Advanced cardiac life support refresher course using standardized objective-based Mega Code testing

An Equivalence Trial Comparing Instructor-Regulated With Directed Self-Regulated Mastery Learning of Advanced Cardiac Life Support Skills

INTRODUCTION

Instructor-led simulation-based mastery learning of advanced cardiac life support (ACLS) skills is an effective and focused approach to competency-based education. Directed self-regulated learning (DSRL) may be an effective and less resource-intensive way to teach ACLS skills.

METHODS

Forty first-year internal medicine residents were randomized to either simulation-based DSRL or simulation-based instructor-regulated learning (IRL) of ACLS skills using a mastery learning model. Residents in each intervention completed pretest, posttest, and retention test of their performance in leading an ACLS response to a simulated scenario. Performance tests were assessed using a standardized checklist. Residents in the DSRL intervention were provided assessment instruments, a debriefing guide, and scenario-specific teaching points, and they were permitted to access relevant online resources. Residents in the IRL intervention had access to the same materials; however, the teaching and debriefing were instructor led.

RESULTS

Skills of both the IRL and DSRL interventions showed significant improvement after the intervention, with an average improvement on the posttest of 21.7%. After controlling for pretest score, there was no difference between intervention arms on the posttest [F(1,37) = 0.02, P = 0.94] and retention tests [F(1,17) = 1.43, P = 0.25]. Cost savings were realized in the DSRL intervention after the fourth group (16 residents) had completed each intervention, with an ongoing savings of $80 per resident.

CONCLUSIONS

Using a simulation-based mastery learning model, we observed equivalence in learning of ACLS skills for the DSRL and IRL conditions, whereas DSRL was more cost effective.

Counteracting skill decay: four refresher interventions and their effect on skill and knowledge retention in a simulated process control task

In process automation, skill decay has not been investigated systematically. In two experimental studies, refresher interventions (RIs) were compared to support skill and knowledge retention of a start-up procedure on a simulated process control task. Based on theories of proceduralisation, the 'testing-effect' and mental practice, four different RIs were designed. In Study 1 (N = 68), two experimental groups (EGs) received either an RI called 'Practice' or an RI called 'Skill Demonstration'. Both RIs support skill retention, but the Skill Demonstration-RI performed with a higher mental workload. In Study 2 (N = 68), two EGs received an RI called 'Symbolic Rehearsal' or an RI called 'Procedural Knowledge Test', and aimed at supporting knowledge retention. Both EGs supported knowledge retention but showed moderate skill decay. Results imply that RIs affect skill and knowledge retention differently and should be applied in accordance with the task requirements and their dependence on accurate skill or knowledge maintenance.

A human cadaver fascial compartment pressure measurement model

BACKGROUND

Fresh human cadavers provide an effective model for procedural training. Currently, there are no realistic models to teach fascial compartment pressure measurement.

OBJECTIVES

We created a human cadaver fascial compartment pressure measurement model and studied its feasibility with a pre-post design.

METHODS

Three faculty members, following instructions from a common procedure textbook, used a standard handheld intra-compartment pressure monitor (Stryker(®), Kalamazoo, MI) to measure baseline pressures ("unembalmed") in the anterior, lateral, deep posterior, and superficial posterior compartments of the lower legs of a fresh human cadaver. The right femoral artery was then identified by superficial dissection, cannulated distally towards the lower leg, and connected to a standard embalming machine. After a 5-min infusion, the same three faculty members re-measured pressures ("embalmed") of the same compartments on the cannulated right leg. Unembalmed and embalmed readings for each compartment, and baseline readings for each leg, were compared using a two-sided paired t-test.

RESULTS

The mean baseline compartment pressures did not differ between the right and left legs. Using the embalming machine, compartment pressure readings increased significantly over baseline for three of four fascial compartments; all in mm Hg (±SD): anterior from 40 (±9) to 143 (±44) (p = 0.08); lateral from 22 (±2.5) to 160 (±4.3) (p < 0.01); deep posterior from 34 (±7.9) to 161 (±15) (p < 0.01); superficial posterior from 33 (±0) to 140 (±13) (p < 0.01).

