRD42020199176

Consensus on Science

Overall, 41 studies reported short and long-term outcomes of interest for self-directed digital BLS training (referred to below as digital training) compared to instructor-led training (33 RCTS: Ali 2019 188; Assadi 2015 291; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Dracup 2000 3289; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Kim 2016 465; Krogh 2015 7; Li 2020 97; Liberman 2000 249; Lynch 2005 31; Lynch 2010 568; Lyness 1985 2; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Raaj 2016 142; Reder 2006 443; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Van Raemdonck 2013 284; Yeung 2017 138; and 8 non-RCTS: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Edwards 1987 492; Hasani 2015 1; Isbye 2006 435; Jones 2007 350; Long 1992 30). We included studies reporting outcomes for: CPR training (26 studies: Ali 2019 188; Barr 2013 538; Beskind 2016 28; Braslow 1997 207; Chung 2010 165; Dracup 1998 170; Edwards 1987 492; Einspruch 2007 476; Hasani 2015 1; Hasselager 2019 28; Heard 2019 599; Isbye 2006 435; Jones 2007 350; Kim 2016 465; Krogh 2015 7; Li 2020 97; Liberman 2000 249; Long 1992 30; Lynch 2005 31; Lyness 1985 2; Raaj 2016 142; Raemdonck 2013 284; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Yeung 2017 138); CPR and automated external defibrillator (AED) training (12 studies: Assadi 2015 291; Batcheller 2000 101; Bylow 2019 122; Cerezo Espinosa 2018 28; de Vires 2010 1004; Doucet 2019 317; Mancini 2009 159; Nas 2019 328; Pedersen 2018 147; Reder 2006 443; Roppolo 2007 276; Roppolo 2011 319) or automated external defibrillator (AED) training (1 study: Meischke 2001 216). The overall quality of evidence was rated as very low to moderate for all outcomes primarily due to a risk of bias. The majority of individual studies were at critical risk of bias primarily due to missing outcome data (RCTS) and potential for confounding (non-RCTs). Because of this, and the high degree of heterogeneity in the interventions and in the measurements of outcomes, we performed a narrative synthesis of the findings for each outcome overall and by the different mediums of digital training tested.

Interventions

Studies examined single or multiple mediums of digital training. Mediums used included video only (n= 11 studies: Ali 2019 188; Assadi 2015 291; Beskind 2016 28; Cerezo Espinosa 2018 28; de Vires 2010 1004; Hasani 2015 1; Heard 2019 599; Kim 2016 465; Li 2020 97; Long 1992 30; Raaj 2016 142), videos with self-directed manikin practice (26 studies: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Edwards 1987 492; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Isbye 2006 435; Jones 2007 350; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Lynch 2010 567; Lyness 1985 2; Meischke 2001 216; Pedersen 2018 147; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Van Raemdonck 2013 284), interactive computer training with video and self-directed manikin practice (2 studies: Mancini 2009 159; Roppolo 2011 319), interactive computer gaming without manikin practice (1 study; Reder 2006 443), virtual reality (1 study: Nas 2019 328), and gaming in an interactive film (1 study: Yeung 2017 138). In some studies, learners in the digital training arm were sent home with materials (e.g. video and manikin) and returned for assessment either at a set time or when they felt competent (8 studies: Barr 2013 538; Bylow 2019 122; Chung 2010 165; Isbye 2006 435; Krogh 2015 7; Liberman 2000 249; Pedersen 2018 147; Roppolo 2011 319).

Instructor-led training varied between: formal BLS, CPR or AED classes (19 studies: Assadi 2015 291; Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Chung 2010 165; de Vires 2010 1004; Einspruch 2007 476; Isbye 2006 435; Jones 2007 350; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Lynch 2010 568; Lyness 1985 2; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730), instructor skill demonstrations and/or feedback during practice (19 studies: Dracup 1998 170; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Doucet 2019 317; Edwards 1987 492; Hasani 2015 1; Hasselager 2019 28; Heard 2019 599; Kim 2016 465; Li 2020 97; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Raaj 2016 142; Reder 2006 443; Van Raemdonck 2013 284; Yeung 2017 138), and instructor-led lectures (3 studies: Ali 2019 188; Li 2020 97; Long 1992 30). The comparison group in one non-RCT was a group of adults with prior CPR training (Barr 2013 538). Use of hands-on manikin practice and feedback devices (e.g. compression clickers or feedback meters) during training varied widely between studies, and in some studies also varied between the intervention and control groups.

