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Resuscitation Training Frequency

Question Type:
Intervention
Full Question:
For course participants including (a) trainees and (b) practitioners  (P), does frequent training  (I), compared with to less frequent training (annual or biennial)  (C), change improve all levels of education or practice, clinical outcome (O)?
Consensus on Science:
Sixteen studies were identified that have investigated this PICO question. Ten randomized controlled studies (Stross 1983, 3339; Berden 1993, 1576; Kaczorowski 1998, 705; Kovacs 2000, 301; Su 2000, 779; Oermann 2011, 447; Sutton 2011, e116; Turner 2011, 731; Montgomery 2012, 1548-1923X; Ernst 2014, 505) and 6 nonrandomized controlled trials(O'Donnell 1993, 193; Nadel 2000, 1049; Lubin 2009, 195; Niles 2009, 909; Nishisaki 2010, 214; Mosley 2013, 582) were identified for inclusion. The evidence for frequency of resuscitation training is very low quality (downgraded for high risk of bias, inconsistency, and imprecision), with the exception of studies of psychomotor performance, which are of moderate quality (downgraded for risk of bias). Meta-analyses were greatly limited by the heterogeneity between studies of training frequency, educational interventions, and outcomes. For the critical outcome of patient outcomes, 2 studies (Lubin 2009, 195; Nishisaki 2010, 214) of very low quality (downgraded for high risk of bias, inconsistency, and imprecision) looked at endotracheal intubation success. Both studies included psychomotor skill training on an airway simulator, and Nishisaki (Nishisaki 2010, 214) included simulation-based training. There was no significant difference in first-time intubation success (RR, 0.879; 95% CI, 0.58–1.33) or any intubation success (RR, 0.87; 95% CI, 0.65–1.17) between the providers who were exposed to frequent training and controls. For the important outcome of prevention of adverse events, the Nishisaki study also included the important outcome of prevention of adverse outcomes and airway injury as a secondary outcome. No significant difference was seen between groups (RR, 1.097; 95% CI, 0.747–1.612). (Nishisaki 2010, 214) For the important outcome of performance in simulation, 3 studies (Stross 1983, 3339; Kovacs 2000, 301; Nadel 2000, 1049) of very low quality (downgraded for high risk of bias, inconsistency, and imprecision) investigated the important outcome of performance in simulated scenarios using both validated and nonvalidated evaluations. In all studies, subjects in the intervention groups trained more frequently than controls. The range of time between initial course completion and first additional training session was 1 to 4 months. The educational interventions were heterogeneous, including independent and facilitated practice on airway simulators,(Kovacs 2000, 301) didactic lectures, skill station practice, mock codes, (Nadel 2000, 1049) and periodic review of course material and case-based study. (Stross 1983, 3339) Kovacs(Kovacs 2000, 301) and Stross (Stross 1983, 3339) found no significant difference between frequent and infrequent practice with respect to simulation-based performance. Only 1 of these studies (Nadel (Nadel 2000, 1049)) offered quantitative data: After averaging of multiple outcomes, there was a trend to improved performance in those exposed to increased frequency of training compared with controls (RR, 1.51; 95% CI, 0.971–2.35). For the important outcome of psychomotor performance, there were 8 studies (Stross 1983, 3339; Berden 1993, 1576; O'Donnell 1993, 193; Nadel 2000, 1049-1054; Niles 2009, 909; Oermann 2011, 447; Sutton 2011, e116; Ernst 2014, 505) of moderate quality (downgraded for risk of bias) that evaluated the important outcome of impact of frequent training on psychomotor performance, demonstrated on a task trainer or simulator. With the exception of O’Donnell (O'Donnell 1993, 193) and Stross (Stross 1983, 3339-3341) (which were neutral to the question), studies demonstrated improvements in psychomotor performance with no negative effect. The range of time between course completion and first additional training session was 1 week to 6 months. The educational interventions were again heterogeneous. Psychomotor task trainers were used to achieve competency in a specific technical skill, including practice on a chest compression task trainer (Niles (Niles 2009, 909)), neonatal airway management task