Resuscitation Training – The Future of ALS Courses in Australia

Mike Gale National Course Coordinator

Australian Resuscitation Council

Conflicts • ARC

• My views

• Clinical Role at Fiona

Stanley Hospital, WA

• Consultant for: • Laerdal RQI • iSimulate

• West Australian

GST donor

Proposed separation line

• ALS in Australia

• The ARC ALS Journey

• Possibilities for the future

Chain of survival

Traditional Focus

Increased Recognition

Generic ALS Course Format

• Pre-course preparation • Face to Face • Assessment

• Resource intensive

Faculty for 24 Candidate Instructor Course

Adult Education is regarded as a marginal activity stuck on to our education system somewhere between our leaving primary school and our going senile; we have to run it with meagre budgets, leftover facilities and other people’s spare time ... Though the situation is improving slightly all the time adult education has not achieved a recognised standing in this country. Hanna, I. (1965). ‘The adult student and languages’, Australian Journal of Adult Education, 5(2), 3–9.

Australian Courses

Area Specific • Unit/staff driven • Departmental

Hospital and Organisational Courses

State Courses •Department of Health •Private organisations

National Courses •ARC •Professional Colleges •Private organisations

Australian ALS Courses

• Majority are locally developed courses

- Includes imported adapted courses – AHA ACLS

• Significant variation between organisations in the content of the training and in assessment

One City Local ‘ALS’ Courses

• Organisation A • Developed by Nurse

Educator • 1 day duration • Lecture format only no

practical

• Organisation B • Developed by ED staff • Pre-reading printed and 1

day lectures/workshops • Medical staff only attend

second day

• Organisation C • Developed by ICU Nurse

Educator • 3 hour duration

• Organisation D • Developed by Education

unit • 10 workshops/lectures over

6-12 months

Local Courses

• Meet local needs

• Development appears to be cheap • Cross recognition/Credentialing

• “Well at the Royal….. we do it this way”

Challenge for National Courses

National Courses (pre 2010)

• Professional Healthcare Colleges

• Specialist National Courses – APLS/EMST

• One Australian Skills Quality Authority accredited course (expired May 2014)

National Courses

• Standard

• Credentialing

• One size fits all??

• Subject specific material written by national experts

https://crana.org.au/education/nationally-accredited-training/overview/

From a College ALS Manual

ARC ALS

• 2000’s • Course Endorsement process • Discussions to develop an ARC ALS course

• 2004-5 • Collaboration with RC(UK) • April 2005 – First ARC ALS Course

• 2006 • 2 courses for 28 candidates in WA/VIC

• 2015 • Courses in every state and territory

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1000

2000

3000

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2006 2007 2008 2009 2010 2011 2012 2013 2014

ALS Instructor Training

• Standards

• Results

• Candidate feedback

Current Courses

APLS/PLS ALS

EMST

Literature Review of Evidence

Future for ARC ALS

Ask the boss

Ideal World

• All Algorithms same

• Consistent approach

Trends In Adult Education

• Include stakeholder needs

• Real world experiences

• Current and relevant

• Multiple modality

Key Stakeholders

Community

Employers

Candidates Credentialing Authorities

Candidate Satisfaction

17 ALS Candidates interviewed ALS competence is taught well in ALS courses, but that the form and content of these highly structured/model courses are insufficient in training the innovative dimension of competence that is needed for transfer of skills in unstructured, emergency situations.

Candidate Satisfaction

Course Objectives need to be clear

Candidate Satisfaction

• Lectures

• Workshops

• Evidence Based Practice

• Additional ‘spaced’ learning and relearning – no longer one size

1

2

3

4

Standard 9

• Australia has no standardised training requirements for recognising and responding to clinical deterioration

• In adult patients admitted to hospital, there is insufficient evidence to support or refute the use of early warning/RRT/MET systems, compared with no such systems, to reduce cardiac and respiratory arrests and hospital mortality. However, it is reasonable for hospitals to provide a system of care that includes (a) staff education about the signs of patient deterioration; (b) appropriate and regular vital signs monitoring of patients; (c) clear guidance (eg, via calling criteria or early warning scores) to assist staff in the early detection of patient deterioration; (d) a clear, uniform system of calling for assistance; and (e) a clinical response to calls for assistance.

• There is insufficient evidence to identify the best methods for the delivery of these components and, based on current evidence, this should be based on local circumstances.

2010 Treatment Recommendation

Simulation Training

• High Fidelity • Costs • Low volume • Improved human

factors • Team based option • Complex infrastructure

to maintain

• Low Fidelity • Standard ALS

Approach • Loss of realism • Higher volume • Technical/Skill based • Team based option

• Simulation-based resuscitation training works, in the sense that it substantially improves outcomes in comparison with no intervention.

• Educational Outcomes

• No Direct Patient Outcomes

Training Frequency More is better – “practice makes perfect” but optimal frequency not known Evidence of rapid loss of skill quality

Training Frequency In-situ refresher – “Gorilla Sim” Low dose high frequency refreshers doubled retention • Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-

Hospital Pediatric Providers Sutton et al. Pediatrics. 2011;128:e145-e151

Consistent educational research evidence from outside of resuscitation, along with more recent literature in resuscitation, demonstrates improved learning from ‘spaced’ vs. ‘massed’ instruction and a learner preference for this format. ILCOR Draft Treatment Recommendation 2015 - EIT 633: Timing for advanced resuscitation retraining

New Technology

Skill/Technical Outcomes

Feedback devices for skills

Objective data measurement of skills ILCOR 2015 Draft Treatment Recommendations

• We recommend data-driven, performance-focused debriefing of rescuers following in-hospital/out-of-hospital cardiac arrest cardiac arrest in both adults and children

• We have placed a high value on the consistency and precision of the improvement in CPR quality and short term survival as the proximal endpoints of the educational intervention. We have placed a lesser value on the potential costs of implementation.

Remote/Multiple Modality Learning

• New Concept?? • Vinyl record • Audio tape • Open University • Radio/TV broadcast • Video tape • CD/DVD • WWW. (On-Line) • MOOC (massive open on-line course)

vs.

Dr Grey Mr Mac

• Substantial hands-on practice is needed to meet psychomotor skill performance objectives

• Key skills and course content should be repeated with deliberate practice that builds mastery

Education, Implementation, and Teams 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Bhanji et al. Circulation. 2010;122(suppl 3):S920-S933

e-ALS

• 3732 ALS candidates in UK/Australia • An ALS course supplemented with e-learning was

less expensive but had lower pass rates on cardiac arrest simulation tests than did conventional training. • Conventional 2 day course 80% pass practical test • e-ALS 75% pass for practical test

• Blended approach to ALS training that included e-learning reduced the duration and costs of face-to-face training by one half

• The blended and conventional approaches had similar outcomes for knowledge- and skill based domains

• CASTest in the e-ALS group …….. resulted in 1 additional participant who did not successfully complete the course for every 39 course participants

e-Learning

Interactive e-learning – not just replacing lectures

New Team Technology

• Technology • Cognitive • Potentially complex to alter

• Human • Psychomotor

- Technology bridging the gap

• Dynamic • Feedback/Debriefing • Ability to update

"Adult Education is an intervention into the ordinary business of life-----an intervention whose immediate goal is change, in knowledge or in competence. An adult educator is one, essentially, who is skilled at making such interventions.” From: Courtney, S. (1989). Handbook of Adult and Continuing Education. San Francisco: Jossey-Bass

Summary

• New technology is an adjunct to good education

• Blended approaches are cost effective

• Frequent skills practice