Learners

Learners included adults (23 studies: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; Dracup 1998 170; Edwards 1987 492; Einspruch 2007 476; Hasani 2015 1; Hasselager 2019 28; Heard 2019 599; Isbye 2006 435; Kim 2016 465; Krogh 2015 7; Li 2020 97; Long 1992 30; Lynch 2005 31; Mancini 2009 159; Nas 2019 328; Raaj 2016 142; Roppolo 2007 276; Thoren 2007 333; Todd 1999 730), undergraduate university students (8 studies: Ali 2019 188; Assadi 2015 291; Hasani 2015 1; Liberman 2000 249; Lyness 1985 2; Pedersen 2018 147; Roppolo 2011 319; Todd 1998 364), high-school students aged >10 years (6 studies: Beskind 2016 28; Cerezo Espinosa 2018 28; Doucet 2019 317; Reder 2006 443; Raemdonck 2013 284; Yeung 2017 138) and a mixture of adults and children of unknown age (1 study de Vires 2010 1004).

Brief summary of outcomes

Subsequent use of skills and patient outcomes

Two RCTs (Dracup 2000 3289; Yeung 2017 138) reported results for subsequent use of BLS skills and patient outcomes following training. Only Dracup et al. (2000 3289) reported any OHCA events (n=13) where trainees used skills, however there were too few events (n=13) and outcomes of this study were of too low quality (very low certainty of evidence, downgraded for serious risk of bias and imprecision) to be confident in the findings.

Educational outcomes (CPR and AED skills immediate and to one year)

Testing of CPR and AED skills was conducted immediately to one-month after training in 36 studies (29 RCTs: Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Hasselager 2019 28; Heard 2019 599; Kim 2016 465; Krogh 2015 7; Li 2020 97; Liberman 2000 249; Lynch 2005 31; Lynch 2010 568; Lyness 1985 2; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Raaj 2016 142; Reder 2006 443; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1999 730; Van Raemdonck 2013 284; Yeung 2017 138 and 7 non-RCTs: Barr 2013 538; Braslow 1997 207; Batcheller 2000 101; Edwards 1987 492; Hasani 2015 1; Jones 2007 350; Long 1992 30) and between two-months and one-year in 23 studies (18 RCTs: Assadi 2015 291; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Chung 2010 165; de Vires 2010 1004; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Li 2020 97; Liberman 2000 249; Meischke 2001 216; Pedersen 2018 147; Reder 2006 443; Roppolo 2007 276; Todd 1998 364; Van Raemdonck 2013 284; Yeung 2017 138 and 5 non-RCTs: Barr 2013 538; Braslow 1997 207; Edwards 1987 492; Hasani 2015 1; Isbye 2006 435). Methods of measurement and the types of educational outcomes varied widely between studies, which precluded any pooling of data or meta-analysis.

Moderate certainty of evidence (downgraded for risk of bias) from 28 studies, comparing instructor-led training and digital training using video or interactive computer programs with manikin practice, showed comparable educational outcomes for most CPR skills and knowledge gained immediately following training and to one-year (22 RCTS: Bylow 2019 122; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Lynch 2010 567; Lyness 1985 2; Mancini 2009 159; Meischke 2001 216; Pedersen 2018 147; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Van Raemdonck 2013 284; 6 non-RCTS: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Edwards 1987 492; Isbye 2006 435; Jones 2007 350).

Low certainty of evidence (downgraded for risk of bias and imprecision) from 9 studies, comparing instructor-led training and digital training using video-only, showed comparable educational outcomes for most CPR skills and knowledge gained immediately following training and to one-year (3 RCTs: Ali 2019 188; Assadi 2015 291; Beskind 2016 28) and overall CPR competency and knowledge immediately (7 RCTs: Ali 2019 188; Assadi 2015 291; Beskind 2016 28; Cerezo Espinosa 2018 28; Kim 2016 465; Li 2020 97; Raaj 2016 142 and 2 non-RCTs: Hasani 2015 1; Long 1992 30).