trainer (Ernst (Ernst 2014, 505)), or a CPR task trainer where both chest compressions and ventilation were emphasized. (Berden 1993, 1576; O'Donnell 1993, 193; Oermann 2011, 447) The study by Stross (Stross 1983, 3339) included periodic review of course material and case-based study. (Stross 1983, 3339) The educational intervention in the Nadel (Nadel 2000, 1049) study used didactic lectures, skill station practice, and mock codes. Although 8 studies were identified, only 1 randomized (Nadel 2000, 1049) and 2 observational studies (Stross 1983, 3339; O'Donnell 1993, 193) with dichotomous quantitative data were included in the analysis. The 1 randomized study (Nadel 2000, 1049) demonstrated a significant improvement in psychomotor skills in subjects in the intervention group when compared with controls. One randomized study (Oermann 2011, 447) with multiple outcomes showed significantly improved performance of the important outcomes of manual ventilation volume and chest compression depth after practice every 3 months. However, an improvement in psychomotor skills in the intervention groups was not seen when 3 studies (Stross 1983, 3339; O'Donnell 1993, 193; Nadel 2000, 1049) were included in a meta-analysis after averaging of scores (RR, 1.38; 95% CI, 0.87–2.2). For the important outcome of knowledge, 5 studies (O'Donnell 1993, 193; Kaczorowski 1998, 705; Nadel 2000, 1049; Su 2000, 779; Turner 2011, 731) of very low quality (downgraded for high risk of bias, inconsistency, and imprecision) investigated the relationship between frequent training and the important outcome of acquisition of medical knowledge assessed by written tests or oral exams. Studies by Nadel, (Nadel 2000, 1049) O’Donnell,260 and Turner254 demonstrated sustained knowledge with refreshers when compared with controls, whereas Kaczorowski (Kaczorowski 1998, 705) and Su252 were neutral to the question. The educational interventions for these studies have been described previously except for 2 studies: Su used a knowledge exam and mock resuscitation at 6 months, and the Kaczorowski (Kaczorowski 1998, 705) study included subjects in the intervention groups either watching a newborn resuscitation education video or hands-on practice. The range of time between course completion and first additional training session was 1 to 6 months. Although 5 studies were identified, only 2 had quantitative data.(Nadel 2000, 1049; Turner 2011, 731) The analysis of the 2 observational studies was not possible because it was difficult to average the means ± SDs and then pool the 2 studies for a meta-analysis. The Nadel (Nadel 2000, 1049) study found a significant improvement in knowledge with more frequent training in a short answer test (mean scores 73±11 versus 60±10; P=0.0003). The Turner254 study showed significant improvement in 2 out of 3 test scores in the intervention group (mean scores 7.1 versus 6.2 and 29.0 versus 25.8, respectively; P
Treatment Recommendation:
We suggest that training should be recurrent and considered more frequently than once per year. This retraining may be composed of specific tasks and/or behavioral skills, depending on the needs of the trainees (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In drawing our conclusions, we place value on improved psychomotor skills, knowledge, and provider confidence during more-frequent training versus less-frequent training (and versus the established and unproven practice of training every 1 to 2 years). The debate included the fact that the PICO question does not specify that it is resuscitation training, although the search did restrict itself to this. Should the costs of training be addressed? However, it was noted that it was hard to comment on cost based on studies, because the interventions themselves were so different. Could the follow-up programs be briefer and more focused on needs? What is best for the patient? What is the cost to the child and family when the patient does not receive adequate resuscitation? What is a technical proficiency program? How do we achieve it? There is no assessment of translation of increased training to improved outcomes. We need data to show that improved education is worth the staff time. The PICO question specifically avoided looking at studies about decay of knowledge and skills.
CoSTR Attachments:
Evidence+review+summary+v1a (2).pdf    

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