CONCLUSION

We created a novel and measurable fascial compartment pressure measurement model in a fresh human cadaver using a standard embalming machine. Set-up is minimal and the model can be incorporated into teaching curricula.

“Being prepared for the infrequent”: A comparative study of two refresher training approaches and their effects on temporal and adaptive transfer in a process control task

Operators working with highly automated technical systems face the challenge of skill retention due to few opportunities to apply the skills they acquired during initial training. Therefore, the use of refresher training is common in many high-risk environments. However, so far, the design and effectiveness of refresher training has not been focused on in training and human factors related research. We compared two refresher training approaches–practice and symbolic rehearsal–to a control group without refresher training. Fifty-nine engineering students were trained for one hour on a simulated process control task. A week later, the practice group completed four trials with the simulated task and the symbolic rehearsal group underwent four trials in written form. The final testing session took place two weeks after initial training. Refresher training was effective for temporal transfer, with the practice refresher group performing significantly better than the symbolic rehearsal group.

Supporting chronic disease self-management: translating policies and principles into clinical practice

To support self-management, health professionals need to adopt a client-centred approach and learn to deliver evidence-based behaviour change interventions. This paper reports on the evaluation of 1- and 2-day training programs developed to improve health professionals' capacity to support chronic disease self-management (CDSM). The 321 participants attended one of eighteen supporting CDSM courses held in urban and rural settings. Participants included nurses, allied health professionals, Aboriginal health workers and general practitioners. Data were collected at three time points: before participation; immediately after the training; and, for a sub-sample of 37 participants, 2 months after the training. Results revealed a significant and sustained increase in CDSM self-efficacy following training regardless of participants' gender, age or qualifications. A thematic analysis of the responses concerning intended practice revealed four main areas of intended practice change, namely: use behavioural strategies; improve communication with clients; adopt a client-centred approach; and improve goal setting. The number of practice changes at 2 months reported by a sub-sample of participants ranged from 1 to 20 with a mean of 14 (s.d.=4). The three most common areas of practice change point to the adoption by health professionals of a collaborative approach with chronic disease patients. Lack of staff trained in CDSM was seen as a major barrier to practice change, with lack of support and finance also named as barriers to practice change. Participants identified that increased training, support and awareness of the principles of supporting CDSM would help to overcome barriers to practice change. These results indicate a readiness among health professionals to adopt a more collaborative approach given the skills and the tools to put this approach into practice.

Effectiveness of a simulation-based medical student course on managing life-threatening medical conditions

OBJECTIVES

To assess the competency and the comfort level of medical students in lifesaving skills after a simulation-based training session and then determine skill retention after 1 year.

METHODS

Prospective observational before-after case series of medical students entering the third year. Each student participated in a half-day "How to Save a Life" course. The course consisted of a half-hour lecture on lifesaving skills followed by small group simulation-based skill sessions. Critical resuscitation actions were reviewed and demonstrated by the instructor using case-based scenarios and mannequins. The emergency medicine faculty and residents evaluated individual students' performance of clinical skill using a standardized checklist at each skill station. Each checklist specified the critical actions necessary to perform the procedure properly. Outcome measures included global competency and level of comfort questionnaire for each skill, using a 5-point Likert scale, with 1 being "strongly disagree" and 5 "strongly agree." Retention of lifesaving skills was assessed approximately 1.5 years later using a subset of the original group of the third year medical students. Without prior notification, students were assessed on the same skills using the same scenarios and outcome measures. Comparison of competency and level of comfort data between the initial group and the follow-up group were analyzed using descriptive statistics.

RESULTS

One hundred fifteen third year students participated in the initial training program. Initial demographic information was available on 104 students and revealed that 96% of the students had previous experience with basic life support. After the initial training course, all students were rated as competent in all procedures. In the retention group, the proportion of students achieving competence in each procedure ranged from 47% to 100%. The level of comfort decreased during the interval period.

