Resuscitation education is an area that has remained virtually unchanged for decades and has relied heavily on classroom instruction in which content from organization-to-organization is inconsistent. It is difficult to teach critical skills in a classroom setting, like decision-making and problem solving in high stress environments. The pandemic has added other obstacles to the mix, including the need for change in education and intensifying the focus on care provider safety. With the latest improvements in technology and adult learning techniques, resuscitation training can be updated to improve patient survival rates, but it takes organizations who are willing to leave the past behind and embrace processes that are better suited to today’s reality.
Survival rates have improved only slightly over the years (Andersen et al., 2019), making it imperative and past time to rethink our approach to resuscitation. The good news is that it is easily within our grasp to modernize our tactics. Is your organization ready to strive
for significant improvement in its survival rates? The following is an overview of innovations incorporated in the American Red Cross Resuscitation Suite that can revolutionize resuscitation practices in your organization.
The Need for Adaptive Learning Offered 24/7
Dr. Eunice M. Singletary is an Emergency Medicine physician in Charlottesville, Virginia, a clinical professor in the emergency medicine department at the University of Virginia, and the co-chair for the Scientific Advisory Council of the American Red Cross. In a recent interview, Dr. Singletary commented on the importance of moving to adaptive learning for resuscitation training. Adaptive learning allows for content that can be tailored to the specific needs of the learner. She believes there is an opportunity to make courses more concise and targeted to the education the care provider really needs, thereby improving learning and providing the ability to move hospital staff from the classroom to the bedside.
“Resuscitation courses have grown in scope over the years, and there is a lot of material now that may not be relevant to me or other healthcare professionals. For example, I don’t need to know neuro-prognostication for someone who has been resuscitated from cardiac arrest and in an ICU for three or four days. I’m not going to be working in the ICU, nor am I an ICU critical care specialist. I’m an ER doctor who does not need a lot of this extraneous material, highlighting the fact that there is course content that may not be relevant based on the person’s level of training or work setting. A physician assistant, nurse, doctor, or dentist may not need the same course content and, likewise, a person working in a dental office may not need the same course content as a neonatal intensivist. A paramedic or ER doctor who is regularly involved in resuscitation of cardiac arrest may not need to spend time on a topic that they could teach to others.”
Dr. Singletary also commented on the benefits of being able to take resuscitation courses on her own time. “I want to learn what I need to know on my own time. I can tell you after working a 10- or 12-hour night shift, the last thing I want to do is go in after my shift and do an all-day or half-day recertification class when I am too tired to think about or learn new material.”
The good news is that courses are now available that allow healthcare professionals to train on the information they most need for BLS, ALS, and PALS. These educational sessions start with a thorough evaluation and if learners show they are already competent in an area, they are given the option of skipping that section. According to Dr. Singletary, “by taking a ‘bye,’ it allows you to focus your valuable time on the areas where you are feeling a little rusty or an area with content that you seldomly use (and therefore need to refresh); or perhaps you’re getting ready to change your practice setting from a pediatric clinic to the ER, so you want to brush up on topics that may be different.”
Realistic Training for Individuals and Teams
Adaptive learning and flexibility are only two of the improvements taking place in resuscitation training. Many other advancements are being introduced to help improve the training experience and increase survival rates. For one, the quality of training videos is improving. The old standard included comic book-like videos that presented good resuscitation practices. Today’s state-of-the-art training includes realistic videos that use actual doctors and nurses demonstrating proper resuscitation techniques and sequences. The scenarios mirror situations that caregivers are likely to encounter.
The breadth of the training is also increasing to include critical decision-making. The goal is not to have students rely on rote memorization of a flow sheet but instead use decision aids in critical moments, individual performance, and team dynamics in a resuscitation event. When a “code” is called, it is essential that individuals responding to the event have achieved competence in resuscitation and that everyone knows the role they are to play.
Online Training with Real-Time Manikin Feedback
Manikin technology is advancing swiftly as well. Current guidance from International Liaison Committee on Resuscitation (ILCOR) states that practice with high fidelity manikins improves resuscitation competence (Greif et al., 2020). The guidance also supports shorter bouts of training taken with greater frequency than the previously recommended cadence of every two years. Frequency increases are easily achieved with new smart manikins. Original versions were tethered to a computer and required the learner to look at a monitor to see such things as compression rate and depth. Today, the latest manikins are Bluetooth enabled, and therefore instead of having to look at a monitor, feedback is being delivered through LED lighting under the manikin’s skin, allowing the learner to keep their attention entirely focused on the “patient.” Manikins are also used in various body sizes ranging from newborns to adults.
Reducing Hospital-to-Hospital Variation
There is also an opportunity to improve resuscitation outcomes by reducing educational variation across hospitals. Research has shown that survival for in-hospital cardiac arrest varies threefold across hospitals, from 11% to 35% (Chan, 2016). What differences account for this variation? Comparison of practices of higher performing versus lower performing hospitals will likely shed light on what can be done to reduce this wide range in survival.
