ReviewA systematic review of retention of adult advanced life support knowledge and skills in healthcare providers☆,☆☆
Introduction
Maximizing outcomes from cardiac arrest requires healthcare providers to acquire and retain the knowledge and skills associated with advanced life support.1 Furthermore, the providers must be able to translate the knowledge and skills into practice and provide high-quality resuscitation when needed in actual situations. In response to this need, the advanced life support (ALS) guidelines were first published in 1974 by the American Heart Association (AHA)2 and have had six subsequent revisions. The most recent AHA and European Resuscitation Council (ERC) ALS guidelines were based on the 2010 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTR).1, 3, 4 These guidelines have been regarded as a “gold standard” for the treatment of cardiac arrest and other life threatening medical emergencies.
The 2010 ILCOR CoSTR includes a new chapter on education and implementation, emphasizing the importance of provider education in optimizing the chain of survival and delivery of high-quality resuscitation and post-cardiac arrest care.4 Significant effort and financial resources have been expended worldwide to train healthcare providers in standardized ALS courses.5 Yet despite rigorous knowledge and skills training and initial demonstration of competence, poor quality resuscitation is commonly observed in actual cardiac arrests.6, 7, 8 Decay of acquired skills over time in many settings has been documented in the educational literature.9, 10 Cardio-pulmonary resuscitation (CPR) knowledge and skills have also been shown to decay in both healthcare providers and lay rescuers.11, 12, 13, 14 It is unclear if ALS knowledge and skills show similar patterns of decay, and whether the rigorous and intensive training in ALS courses slows the decay of knowledge and skills.
Resuscitation Councils worldwide traditionally recommend that healthcare providers receive ALS retraining or refresher courses every 2 years or longer.15, 16, 17 However, the choice of a specific interval for refresher training was somewhat arbitrary and it is not clear whether trained providers can maintain an adequate level of knowledge and skills appropriate for patient care throughout the interval. On the other hand, more frequent updates with hands-on practice increase the burden on trainees and instructors at a time when resources and time for training of healthcare professionals are limited.18 In this systematic review we analyzed the current evidence for learning retention of adult ALS knowledge and skills in healthcare providers and the implications of the evidence in terms of optimal refresher intervals and strategies for retraining.
Section snippets
Search strategies
We based our search strategy and review on the ILCOR evidence evaluation process.19, 20 We identified studies published between 1974 and 2011 for review that addressed the question “What is the retention time of adult ALS knowledge and skills in healthcare providers after initial training?”. We searched Medline (OvidSP), CINAHL (EBSCOhost), Cochrane Library, and PubMed databases using the keywords “advanced life support”, “education”, “learn”, “memory”, “retention”, “interval” and “skill
Results
Our initial database search produced 336 citations. After removing the duplications, and following a screening review of the titles and abstracts, we identified 17 original articles published in peer-reviewed journals that appeared relevant to our topic. Of these, 9 studies were ultimately excluded because they addressed training courses other than adult ALS or used modified teaching modalities. Three articles not initially found by the database search were identified and included after review
Discussion
The literature demonstrates that ALS knowledge and skills of healthcare providers decline before the traditionally recommended 2-year (or even longer) ALS retraining interval. This decline appears to occur, on average, between 6 months and 1 year after ALS training and may occur sooner. The evidence for decay of knowledge and skills between 6 weeks and 6 months of training remains less certain and requires further study. Perhaps not surprisingly, skills appear to deteriorate more rapidly than
Conclusions
There is a lack of large well-designed studies that examined the retention of adult ALS knowledge and skills in healthcare providers. The available studies suggest that ALS knowledge and skills decay between 6 months and 1 year after ALS training, and skills decay faster than knowledge. Clinical experience, either prior to or after the courses, may slow this decay process. Many issues such as determining the acceptable or clinically meaningful level of ALS knowledge and skills for providers,
Conflict of interest statement
Several authors served as co-chairs (MEM, JS), worksheet authors (JEM, MHMM), and worksheet collaborators (CWY, ZSY) on the working group to develop the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations Part 12: Education, Implementation, and Teams.
Acknowledgment
This work was partially supported by National Science Council, Taiwan (NSC97-2511-S-002-006 and NSC99-2511-S-002-010).
References (43)
- et al.
European Resuscitation Council Guidelines for Resuscitation 2010. Section 9. Principles of education in resuscitation
Resuscitation
(2010) - et al.
Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30-minute video training: a controlled randomized study
Resuscitation
(2007) - et al.
Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students
Resuscitation
(2006) - et al.
Education in adult advanced cardiac life support training programs: changing the paradigm
Ann Emerg Med
(1993) Evidence evaluation worksheets: the systematic reviews for the evidence evaluation process for the 2010 International Consensus on Resuscitation Science
Resuscitation
(2009)- et al.
The significance of clinical experience on learning outcome from resuscitation training – a randomised controlled study
Resuscitation
(2009) - et al.
Advanced cardiac life support courses: live actors do not improve training results compared with conventional manikins
Resuscitation
(2008) - et al.
Evaluation of staff's retention of ACLS and BLS skills
Resuscitation
(2008) - et al.
Retention of CPR performance in anaesthetists
Resuscitation
(2006) - et al.
Advanced life support: retention of registered nurses’ knowledge 18 months after initial training
Aust Crit Care
(2000)
Evaluation of advanced life support in a community hospital by use of actual cardiac arrests
Heart Lung
Written evaluation is not a predictor for skills performance in an Advanced Cardiovascular Life Support course
Resuscitation
Validation for a scoring system of the ALS cardiac arrest simulation test (CASTest)
Resuscitation
Knowledge and skill retention of emergency care attendants, EMT-A's and EMT-P's
Ann Emerg Med
Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Circulation
“The ABCs of CPR – again”
Am J Nurs
Part 12: education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations
Resuscitation
Improving survival from sudden cardiac arrest: the chain of survival concept
Circulation
Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest
JAMA
Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest
JAMA
Resuscitation skills of first year postgraduate doctors
N Z Med J
Cited by (0)
- ☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2012.02.027.
- ☆☆
This review project grew out of work that several authors initially completed for the ILCOR Task Forces working through the C2010 Consensus on Science and Treatment Recommendations process. Authors JEM and MHMM were individually assigned to complete a detailed structured review of the literature and complete a detailed worksheet on the research question relating to ALS knowledge and skills retention. Their worksheets were reviewed and discussed at ILCOR meetings to reach consensus and guidelines were published in 2010 as the Consensus on Science and Treatment Recommendations (CoSTR).4 The conclusions and recommendations published in the final CoSTR consensus document may differ from the discussion points and conclusions in this review since the CoSTR consensus reflects input from other working group members and discussants at the conference, and takes into consideration implementation and feasibility issues.