CONCLUSION

A short course in simulation-based life-saving clinical skills is an effective means to teach the third year medical students. We observed a decline in competency over time for recognition of ventricular fibrillation, defibrillation, airway management, and management of a choking child. Cardiopulmonary resuscitation and automatic external defibrillator competency did not decrease over time.

Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance

OBJECTIVES

Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to determine whether an HFS with added emotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course.

METHODS

Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment using the same actors.

RESULTS

Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p<0.05]; average heart rate [HR]: 94.6 bpm versus 72.9 bpm [p<0.05]; maximum HR: 120.8 bpm versus 95.3 bpm [p<0.05]). Six months later, written test scores were similar, but the EC group participants achieved higher practical competency examination ('mega code') scores than controls (32.5 versus 25.0; p<0.05). Independent t-tests and Spearman rank coefficients were employed where applicable.

CONCLUSIONS

Simulation with added emotional stressors led to greater anxiety during ACLS instruction but correlated with enhanced performance of ACLS skills after this course. The quantitative and qualitative values of added stressors need further exploration, but these values represent important variables in simulation-based education.

Severe contrast reaction emergencies high-fidelity simulation training for radiology residents and technologists in a children's hospital

RATIONALE AND OBJECTIVES

Severe reactions to radiographic contrast agents can be life threatening, and although they are rare, effective recognition and management are essential to improving outcomes. A high-fidelity radiology simulation course for radiology residents and technologists focusing on severe contrast reactions and immediate treatments was designed to test the hypothesis that knowledge would improve with this educational intervention.

MATERIALS AND METHODS

A prospective pretest and posttest study design was used. Residents and technologists worked in teams of three to five members. Learning objectives focused on demonstrating when and how to use basic life support skills and epinephrine auto-injectors. Each resident and technologist was administered a pretest prior to the start of the case scenarios and a posttest following the debriefing session. Scores from the pretest and posttest for the residents and technologists were compared using a paired-samples t test.

RESULTS

Nineteen radiology residents and 11 radiology technologists participated. The average test scores were higher and improved significantly following the simulation experience for both the radiology residents (57% vs 82%, P < .001) and technologists (47% vs 72%, P = .006). Anonymous evaluations demonstrated that the experience was well received by residents and technologists, with 97% of learners (29 of 30) rating the experience as extremely or very helpful. Important learning themes included the knowledge of epinephrine auto-injector use and basic life support skills.

DISCUSSION

High-fidelity simulation for radiology residents and technologists focusing on epinephrine auto-injector use and basic life support skills during the first 5 minutes of a severe contrast reaction can significantly improve recognition and knowledge in treating patients having severe contrast reactions.

Cost-efficiency assessment of Advanced Life Support (ALS) courses based on the comparison of advanced simulators with conventional manikins

BACKGROUND

Simulation is an essential tool in modern medical education. The object of this study was to assess, in cost-effective measures, the introduction of new generation simulators in an adult life support (ALS) education program.

METHODS

Two hundred fifty primary care physicians and nurses were admitted to ten ALS courses (25 students per course). Students were distributed at random in two groups (125 each). Group A candidates were trained and tested with standard ALS manikins and Group B ones with new generation emergency and life support integrated simulator systems.

RESULTS

In group A, 98 (78%) candidates passed the course, compared with 110 (88%) in group B (p < 0.01). The total cost of conventional courses was euro 7689 per course and the cost of the advanced simulator courses was euro 29034 per course (p < 0.001). Cost per passed student was euro 392 in group A and euro 1320 in group B (p < 0.001).

CONCLUSION

Although ALS advanced simulator systems may slightly increase the rate of students who pass the course, the cost-effectiveness of ALS courses with standard manikins is clearly superior.

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents

OBJECTIVE

We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal.

DESIGN

Cross-sectional postal survey.

