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Timing for advanced resuscitation retraining

Question Type:
Full Question:
Among students who are taking advanced life support courses in an educational setting (P), does any specific interval for update or retraining (I), compared with standard pracitice (ie. 12 or 24 monthly) (C), change improve patient outcomes, skill performance in actual resuscitations, skill performance at 1 year, skill performance at course conclusion, cognitive knowledge (O)?
Consensus on Science:
For the important outcome heading of skill performance at 1 year, there were 4 studies(Stross 1983, 3339; Jensen 2009, 903; Bender 2014, 664; Kurosawa 2014, 610) using a variety refresher techniques and unique outcome measures. The refreshers included a simulation-enhanced booster 7 to 9 months after the course, a commercially available eLearning tool used monthly, mail-outs of information related to course objectives or a patient management problem every 3 months, or in situ monthly simulation for 6 months. The outcome measures respectively used in the 4 studies were a validated procedural skills and teamwork behavior assessment tool; a previously validated composite score of a written test and cardiac arrest simulation test (CASTest); mock arrest, compression, and ventilation performance with no evidence provided of validity/reliability of the tools; and the change in score on the previously validated Clinical Performance Tool (CPT) and Behavioral Assessment Tool (BAT). One study used simulation boosters and demonstrated benefit from the refresher in procedural skills and teamwork behavior scores (very-low-quality evidence, downgraded for indirectness and imprecision).(Bender 2014, 664) The studies that used periodic eLearning and mailings (very-low-quality evidence, downgraded for indirectness and imprecision) demonstrated no benefit from the refreshers except in the performance on mock arrests. Only 1 of the studies related directly to the research question comparing frequent refreshers to standard retraining intervals, using manikin-based simulation(Kurosawa 2014, 610); this study documented better scores on the CPT and equivalent outcomes for the BAT while using less total time of retraining: 4.5 versus 7.5 hours (low-quality evidence, downgraded for imprecision). For the important outcome of skill performance beyond course completion and before 1 year, there was 1 study that compared a single refresher using video and self-guided practice or a single 2-hour hands-on session with no retraining(Kaczorowski 1998, 705); it showed no benefit for the refresher (very-low-quality evidence, downgraded for serious bias, indirectness and imprecision). For the important outcome of knowledge, there were 4 studies using a variety of refresher techniques, such as simulation-enhanced booster, video and self-guided practice, knowledge examination, and mock resuscitation training or mail-outs as described above. The assessment tools varied from those with no reported validity/reliability evidence to well-described psychometrics in 1 study. There was no benefit of refresher training (very-low-quality evidence, downgraded for serious bias, indirectness, and imprecision).
Treatment Recommendation:
Compared with standard retraining intervals of 12 to 24 months, we suggest that more frequent manikin-based refresher training for students of ALS courses may be better to maintain competence (weak recommendation, very-low-quality evidence). The optimal frequency and duration of this retraining is yet to be determined. Values, Preferences, and Task Force Insights In making this recommendation, we consider the rapid decay in skills after standard ALS training to be of concern for patient care. Refresher training, in the form of frequent low-dose in situ training using manikins, offers promise.(Kurosawa 2014, 610) The potential cost savings of integrating these sessions into daily workflow rather than removing staff for standard refresher training may be important, as might a reduced total time of retraining. More recent literature in resuscitation demonstrates improved learning from “frequent, low-dose” compared with “comprehensive, all-at-once” instruction and a learner preference for this format.(Patocka 2015, 6) Ultimately, the question to be asked is, how frequently should training be delivered? As yet, there is no definitive answer to this question because it is dependent on the type of training. For example, it has been shown in another systematic review (EIT 623) that the use of different types of manikins can lead to improved outcomes in the short term. However, there is a paucity of published literature, so there was no consensus within the task force about an overall specified time interval.
CoSTR Attachments:
Copy of EIT_633_ILCOR_Data_Collection_Form.xls    
Grade Recommendation ALS retraining v1.doc    
Summary of Findings_ALS retraining intervals v4.doc    

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