Low certainty of evidence (downgraded for risk of bias and imprecision) from 11 RCTs testing methods of digital training for AED skills, suggests instructor-led training may be more effective immediately following training but not in the long-term (Assadi 2015 291; Bylow 2019 122; Cerezo Espinosa 2018 28; de Vries 2010 1004; Doucet 2019 317; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Reder 2006 443; Roppolo 2011 319).

Insufficient (low quality, downgraded for risk of bias and inconsistency) evidence was found comparing gaming training to instructor-led training (3 RCTS: Nas 2019 328; Reder 2006 443; Yeung 2017 138).

Detailed summary of outcomes

Critical Subsequent use of skills and patient outcomes

Two RCTs (Dracup 2000 3289; Yeung 2017 138) and one non-RCT (Barr 2013 538) reported following learners for subsequent use of BLS skills and patient outcomes (very low certainty of evidence, downgraded for risk of bias and imprecision). However, the non-RCT (Barr 2013 538) did not report data for this outcome.

Dracup et al. (2000 3289) compared video-CPR (with manikin practice) training, two types of instructor-led CPR training and no training in caretakers of high-risk infants. At 12-months, in 58% of their original sample, they reported the occurrence of 13 OHCAs evenly spread across the three intervention groups and no events in the no training group, and state all were successfully resuscitated; however, it is unclear who performed the resuscitation and outcomes were not defined.

Yeung et al. (2017 138) compared CPR training with gaming in an interactive film to instructor-led training in high-school aged children. At 6-months follow-up, in 79% of their original sample, no children reported using CPR for OHCA events.

We found further indirect evidence from three non-RCTs examining either digital only training (Pierick 2012 1140) or that compared digital training to no training (Eisenberg 1995 200; Isbye 2007 1380):

• A single arm non-RCT by Pierick (2012 1140) taught parents (n=311) of high-risk infants using a self-directed DVD with a practice manikin, they then surveyed parents over a 12-month period (41% of original sample). They reported eight emergency events: 7/8 received CPR from a parent (one unknown), 6/8 survived, and parents report good to stable neurological outcomes in survivors.

• Eisenberg et al. (1995 2000) sent CPR videos (no manikin) to households and compared OHCA data (registry and case follow-up) over a 16-month period from this region and from a region not sent videotapes. They report no difference between regions for rates of CPR training, bystander CPR, survival to hospital and survival to hospital discharge.

• Isbye (2007 1380) sent 35,000 digital CPR training kits to schools and report no change in regional rates of bystander CPR and OHCA survival to the previous year.

Important educational outcomes (CPR and AED skills and knowledge)

We found 40 studies reporting educational outcomes from digital training (32 RCTS: Ali 2019 188; Assadi 2015 291; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Kim 2016 465; Krogh 2015 7; Li 2020 97; Liberman 2000 249; Lynch 2005 31; Lynch 2010 568; Lyness 1985 2; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Raaj 2016 142; Reder 2006 443; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Van Raemdonck 2013 284; Yeung 2017 138; and 8 non-RCTS: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Edwards 1987 492; Hasani 2015 1; Isbye 2006 435; Jones 2007 350; Long 1992 30).

Outcomes from testing within one-month of training:

• Compression rate – moderate certainty of evidence (downgraded for risk of bias) was reported by 21 studies (17 RCTs and 4 non-RCTs) for either compression rate/minute (n=15 studies: Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Jones 2007 350; Krogh 2015 7; Lynch 2005 31; Mancini 2009 159; Nas 2019 328; Pedersen 2018 147; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1999 730; Van Raemdonck 2013 284; Yeung 2017 138) and/or the proportion of compressions with correct rates (n=9 studies: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; Doucet 2019 317; Heard 2019 599; Mancini 2009 159; Roppolo 2007 276). No difference between groups was reported in 10 of 15 RCTs (Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Krogh 2015 7; Lynch 2005 31; Nas 2019 328; Pedersen 2018 147; Roppolo 2007 276; Van Raemdonck 2013 284; Yeung 2017 138) and 1 non-RCT (Jones 2007 350) for compression rate/minute and 3 of 6 RCTs (Bylow 2019 122; Chung 2010 165; Doucet 2019 317) and 1 of 3 non-RCTs (Batcheller 2000 101) for the proportion of compression with correct rate. For compression rate/minute, 2 of 15 RCTs favoured instructor-led training (Mancini 2009 119; Roppolo 2011 319) and 2 of 15 RCTs favoured digital training (Thoren 2007 333; Todd 1999 730). However, these differences were marginal and in three studies mean rates in the digital groups were at guideline standard (Mancini 2009 119; Roppolo 2011 319; Thoren 2007 333). One RCT favoured instructor-led training for the proportion of compressions with correct rate (Mancini 2009 119), and four studies (2 RCTs: Heard 2019 599; Roppolo 2007 276 and 2 non-RCTs: Barr 2013 538; Braslow 1997 207) favoured digital training.

• Compression depth – moderate certainty of evidence (downgraded for risk of bias) was reported by 19 studies (15 RCTs and 4 non-RCTs) for mean compression depth (n=11 studies: Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Jones 2007 350; Lynch 2005 31; Nas 2019 328; Pedersen 2018 147; Roppolo 2007 276; Todd 1999 730; Van Raemdonck 2013 284; Yeung 2017 138) or the proportion of compressions with correct compression depth (n=12 studies: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; Doucet 2019 317; Heard 2019 599; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Pedersen 2018 147; Roppolo 2007 276). Of these, the majority of RCTs reported no difference between groups for mean compression depth (7 of 10 RCTs: Ali 2019 188; Bylow 2019 122; Lynch 2005 31; Pedersen 2018 147; Roppolo 2007 276; Todd 1999 730; Van Raemdonck 2013 284), with only two RCTs (Beskind 2016 28; ) reporting a significant improvement in chest compression depth in the instructor-led group. Similarly, the majority of studies reported no difference between groups for the proportion of compressions with correct depth (6 of 9 RCTs: Bylow 2019 122; Doucet 2019 317; Liberman 2000 249; Lynch 2005 31; Pedersen 2018 147; Roppolo 2007 276 and 1 of 3 non-RCTs: Braslow 1997 207). Three of the four studies (3 RCTs: Beskind 2016 28; Nas 2019 328; Yeung 2017 138 and 1 non-RCT: Jones 2007 350) that favoured instructor-led training for mean compression depth trialled either a very short video without practice (Beskind 2016 28) or gaming-style training (Nas 2019 328; Yeung 2017 138), and two of these studies were conducted in high-school students (Beskind 2016 28; Yeung 2017 138). Two non-RCTs favoured digital training for the proportion of compressions with correct depth (Barr 2013 538; Batcheller 2000 101), but compression feedback in training was either not used in the instructor-led group or unclear. Most studies including children reported lower mean compression depths than studies including adults regardless of the type of training (Beskind 2016 28; Van Raemdonck 2013 284; Yeung 2017 138).

• Chest compression fraction: moderate certainty of evidence (downgraded for risk of bias) was reported by 8 studies (7 RCTs: Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Nas 2019 328; Pedersen 2018 147; Roppolo 2007 276; Yeung 2017 138 and 1 non-RCT: Jones 2007 350) for chest compression fraction. The majority of these studies (n=6) reported no difference between methods of training (Ali 2019 188; Beskind 2016 28; Bylow 2019 122; Pedersen 2018 147; Roppolo 2007 276; Yeung 2017 138). One RCT (Nas 2019 328) and one non-RCT (Jones 2007 350) favoured instructor-led training.

• Complete chest recoil: moderate certainty of evidence (downgraded for risk of bias) was reported by 9 studies (6 RCTs: Ali 2019 188; Bylow 2019 122; Liberman 2000 249; Mancini 2009 159; Nas 2019 328; Pedersen 2018 147 and 3 non-RCTs: Batcheller 2000 101; Braslow 1997 207; Jones 2007 350) for complete chest recoil. The majority of these studies (n=6) reported no difference between methods of training (Ali 2019 188; Bylow 2019 122; Liberman 2000 249; Batcheller 2000 101; Jones 2007 350; Pedersen 2018 147). One RCT (Nas 2019 328) and one non-RCT (Braslow 1997 207) favoured instructor-led training and one RCT favoured digital training (Mancini 2009 159).