SETTING

Canadian internal medicine training programs.

PARTICIPANTS

Internal medicine residents attending Canadian English-speaking medical schools.

INTERVENTIONS

A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools.

MEASUREMENTS AND MAIN RESULTS

Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence.

CONCLUSIONS

The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.

Bioterrorism training in U.S. emergency medicine residencies: has it changed since 9/11?

OBJECTIVES

To assess the change in prevalence of bioterrorism training among emergency medicine (EM) residencies from 1998 to 2005, to characterize current training, and to identify characteristics of programs that have implemented more intensive training methods.

METHODS

This was a national cross sectional survey of the 133 U.S. EM residencies participating in the 2005 National Resident Matching Program; comparison with a baseline survey from 1998 was performed. Types of training provided were assessed, and programs using experiential methods were identified.

RESULTS

Of 112 programs (84.2%) responding, 98% reported formal training in bioterrorism, increased from 53% (40/76) responding in 1998. In 2005, most programs with bioterrorism training (65%) used at least three methods of instruction, mostly lectures (95%) and disaster drills (80%). Fewer programs used experiential methods such as field exercises or bioterrorism-specific rotations (35% and 13%, respectively). Compared with other programs, residency programs with more complex, experiential methods were more likely to teach bioterrorism-related topics at least twice a year (83% vs. 59%; p = 0.018), to teach at least three topics (60% vs. 40%; p = 0.02), and to report funding for bioterrorism research and education (74% vs. 45%; p = 0.007). Experiential and nonexperiential programs were similar in program type (university or nonuniversity), length of program, number of residents, geographic location, and urban or rural setting.

CONCLUSIONS

Training of EM residents in bioterrorism preparedness has increased markedly since 1998. However, training is often of low intensity, relying mainly on nonexperiential instruction such as lectures. Although current recommendations are that training in bioterrorism include experiential learning experiences, the authors found the rate of these experiences to be low.

A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills

BACKGROUND

Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification. Traditional ACLS courses have limited ability to enable residents to achieve and maintain skills. Educational programs featuring reliable measurements and improved retention of skills would be useful for residency education.

METHOD

We developed a training program using a medical simulator, small-group teaching and deliberate practice. Residents received traditional ACLS education and subsequently participated in four two-hour educational sessions using the simulator. Resident performance in six simulated ACLS scenarios was assessed using a standardized checklist.

RESULTS

After the program, resident ACLS skill improved significantly. The cohort was followed prospectively for 14 months and the skills did not decay.

CONCLUSIONS

Use of a simulation-based educational program enabled us to achieve and maintain high levels of resident performance in simulated ACLS events. Given the limitations of traditional methods to train, assess and maintain competence, simulation technology can be a useful adjunct in high-quality ACLS education.

Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice

BACKGROUND

Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification.

OBJECTIVE

To use a medical simulator to assess postgraduate year 2 (PGY-2) residents' baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards.

DESIGN

Pretest-posttest design without control group. After baseline evaluation, residents received 4, 2-hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research-derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached.

PARTICIPANTS

Forty-one PGY-2 internal medicine residents in a university-affiliated program.

MEASUREMENTS

Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility.

RESULTS

Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly.

CONCLUSIONS

A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency-based efforts illustrate outcome-based medical education that is now prominent in accreditation reform of residency education.

Retention of CPR performance in anaesthetists

The objective of this study was to evaluate retention of ALS knowledge and performance among anaesthesiologists, who, in Italy, respond to in-hospital emergencies as team leaders.

METHODS

47 anaesthesiologists (23 consultants and 24 residents) were invited at one weeks notice to attend a re-evaluation session, 6 months after successful completion of an ERC ALS course. Knowledge retention was assessed by a multiple choice question test, and skills and management by evaluation of performance as team leader in one of the six standardized CAStest scenarios. During the performance, the timeliness of first defibrillation, completion of the three shock sequence, adrenaline (epinephrine) administration and intubation were recorded. Results were compared between consultants and residents.

