Teaching teamwork competencies for resuscitation: EIT 6415 TFSR

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: Joyce Yeung.

CoSTR Citation

Farquharson B, Cortegiani A, Lauridsen KG, Yeung, J, 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 training with a specific emphasis on teamwork competencies in resuscitation training compared with training without specific emphasis. 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 undertaking life support training in any setting

Intervention: Life support training with a specific emphasis on teamwork competencies

Comparators: Life support training without specific emphasis on teamwork competencies

Outcomes: Patient survival (CRITICAL), CPR skill performance at course completion (IMPORTANT), CPR skill performance in actual resuscitation (CRITICAL) AND simulation <1yr (CRITICAL) and ≥ 1yr of course completion (CRITICAL); CPR quality at course completion (IMPORTANT), <1yr and ≥ 1yr of course completion(CRITICAL); confidence (at course completion and <1yr and ≥ 1yr of course completion), teamwork competencies (at course completion, <1yr and ≥ 1yr of course completion, IMPORTANT); resources (time, equipment, cost) (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) were eligible for inclusion. Studies evaluating scoring systems (no relevant outcome), studies with self-assessment as the only outcome, reviews and abstracts without full article were excluded.

Timeframe: Literature search 1 Jan 1999 to 30 Aug 2023.

PROSPERO Registration CRD42023473154

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 30 August 2023 identified 5361 references (Figure 1). After de-duplication, 3288 titles and abstracts were reviewed. Full text review was conducted on 29 papers. Seventeen studies were identified that addressed the PICOST question comparing life support training with a specific emphasis on teamwork competencies with life support training without specific emphasis (see Table 2).

Attachment:

EIT 6415 Figure 1 PRISMA

EIT 6415 Summary of findings table 031223refs

Survival

For the critical outcome of patient survival, we identified one RCT⁸ which reported descriptive data on patient outcomes, reporting 11% patients died in intervention group vs 13% patients in control but without information about time period and not powered to make inferences.

CPR skill performance

For the important outcome of CPR skill performance at course completion, we found 11 studies (10 RCTs^{3,4,7,8,11,12,13,14,16,17} and one before and after¹). Four^1,4,11,14 of 6^{1,3,4,11,12,14} studies reporting time to key resuscitation behaviors reported no significant difference between intervention and control groups. One RCT¹² reported significantly shorter time for 1 (time to chest compressions) of 5 behaviors measured and another³ for 8 of 9 behaviors. Seven^{4,8,12-14,16,17} of 8^{1,4,8,12-14,16,17} studies reporting CPR performance scores found no significant difference between intervention and control groups and nor did single RCT¹¹ reporting rate of correct arm and shoulder positioning. One non-randomised study¹ reported higher median scores in a checklist of expected CPR acts in intervention group (95%) vs control (85%), p=0.001. A single RCT⁷ reported adherence to ALS guidelines, finding greater adherence in intervention group (37.58) vs control (31.41), 95% CI: -10.3, -2.4, p=0.002).

For the critical outcome of CPR skill performance beyond course completion, we found 4 RCTs^4,11,13,17. Two^13,17 reported no significant difference in performance scores at 4 months¹⁷ and 6 months¹³. One RCT⁴ reported significantly higher technical CPR skill scores (calculated from compression depth and rate; detection of shockable rhythm; ventilation efficiency and time to CPR initiation) in the intervention group (70%) vs control (62%), p=0.014 at follow-up (time unspecified) despite finding no difference at course completion. One RCT¹¹ reported significantly shorter time to first meaningful resuscitation measure in intervention group at 4 months.

CPR quality

For the important outcome of CPR quality at course completion, we found 4 RCTs^6,7,9,11. Two RCTs^6,7 measured no-flow time, one⁶ reported significantly shorter no flow time in intervention group (31.4 secs) vs. in the control group (36.3 sec), (p=0.014) and the other⁷ found no significant difference between the intervention and control. One RCT¹¹ measured hands-on time and compression rate and found no difference between intervention and control group. One RCT⁹ found no difference in chest compression quality or in chest compression pauses.

