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Resuscitation training in low income countries

Question Type:
Intervention
Full Question:
Among students who are taking BLS or ALS courses in a resource limited educational setting (P), does does any educational approach
 (I), compared with compared with other approaches
 (C), change clinical outcome, skill performance in actual resuscitations, skill performance at 1 year, skill performance at time between course conclusion and 1 year, skill performance at course conclusion, cognitive knowledge (O)?
Consensus on Science:
For the critical outcomes of change in clinical outcome and skill performance in actual resuscitations and the important outcome of skill performance at 1 year, we found no evidence in low-resource settings. For the important outcome of skill performance at time of course conclusion and 1 year, we found very-low-quality evidence (downgraded for serious risk of bias, imprecision and possible publication bias) from 2 RCTs.(Delasobera 2010, 217; Meaney 2012, 1484) One study tested cognitive and skill retention 3 weeks after ALS refresher training in 3 arms, namely simulation (traditional course format) versus multimedia (computer-based learning) and self-directed reading.(Delasobera 2010, 217) In another study, students were tested at 3 and 6 months after training.(Meaney 2012, 1484) This study involved BLS training in a traditional course format versus limited instruction (larger student-to-instructor ratio) and self-directed computer-based learning. All modalities were shown to be equivocal or to have mixed but not constant benefit over traditional format. For the important outcome of skill performance at course conclusion, we identified 6 RCTs(Delasobera 2010, 217; Jain 2010, 773; Shavit 2010, 979; Li 2011, e549; Jenko 2012, 486; Meaney 2012, 1484) and 1 observational study.(Nilsson 2014, 517) Studies varied significantly in the subject taught from BLS to ALS, range of participants (paramedic students, medical students in various stages of training, nursing staff, general healthcare providers), duration of course, and training methods. Educational strategies included traditional course format versus computer-based learning, telemedicine, self-directed reading, limited instruction (larger student-to-instructor ratio), 4-stage skill teaching, video instruction, and video-based group feedback. Studies ranged from very-low-quality evidence(Delasobera 2010, 217) (downgraded for serious risk of bias and imprecision) to moderate-quality evidence(Jain 2010, 773; Shavit 2010, 979; Li 2011, e549; Jenko 2012, 486) (downgraded for imprecision). Because the outcome of skill performance in all 7 studies(Delasobera 2010, 217; Jain 2010, 773; Shavit 2010, 979; Li 2011, e549; Jenko 2012, 486; Meaney 2012, 1484; Nilsson 2014, 517) demonstrated equivocal or minimal benefit in skill performance compared with traditional course format, we suggest the possibility of using other training methods for teaching BLS or ALS. However, the heterogeneity of the studies makes it is unclear what this alternative method might be (weak recommendation, low-quality evidence). For the important outcome of cognitive knowledge, we identified 4 RCTs: 2 were of very low quality (downgraded for serious risk of bias, imprecision, and possible publication bias),(Delasobera 2010, 217; Meaney 2012, 1484) 1 was of low quality (downgraded for risk of bias and imprecision),(Li 2011, e549) and 1 was of moderate quality (downgraded for imprecision).(Jain 2010, 773) These studies differed in the teaching methods used to compare cognitive outcome, including simulation (traditional course format), multimedia (computer-based learning), self-directed reading, limited instruction (larger student-to-instructor ratio), and self-directed computer-based learning. In comparing traditional course format to alternative teaching strategies for BLS or ALS training, there were some studies showing slight cognitive knowledge benefit of various teaching strategies, but no constant benefit over the traditional method, and no studies could be pooled together to strengthen a recommendation or quality of evidence. All of the RCTs included few participants. Therefore, we suggest the possibility of using alternative educational strategies (weak recommendation, low-quality evidence).
Treatment Recommendation:
We suggest that alternative instructional strategies would be reasonable for BLS or ALS teaching in low-income countries (weak recommendation, very-low-quality evidence). The optimal strategy has yet to be determined. Values, Preferences, and Task Force InsightsIn making this recommendation, we consider that cost of and access to training may play a large role in the ability of healthcare workers to receive training in BLS and ALS in low-income countries. Some of the alternative techniques for BLS or ALS teaching identified in this review may be less expensive and require less instructor resource than a traditional teaching format, and may enable wider dissemination of BLS and ALS training in low-income countries.The heterogeneity of the content taught (eg, BLS versus ALS), the learner populations, and the different instructional methods studied in resource-limited settings were challenging to summarize as a single systematic review. As the body of evidence develops, this PICO question may benefit from subdivision across content taught, learner populations, and instructional methods.
CoSTR Attachments:
CoS_n.docx    
EIT 634_Resuscitation training in low income countries_list of included studies_n.docx    
EIT 634_Resuscitation training in low income countries-characteristics of included studies_n.docx    
Grade recomm table_edited 3_n.docx    
Grade tables combined_n.docx    

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