RESULTS

Compared to the results at the end of the ALS course, the percent of correct answers to the multiple choice question test decreased from 85.89 +/- 5.28% to 79.45 +/- 6.62% (P < 0.001), the number of candidates achieving a pass performance decreased from 47/47 to 30/47 (P < 0.001). Time to first defibrillation was 73.38 +/- 18.72 s, time for completion of the third defibrillation was 113.04 +/- 35.58 s and subsequent ALS interventions were very delayed or forgotten. Comparison between consultants and residents showed that consultants retained knowledge information better, skills decreased comparably in both groups and residents performed tasks faster.

CONCLUSIONS

The significant decay of ALS skills 6 months post-ALS recorded among anaesthesiologists supports the need for periodical reinforcement during intervals before recertification.

Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial

BACKGROUND

Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification.

PURPOSE

The purpose was to use a medical simulator to assess baseline proficiency in ACLS and determine the impact of an intervention on skill development.

METHOD

This was a randomized trial with wait-list controls. After baseline evaluation in all residents, the intervention group received 4 education sessions using a medical simulator. All residents were then retested. After crossover, the wait-list group received the intervention, and residents were tested again. Performance was assessed by comparison to American Heart Association guidelines for treatment of ACLS conditions with interrater and internal consistency reliability estimates.

RESULTS

Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.

Enhancing the clinical skills of surgical residents through structured cancer education

OBJECTIVE

To assess the short and long-term educational value of a highly structured, interactive Breast Cancer Structured Clinical Instruction Module (BCSCIM).

SUMMARY BACKGROUND DATA

Cancer education for surgical residents is generally unstructured, particularly when compared with surgical curricula like the Advanced Trauma Life Support (ATLS) course.

METHODS

Forty-eight surgical residents were randomly assigned to 1 of 4 groups. Two of the groups received the BCSCIM and 2 served as controls. One of the BCSCIM groups and 1 of the control groups were administered an 11-problem Objective Structured Clinical Examination (OSCE) immediately after the workshop; the other 2 groups were tested with the same OSCE 8 months later. The course was an intensive multidisciplinary, multistation workshop where residents rotated in pairs from station to station interacting with expert faculty members and breast cancer patients.

RESULTS

Residents who took the BCSCIM outperformed the residents in the control groups for each of the 7 performance measures at both the immediate and 8-month test times (P < 0.01). Although the residents who took the BCSCIM had higher competence ratings than the residents in the control groups, there was a decline in the faculty ratings of resident competence from the immediate test to the 8-month test (P < 0.004).

CONCLUSIONS

This interactive patient-based workshop was associated with objective evidence of educational benefit as determined by a unique method of outcome assessment.

A model to enhance staff response in cardiopulmonary arrest

Dissatisfaction with doing a yearly written test to evaluate competency in the management of cardiopulmonary arrest led to our exploration of ways to change our processes at St. Joseph Regional Medical Center. Guided by our Mission, Vision, and Values, we strove to create a process that would deliver exceptional health care to our patients, while contributing to the personal and professional growth of our staff. Cardiopulmonary arrest is a low volume, high-risk occurrence, which is anxiety provoking for staff. Therefore, it is difficult for staff to feel comfortable and maintain competence in these situations. A process was implemented incorporating a hands-on approach to manage a simulated cardiopulmonary arrest on an annual basis for registered nurses (RNs) and assistive staff. The opportunity for hands-on practice and skill development has enhanced the confidence of RNs and assistive staff, affording them the ability to handle real emergencies.

Use of a computerized advanced cardiac life support simulator improves retention of advanced cardiac life support guidelines better than a textbook review

OBJECTIVE

To determine whether an advanced cardiac life support (ACLS) computer simulation program improves retention of ACLS guidelines more effectively than textbook review.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center.

PARTICIPANTS

Forty-five anesthesia residents and faculty tested 10 to 11 months after ACLS provider course training.