• Ventilation rate – moderate certainty of evidence (downgraded for risk of bias) was reported by 19 studies (16 RCTs: Bylow 2019 122; Chung 2010 165; Doucet 2019 317; Hasselager 2019 28; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Nas 2019 328; Pedersen 2018 147; Reder 2006 443; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1999 730; Van Raemdonck 2013 284 and 3 non-RCTs: Batcheller 2000 101; Braslow 1997 207; Jones 2007 350) for ventilation rate. The majority of these studies (n=13) reported no difference between methods of training (Braslow 1997 207; Chung 2010 165; Doucet 2019 317; Hasselager 2019 28; Jones 2007 350; Krogh 2015 7; Liberman 2000 249; Mancini 2009 159; Pedersen 2018 147; Roppolo 2007 276; Roppolo 2011 319; Todd 1999 730; Van Raemdonck 2013 284).

• Hand position during compressions – moderate certainty of evidence (downgraded for risk of bias) was reported by 17 studies (13 RCTs: Ali 2019 188; Bylow 2019 122; Chung 2010 165; Doucet 2019 317; Heard 2019 599; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Pedersen 2018 147; Reder 2006 443; Roppolo 2007 276; Todd 1999 730; Van Raemdonck 2013 284; and 4 non-RCTs: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Jones 2007 350) for hand positioning during compressions. The majority of these studies (n=11) reported no difference between methods of training (Ali 2019 188; Bylow 2019 122; Doucet 2019 317; Heard 2019 599; Jones 2007 350; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Pedersen 2018 147; Roppolo 2007 276; Van Raemdonck 2013 284). Four studies (1 RCT and 4 non-RCTs) favoured digital training (Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Todd 1999 730), and two RCTs favoured instructor-led training (Chung 2010 165; Reder 2006 443).

• Overall CPR competency - moderate certainty of evidence (downgraded for risk of bias) was reported by 24 studies (17 RCTs: Ali 2019 188; Bylow 2019 122; Chung 2010 165; Doucet 2019 317; Dracup 1998 170; Hasselager 2019 28; Kim 2016 465; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Lyness 1985 2; Mancini 2009 159; Raaj 2016 142; Roppolo 2007 276; Roppolo 2011 319; Todd 1999 730; Yeung 2017 138 and 7 non-RCTs: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Edwards 1987 492; Hasani 2015 1; Jones 2007 350; Long 1992 30) for overall CPR skill competency judged by instructors. Ten studies (7 RCTs: Ali 2019 188; Chung 2010 165; Doucet 2019 317; Krogh 2015 7; Lyness 1985 2; Raaj 2016 142; Roppolo 2007 276 and 3 non RCTs: Edwards 1987 492; Jones 2007 350; Long 1992 30) reported no difference between groups. Eight studies (7 RCTs) favoured instructor-led training (Bylow 2019 122; Dracup 1998 170; Hasani 2015 1; Hasselager 2019 28; Kim 2016 465; Mancini 2009 159; Roppolo 2011 319; Yeung 2017 138) and 6 studies (3 RCTs) favoured digital training (Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Liberman 2000 249; Lynch 2005 31; Todd 1999 730); however these studies often used different methods of feedback between groups during CPR practice.