One factor contributing to the high variation in outcomes across hospitals is the inconsistency in training that is associated with classroom learning. Due to the COVID-19 pandemic, many healthcare organizations have begun to further question their reliance on in-person instructors. Research supports that some improvements can come with more automated instruction using high fidelity manikins. In one recent study, 90 CPR assessments were performed by 16 instructor pairs. The study found that instructors passed 81 learners (90%), whereas the manikin pass rate was 2%, highlighting that disparity between automated instructors and in-person instructors, specifically in the area of adequate chest compression depth. The study concluded, “Certified BLS instructors assess CPR skills poorly. Particularly, improper chest compression depth and rescue breaths are not identified” (Hansen et al., 2019).
Scientific Evidence Evaluation: The Cornerstone of Guideline Development
It isn’t just new technologies that are being applied to resuscitation training; the science behind resuscitation practices continues to grow, with new studies published daily. The American Red Cross uses the Scientific Advisory Committee to help evaluate the many scientific studies and reviews on all aspects of resuscitation science and education. This 50+ member group of resuscitation specialists, physicians, nurses, paramedics, educators, and researchers evaluate the most recent studies, guidelines, and recommendations from a large group of respected organizations. These include the International Liaison Committee on Resuscitation (ILCOR), the Surviving Sepsis Campaign, the American College of Surgeons, the American College of Emergency Physicians, the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, the Society of Critical Care Medicine, and several others. ILCOR works with international resuscitation specialists to evaluate and summarize the latest research and to create an international Consensus on Science with Treatment Recommendation (CoSTR) for adult, pediatric, and neonatal resuscitation. Because international recommendations do not always apply to the United States, ILCOR expects national resuscitation organizations like the Red Cross to develop educational programs and guidelines that are specific to their countries. The Red Cross Scientific Advisory Council reviews the work and recommendations by ILCOR and when creating guidelines, considers regulatory requirements, resources needed, the impact on health equity, feasibility, and several other considerations specific to practice in the United States. In addition to this work, the Red Cross guidelines address the broader etiologies of cardiac arrest and conditions requiring resuscitation, such as septic shock and drowning. The Red Cross does this by incorporating scientific reviews by the Red Cross Scientific Advisory Council, by ILCOR, and by other national professional organizations and guideline development groups.
Amending Your Hospital’s Policies, Staff Competency Criteria, and Credentialing and Privileging to Allow Innovations
The new innovations in resuscitation training are an exciting improvement, but to get to this point, organizations must first look to remove any potential barriers in the form of existing policies. Documents and policies that include decades-old requirements or language may need to be amended to even allow for more than one educational program. While it is increasingly common to see organizations accept resuscitation certification from more than one organization—for example, both the American Heart Association and the American Red Cross– there is often a certain amount of groundwork necessary to broaden policy acceptance for more flexible, versatile programs that allow less time spent in educational activities while still maintaining rigor and focus on competency. Today, multiple major health system and hospitals, along with the Military Training Network, have certifications issued by the American Red Cross. These certifications total more than 500,000.
Looking to the Future of Resuscitation
Dr. Singletary provided several insights on where resuscitation science is headed. She noted that, due to the pandemic, provider safety has become a key issue: “Because of COVID-19, we’re going to be looking at care provider safety in resuscitation in a completely different light. The safety of our healthcare professionals, front-line workers, educators, and students is critical. What we are learning now about infection transmission will have long term implications for future courses, training, and work practices. The good news is that these changes will also help lower the risk of transmission of other infections besides COVID-19 disease and help keep all of us healthier and better able to care for others.”
Moving forward, Dr. Singletary also sees more of a shift to focus on survival rates, especially with good neurological outcome rather than mortality rates from resuscitation. She sees a need to do more research to determine if some interventions are better than others and examine disparities in outcomes based on gender, race, etc. There are also various aspects of the resuscitation experience that need to be examined in more detail. An example is temperature management once someone is successfully resuscitated from cardiac arrest. What is the best way to cool someone with heatstroke? Is it better to use liquid submersion or a cooling blanket? Another area for research is the position of the body during resuscitation. Does the survival rate improve with a head up or torso up positioning vs. the traditional supine position? Does leg elevation help? Does providing additional rescue breaths following asphyxia and cardiac arrest, such as with drowning, improve survival? “CPR has been done in much the same way for so long,” says Singletary. “It’s time to do more research to test the impact of various interventions in different situations or settings.”
To that point, there is also more to be done to address different environments of care, specific patient populations and the diverse needs of why healthcare professionals take resuscitation education. The Red Cross is addressing these issues by including developing resuscitation education for specific populations such as pregnant females and neonates, by developing programs for those whose resuscitation education needs are based on providing sedation and by creating unique educational programs and tools focused on care for different environments such as operating rooms, out of hospital environments and clinics.
Improvements in resuscitation education are occurring in numerous ways— better methods, better technology, new science, and educational innovations, etc. Hundreds of health systems and hospitals are already adopting these new practices while at the same time offering more adaptive and efficient education, resulting in less time in the classroom and more time at the bedside. Is it time for your organization to rethink your resuscitation education and practices?
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