INTERVENTION

Participants were randomized and asked to prepare for a mock resuscitation (Mega Code) with either textbooks or a computerized ACLS simulation program.

MAIN OUTCOME MEASURE

Performance on a standardized Mega Code examination that required application of supraventricular tachycardia, ventricular fibrillation, and second-degree Type II atrioventricular block algorithms. Mega Code sessions were administered by an instructor who was blinded as to the subject group. The sessions were videotaped and scored by two evaluators who also were blinded as to the subject group.

RESULTS

Participants who used the ACLS simulation program scored significantly higher (mean 34.9 +/- 5.0 [SD] of 47 possible points) than participants who reviewed using a textbook (29.2 +/- 4.9); p < .001. Pass-fail rates for the algorithms were also higher for the group that reviewed with the simulator (mean 2.5 +/- 0.5 of 3 possible passes) than the group that used the textbook (1.6 +/- 1.0); p = .001.

CONCLUSIONS

Use of a computerized ACLS simulation program improves retention of ACLS guidelines better than textbook review.

An evaluative study of the basic life support skills of nurses in an independent hospital

This paper reports on a research study carried out in an independent hospital in the south east of England. The aim of the study was to assess the basic life support skills of nurses in order to compare the results with those reported for nurses in public hospitals. The findings show that the basic life support skills of the nurses studied are poor but no worse than those of their public sector colleagues.

Life support courses: are they effective?

STUDY OBJECTIVE

To determine the effectiveness of life support courses for health care providers on the basis of one of three outcomes: (1) patient mortality and morbidity, (2) retention of knowledge or skills, and (3) change in practice behavior.

METHODS

English-language articles from 1975 to 1992 were identified through MEDLINE and ERIC searches, bibliographies of articles, and current abstracts. Studies were considered relevant if they included a study population of life support providers, an intervention of any of the identified life support courses, and assessment of at least one of the three listed outcomes. Relevant studies were selected and validity scores were assigned to them by agreement of two independent reviewers, using a structured form to assess validity. Data on setting, methods, participants, intervention, and outcomes were then abstracted and verified.

RESULTS

Seventeen of 67 identified studies pertaining to life support courses met the inclusion criteria. (1) All three mortality and morbidity studies indicated a positive impact, with an overall odds ratio of.28 (95% confidence interval [Cl], .22 to .37). (2) No net increase in scores was found in 5 of 8 studies of retention of knowledge and in 8 of 9 studies of skills retention. Two of three studies reporting refresher activities yielded positive effects on knowledge retention. Outcomes were not significantly different between groups taught with modular or didactic techniques. (3) Studies assessing behavioral outcome were methodologically weak.

CONCLUSION

Among providers, retention of knowledge and skills acquired by participation in support courses is poor. However, refresher activities increase knowledge retention. Modular courses are as good as lectures for learning course material. There is evidence that use of the Advanced Trauma Life Support course has decreased mortality and morbidity. Further studies of patient outcome and provider behaviors are warranted.

Does standardized mega-code training improve the quality of pre-hospital advanced cardiac life support (ACLS)?

The aim of our prospective study was to evaluate the effects of a standardized mega-code and arrhythmia training upon process elements of quality of pre-hospital advanced cardiac life support provided by a physician-staffed mobile intensive care unit. In 145 cases of adult cardiac arrest due to cardiac aetiology, time intervals from arrival of the mobile intensive care unit at the patient's side until first ECG diagnosis, first defibrillation, endotracheal intubation, and first epinephrine administration were measured with on-line tape recording, prior to, and following a standardized 8-h arrhythmia and mega-code training. Following the training, patients with asystole or pulseless electrical activity were intubated 1.1 min earlier (P = 0.03), and received epinephrine 1.3 min earlier (P = 0.01) than prior to the training. There were no significant differences in time intervals concerning management of ventricular fibrillation or tachycardia. Neither admission nor discharge rates differed significantly before and after the training. Thus, practical training including rhythm analysis and mega-code session improved the performance of our mobile intensive care unit in cases of asystole and pulseless electrical activity, and, hence, process elements of quality.