• AED competency – low certainty of evidence (downgraded for risk of bias and inconsistency) was reported by 9 RCTs for AED skills (Bylow 2019 122; de Vries 2010 1004; Doucet 2019 317; Mancini 2009 159; Meischke 2001 216; Nas 2019 328; Pedersen 2018 147; Reder 2006 443; Roppolo 2011 319). The majority of these RCTs (n=6) reported instructor-led training to be superior overall (Bylow 2019 122; de Vries 2010 1004; Doucet 2019 317; Mancini 2009 159; Nas 2019 328; Roppolo 2011 319), with the remaining three RCTs reporting no difference between groups (Meischke 2001 216; Pedersen 2018 147; Reder 2006 443). Most of the failures in the digital groups were failure to clear during analysis and shock (Bylow 2019 122; Doucet 2019 317; Mancini 2009 159; Roppolo 2011 319), or failure to activate the AED (de Vries 2010 1004; Nas 2019 328). Important to note is the wide variation in training times between the intervention and control groups, and in the use of the AED’s voice prompts during training and assessment. Two studies focused solely on AED education (de Vries 2010 1004; Meischke 2001 216). An RCT by De Vries (2010 1004) found more participants were competent with a 90-minute instructor-led AED sessions (with practice and feedback) compared to 3 different video interventions (2.5 minute video with no practice, 4.5 minute video with practice, 9 minute video with practice and scenario) when assessed with the AED voice instructions turned off. Meischke (2001 216) found equivalent skills when assessed with comparable training and practice times between groups (~ 45 minutes). These authors also report no difference between groups for willingness or confidence in AED use (Meischke 2001 216). Two other studies reported significant improvement in AED skills with both methods when compared to baseline or groups with no training (Doucet 2018 317; Reder 2006 443).

• CPR knowledge – moderate certainty of evidence (downgraded for risk of bias) was reported by 12 studies (9 RCTs: Cerezo Espinosa 2018 28; Hasselager 2019 28; Kim 2016 465; Li 2020 97; Lyness 1985 2; Raaj 2016 142; Reder 2006 443; Todd 1999 730; Yeung 2017 138) and 3 non-RCTs: Edwards 1987 492; Hasani 2015 1; Long 1992 30) for CPR knowledge. The majority of these studies (6 RCTs: Cerezo Espinosa 2018 28; Lyness 1985 2; Raaj 2016 142; Reder 2006 443; Todd 1999 730; Yeung 2017 138 and 2 non-RCTs: Edwards 1987 492; Long 1992 30) reported no difference between methods of training, with the remaining (3 RCTs: Hasselager 2019 28; Kim 2016 465; Li 2020 97 and 1 non-RCT: Hasani 2015 1) favouring instructor-led training.

• AED knowledge – low certainty of evidence (downgraded for risk of bias and imprecision) was reported by 2 RCTs for AED knowledge (Cerezo Espinosa 2018 28; Reder 2006 443). Both studies reported no difference between groups.

• Confidence – moderate certainty of evidence was reported by 14 studies (11 RCTs: Ali 2019 188; Bylow 2019 122; Kim 2016 465; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Meischke 2001 216; Pedersen 2018 147; Todd 1999 730; Yeung 2017 138 and 3 non-RCTs: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207) for self-reported confidence post-training. The majority of these studies (7 RCTs: Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Meischke 2001 216; Todd 1999 730; Yeung 2017 and 2 non-RCTS: Batcheller 2000 101; Braslow 1997 207) report no difference between groups.

• Willingness to perform CPR – moderate certainty of evidence (downgraded for risk of bias) was reported by 10 studies (9 RCTs: Bylow 2019 122; Chung 2010 165; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Meischke 2001 216; Thoren 2007 333; Todd 1999 730; Yeung 2017 138; and 1 non-RCTs: Barr 2013 538) for willingness to perform CPR on a stranger post-training. The majority of these studies (n=9) report no difference between groups (Bylow 2019 122; Chung 2010 165; Liberman 2000 249; Lynch 2005 31; Mancini 2009 159; Meischke 2001 216; Thoren 2007 333; Todd 1999 730; Yeung 2017 138; and 1 non-RCTs: Barr 2013 538).