For the critical outcome of CPR quality beyond course completion, we found one RCT¹¹. Four months after intervention increased hands-on time was reported in the intervention group (120 secs) vs control (87 secs), p=0.001; higher rates of recommended rate of compression in the intervention group (19) vs. control (6), p=0.002 and higher median compressions per minute in intervention group (109 cpm) vs. control (93 cpm), p=0.001.

Confidence

For the important outcome of confidence at course completion we identified one RCT⁴ which found no significant difference between intervention and control group.

For the important outcome of confidence beyond course completion we identified one RCT⁴ which found no significant difference between intervention and control group at follow-up (time unspecified)

Teamwork competencies

For the important outcome of teamwork competencies at course completion we identified 14 studies (12 RCTs^{3-6, 9-12,14-17} and 2 non-randomised studies^1,2).

Communication Two RCTs^9,15 reported significantly greater proportion of leadership statements in intervention group vs control and three RCTs^5,14,15 identified significantly increased directed team communication in intervention group vs control. One¹⁴ also reported increased completed closed-loop communication and follower-initiated communication in intervention group vs control. One RCT⁶ measured 'teamwork verbalisations' and found significantly higher verbalisations in intervention group vs control: directed orders, task assignments, undirected orders and planning. One RCT¹¹ identified more leading utterances in the control group vs intervention.

Decision making and leadership behaviour Two RCTs^8,10 reported increased leadership behaviour in intervention group vs control. One¹⁰ trial also reported significantly increased correction of improper chest compressions in intervention group. One RCTs⁹ reported increased decision-making in intervention group vs control. One non-randomised study² reported no significant difference in leadership behaviour between intervention and control.

Teamwork One RCT⁴ reported significantly higher team-level efficacy in intervention group vs control and one non-randomised study¹ reported more teamwork intervention events in intervention group vs control. Two RCTs^16,17 and a non-randomised study² found no significant difference in measures of teamwork between intervention and control groups.

Non-technical skills Two RCTs^3,12 reported significantly higher non-technical skill performance³ and total behavioural skills scores¹² in the intervention group vs control.

Workload management Two RCTs^15,16 reported significantly improved workload management in intervention group vs control.

For the important outcome of teamwork competencies beyond course completion we identified 3 RCTs^4,11,17. One RCT¹¹ reported more leadership utterances, task assignments, commands and decisions about what to do in intervention group at 4 months than control group. One RCT⁴ reported significantly higher self-reported teamwork in intervention group at follow-up (timepoint of FU not reported). One RCT¹⁷ reported no significant difference between intervention and control group in TEAM scores at 3 months (following no significant difference at course completion)

No evidence was identified for critical outcomes of CPR skill performance and CPR quality beyond 1 year, nor for the important outcomes of confidence and teamwork competencies beyond 1 year.

Treatment Recommendations

Based on the evidence found in this systematic review the Task Force suggests that teaching teamwork competencies be included in BLS and all kinds of advanced life support training (weak recommendation, very low quality of evidence).

Justification and Evidence to Decision Framework Highlights

We identified no harmful effects of team competence training in either BLS, ILS or ALS contexts. Several studies reported that training in teamwork competencies improved CPR skill performance when compared to training resuscitation without specific emphasis on teamwork competencies and two RCTs found these improvements persisted beyond course completion. The evidence relating to teamwork competencies, whilst still variable was mostly positive and again two RCTs found benefits to extend beyond course completion and thus with potential clinical benefit. Previous clinical studies suggest that a lack of teamwork competencies is a barrier to successful resuscitation and teamwork competencies have been associated with improved technical skill performance during clinical resuscitation attempts.

We valued that training in teamwork competencies appears widely accepted and likely cost-effective (despite no study investigated that).

Knowledge Gaps

The following knowledge gaps were identified:

• Benefits of training teamwork competencies on clinical resuscitation performance outcomes and patient outcomes are unknown.
• The optimal instructional design, duration and mode of delivery for training teamwork competencies is not clear.
• It is unclear whether training of particular competencies are more important than others and whether this depends on the group of learners
• We did not identify any studies evaluating the teaching of team competencies outside the hospital environment
• We found no evidence on cost-effectiveness and no studies from low-resource settings.

Attachment: EIT 6415 teamwork competencies Et D v4 0 JY

References

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