Evaluation of advanced cardiac life support in a community teaching hospital by use of actual cardiac arrests

OBJECTIVE

To determine the retention of Advanced Cardiac Life Support training of internal medicine residents as a function of the time since successfully completing ACLS training.

DESIGN

Prospective, consecutive sample of patients who underwent a cardiopulmonary resuscitation effort directed by physicians who successfully completed ACLS.

SETTING

Eastern community teaching hospital.

PATIENTS

180 consecutive patients over the age of 18 years who sustained a cardiopulmonary arrest and whose resuscitation efforts were directed by physicians who successfully completed ACLS. Forty-five additional resuscitative efforts hospital wide were led by non-ACLS-trained physicians during the study period.

OUTCOME MEASURES

Correctness of the diagnosis of rhythms and treatment of the rhythms diagnosed were assessed, as per ACLS protocols in effect at the time of the study, in 1991.

INTERVENTION

None.

RESULTS

Chi-squares were used for analysis. Seventy-six of the resuscitative efforts were run by medical residents with a 13.2% error rate. The error rate in the first 6 months after ACLS completion among residents was 5.1%, as compared with 21.6% in the next 6 months (p = 0.033), with no impact on actual survival rate. During the study period, error rates among other groups were 8.8% in Emergency Department physicians and 17.8% among non-ACLS-trained physicians.

CONCLUSIONS

The error rate found was lower than in previous studies evaluating retention of ACLS education. It is important to have regular updates in ACLS to ensure proper protocol use.

An education model for otitis media care field-tested in Latin America

The World Health Organization has designated the teaching of otitis media management skills a "priority" status. Effective treatment of ear disease requires that the physician be both informationally educated as well as physically trained to use otoscopy. Little is known about how well this education can be provided in a short time and in a foreign country. To more objectively assess teaching effect, results of an education session for rural Mexican pediatric primary-care providers who were given an intensive otitis media lecture and otoscopy skills workshop in 1990 were evaluated. To test immediate cognitive impact, an anonymous written examination was given both before and after the teaching session. Average test scores after the educational sessions improved 24% (p < 0.001) over baseline scores before the sessions. To evaluate long-term impact on clinical practice, a follow-up telephone survey 2 years later was conducted. The use of an otoscope to diagnose otitis media had increased from 40% to 93% of respondents. We conclude that pediatric primary-care providers in rural Mexico possess a baseline level of knowledge about otitis media that can be significantly enhanced with one educational session. Further, this teaching effort produces an impact on practice pattern that lasts at least 2 years.

An evaluation of a short course in resuscitation training in a district general hospital

One hundred nurses underwent a short form of cardiopulmonary resuscitation training, comprising a short lecture and practical training. This significantly improved theoretical knowledge, but failed to achieve a uniformly high standard of practical skill. After initial training the subjects were divided into three groups. Group 1 underwent monthly refresher sessions, Group 2 a single refresher at 3 months and Group 3 no refresher training prior to re-testing of all subjects at 6 months. Knowledge and skills had declined in all three groups. Theoretical scores were better preserved in the groups having refresher training. Frequent refresher training failed to improve the poor initial performance in the practical skills. The time required to produce adequate training is greater than that which can be provided by clinical staff and necessitates the appointment of a resuscitation training officer.

Unique educational program in critical care medicine for the general internist

OBJECTIVE

To determine the effect of a unique educational program in critical care medicine on the attitudes, knowledge, and skills of general internists who care for critically ill patients.

DESIGN

Comparison of objective assessments and self-assessments obtained before and after the one-year educational program.

SETTING/PARTICIPANTS

Eighteen general internists practicing in a 350-bed university-affiliated community teaching hospital.