Outcomes to one-year:

Long-term CPR and AED knowledge and skills were measured in 23 studies (very-low to low certainty of evidence, downgraded for risk of bias), with follow-up ranging from 2- to 12-months between two-months and one-year in 24 studies (18 RCTs: Assadi 2015 291; Beskind 2016 28; Bylow 2019 122; Cerezo Espinosa 2018 28; Chung 2010 165; de Vires 2010 1004; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Li 2020 97; Liberman 2000 249; Meischke 2001 216; Pedersen 2018 147; Reder 2006 443; Roppolo 2007 276; Todd 1998 364; Van Raemdonck 2013 284; Yeung 2017 138 and 5 non-RCTs: Barr 2013 538; Braslow 1997 207; Edwards 1987 492; Hasani 2015 1; Isbye 2006 435). At these time points, the majority of studies reported no difference in knowledge or skills between digital and instructor-led training. Importantly, there were no differences between groups in chest compression rates in all 12 studies reporting this outcome (Assadi 2015 291; Beskind 2016 28; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; Heard 2019 599; Isbye 2006 435; Pedersen 2018 147; Roppolo 2007 276; Todd 1998 364; Van Raemdonck 2013 284; Yeung 2017 138), and in 11 of 13 studies reporting on chest compression depth (Beskind 2016 28; Braslow 1997 207; Bylow 2019 122; Chung 2010 165; Einspruch 2007 476; Heard 2019 599; Isbye 2006 435; Liberman 2000 249; Pedersen 2018 147; Roppolo 2007 276; Todd 1998 364; Van Raemdonck 2013 284; Yeung 2017 138).

Methods of digital training

Videos with self-directed manikin practice was the most common intervention (25 studies, 22 RCTs: Bylow 2019 122; Chung 2010 165; de Vires 2010 1004; Doucet 2019 317; Dracup 1998 170; Einspruch 2007 476; Hasselager 2019 28; Heard 2019 599; Isbye 2006 435; Krogh 2015 7; Liberman 2000 249; Lynch 2005 31; Lyness 1985 2; Mancini 2009 159; Meischke 2001 216; Pedersen 2018 147; Roppolo 2007 276; Roppolo 2011 319; Thoren 2007 333; Todd 1998 364; Todd 1999 730; Van Raemdonck 2013 284 and 5 non-RCTs: Barr 2013 538; Batcheller 2000 101; Braslow 1997 207; Edwards 1987 492; Jones 2007 350). This method was generally comparable to instructor-led training for most educational outcomes (moderate certainty of evidence, downgraded for risk of bias)–although methods to optimise compression depth to guideline standard are required.

Video-only digital training was examined in nine studies (7 RCTs: Ali 2019 188; Assadi 2015 291; Beskind 2016 28; Cerezo Espinosa 2018 28; Kim 2016 465; Li 2020 97; Raaj 2016 142 and 2 non-RCTs: Hasani 2015 1; Long 1992 30). Only three studies reported individual CPR skills compared to instructor-led training, with no difference reported between the two methods for most skills (Ali 2019 188; Assadi 2015 291; Beskind 2016 28). Studies examining overall CPR competency and knowledge immediately after training favoured instructor-led training (Kim 2016 465; Hasani 2015 1; Li 2020 97) or found no difference between the methods of training (Ali 2019 188; Long 1992 30; Raaj 2016 142) (low certainty of evidence, downgraded for risk of bias and imprecision). One study included pre-testing of CPR skills, and showed an improvement from baseline with video only training (Kim 2016 465).

There was insufficient evidence comparing methods of gaming-style training to instructor-led training (Nas 2019 328; Reder 2006 443; Yeung 2017 138). Yeung (2017 138) tested an interactive game in film app in high school students and found shallower chest compressions and overall CPR competency compared to instructor-led training immediately following training, but these skills were comparable by 3- and 6-months. Virtual reality was tested in one study in adults using a smart phone app, with most CPR skills favouring instructor-led training (Nas 20019 328). One RCT (Reder 2006 443) tested a 45-minute interactive computer program (without practice) in high school students and favoured instructor-led training, but reported improved outcomes with digital training compared to a no training arm.

Treatment Recommendations

We recommend instructor-led training (with manikin practice with feedback device) or the use of self-directed training with video kits (instructional video and manikin practice with feedback device) for the acquisition of CPR theory and skills in lay-adults and high school aged (>10 years) children (strong recommendation, moderate quality of evidence).

We recommend instructor-led training (with AED scenario and practice) or the use of self-directed video kits (instructional video with AED scenario) for the acquisition of AED theory and skills in lay-adults and high school aged (>10 years) children (strong recommendation, low quality of evidence).

We suggest BLS video education (without manikin practice) be used when instructor-led training or self-directed training with video kits (instructional video plus manikin with feedback device) are not accessible, or when quantity over quality of BLS training is needed in adults and children (weak recommendation, weak quality of evidence).

There was insufficient evidence to make a recommendation on gaming as a CPR or AED training method.

There was insufficient evidence to suggest a treatment effect on bystander CPR rates or patient outcomes.

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the EIT Task Force acknowledges that:

• the current evidence suggests some AEDs skills were superior with instructor-led training; however, the Task Force considered the significant improvement in AED skills with both methods when compared to baseline or groups with no training more important since modern AEDs include voice prompts for use.

• adequate training outcomes for some BLS skills may not be achieved with video-only training; however, the Task Force considered the improvement in BLS skills with video-only training when compared to baseline or groups with no training more important.

• high-school aged children may not be able to achieve guideline recommendations for chest compression depth; however, the Task Force considered the acquisition of BLS skills at this age more important.

The EIT Task Force also considered the following:

• Testing of educational outcomes varied in terms of duration of testing and methods of data collection (manikin and checklists). Varied use of manikin practice, feedback devices, and assessment of CPR performance was also noted.

• Manikins have different technical specifications with respect to delivery of CPR.

• The difference in compression depth were discussed at length. Of particular importance:

- Although compression depth favored instructor-led training, it is difficult to know how clinically significant these differences were, because in some studies compression depth was low in both groups and most differences were marginal.

- Studies with pre-testing or with a no training control groups showed improved compression depth outcomes in digital training arms.

- Use of feedback devices for compression depth varied widely.

- Manikins vary with respect to the maximum allowable depth (e.g. some allow compressions beyond depth guidelines, while others do not), force required to generate guideline compliant depth (i.e. resistance), and chest size.

- One study noted that although some video kit manikins contained feedback devices, the video did not always explained its use (Jones 2007 350). How widespread this issue was across other studies is unknown due to lack of reporting.

- One study suggested differences in achieving CPR skills may related to the different manikins used in practice and assessment, with only the instructor-led group training on the same manikins used in assessment (Jones 2007 350).

• That any form of BLS training improves knowledge, confidence and willingness to perform CPR compared to control groups with no training.

• One study suggested insufficient emphasis in AED use in digital training may explain worse AED educational outcomes (Doucet 2019 317).

• Video-only digital training is probably not comparable to instructor-led training, due to the differences in BLS practice and feedback between groups.

• The relevance of older RCTs was discussed, including: advancements in RCT methods; modern training focuses on chest compressions; advancements in technology for CPR assessments.

• Cost-effectiveness analysis performed typically favors digital- training (Hasselager 2019 28; Li 2011 357). Instructor-led classes require human resources, organization, location and equipment. Digital training is generally cheaper and more convenient than instructor-led training.

• Data suggest CPR and AED training must include skills practice –preferably with corrective feedback.

• That provision of bystander CPR and AED use are strong predictors of OHCA patient outcomes.

• Acquisition of different BLS skills may vary across different mediums and age groups.

• The known barriers that exist to attend instructor-led BLS classes (e.g. time, costs, and accessibility) and the need to make BLS training available to everyone.

• The need and ease for updating digital and instructor-led materials to ensure training complies with BLS recommendations.

• Digital training allow skills to be refreshed at any time, and at no additional cost, and provide the opportunity to teach others (~2.5 additional people trained per kit Isbye 2007 1380, Barr 2013 538). Refreshment of CPR skills using digital methods may explain why some skills improved when measured in the longer term (Yeung 2017 138).

• Digital training enables more people to be educated in periods of need (e.g. pandemics).

Knowledge Gaps

• Continued research in methods to improve the achievement of guideline recommended CPR metrics (compression rate and depth) and AED outcomes are needed.

• Reporting and standardization of manikin technical specifications represents an opportunity for future research.

• Studies comparing gaming training to instructor-led training are needed.

• Future studies should use objective methods (e.g. sensor manikins) in CPR skill assessments) and include important CPR metrics (Meaney 2013 417).

Attachment

EIT-647-Final-selfdirected-BLS-training-TFSR-EIT-647-ETD

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