RESULTS

After the program, the internists felt significantly more competent in, knowledgeable about, comfortable with, and satisfied with caring for critically ill patients than they did when completing the precourse self-assessments (p < 0.05). Participants felt particularly more comfortable with managing ventilator patients and leading the advanced cardiac life-support team (p < 0.05). Comfort levels for other commonly performed critical care procedures did not vary. No significant change in knowledge test scores was noted from before to after the one-year program (61% vs 60%). Residents and nurses rated the internists' overall ability in critical care medicine to be the same as that of senior medical residents. They also favorably rated the internists on humanism, teaching skills, and interpersonal interactions. Residents also appreciated the decrease in their night call because of the program.

CONCLUSIONS

This unique educational program increased comfort and satisfaction of general internists caring for critically ill patients. The program was well accepted by residents and nurses because of favorable interaction with the internists and a decrease in resident night-call responsibility. This curriculum is recommended to other teaching hospitals.

Retention of advanced cardiopulmonary resuscitation knowledge by intensive care trained nurses

The teaching and reinforcing of advanced cardiopulmonary resuscitation (ACPR) is an important part of the role of an intensive care nurse manager. This study highlights the need for a structured training programme, as well as regular updates in ACPR. Current research shows poor retention of CPR skills amongst nursing staff. A small study was undertaken amongst intensive care trained nurses at The Middlesex Hospital intensive care unit (ICU). 18 nurses took part in the study, and were each interviewed with regard to their knowledge of ACPR in December 1990. The period of time since last trained in ACPR ranged from 2 months-4 years. Those who had been recently updated in ACPR (up to 4 months prior to interview) scored higher than those who were updated more than 2 years ago. The results showed that most nurses interviewed were only able to answer correctly half the questions asked. These results indicate that the nurses in the study generally demonstrated a severe lack of knowledge of ACPR. This indicates the need for a structured training package in ACPR, followed by frequent reinforcement of ACPR knowledge and skills for nurses practising in an ICU environment.

Educational aspects of cardiopulmonary resuscitation (CPR) training

The knowledge and skills surrounding the practice of cardiopulmonary resuscitation (CPR) have become essential to intensive care nurses and to nurses in general. With formalized training and refresher courses becoming more common in this country, it is evident that after relatively short periods of time the knowledge and skills acquired at such courses may be lost. While much consideration has been given to the content of both Basic and Advanced Cardiac Life Support (BCLS and ACLS) courses, relatively little attention has been paid to the educational issues surrounding CPR training. This paper explores some of these issues from the perspective of adult learning (andragogy). Research is cited from a wide range of sources to illustrate that CPR skill and knowledge deterioration is not unique to nursing, and that educational techniques exist which may improve current educational practices.

Medical student retention of intubation skills

Medical students are trained in airway management by endotracheal intubation in most medical schools. Unfortunately, little data exist examining retention, and no data exist that actually break down the steps of intubation to determine where students encounter problems. We studied 64 medical students trained to intubate as part of an American Heart Association advanced cardiac life support course and their performance two to three months after training. The rate of successful intubation (confirmed by visualization) was 70 +/- 12%. The most frequent errors during intubation were failure to check the light before intubation, use of the teeth as a fulcrum, and failure to check the cuff on the endotracheal tube. Knowledge of the most common errors will allow instructors to place greater emphasis on those areas during the initial instruction period with a focus on decreasing their occurrence in the future.

The basic and advanced cardiopulmonary resuscitation skills of trained hospital nursing staff

The cardiopulmonary resuscitation skills of 105 trained hospital nurses were tested. Both basic and, for the first time in the UK, advanced skills were examined; basic skills were assessed by practical evaluation with a standard manikin and advanced knowledge by multiple choice questionnaire. No nurse adequately performed all four practical skills tested. Knowledge of the ventilatory aspects of resuscitation, defibrillation and advanced technique and drug management were also found to be poor. The findings add further support to adequate training of nurses in resuscitation skills. We describe a solution to overcome the heavy demands of such teaching and suggest that the same model be applied to the training of medical staff in resuscitation skills.