What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20

Figures & data

Table

Practice points

Ensure all staff in a healthcare organisation attends an SRT programme pertaining to their speciality. Ensure that any reassessment of staff clinical practice skills takes place in an authentic, as well as a simulated, clinical learning context. Assess staff for competency in resuscitation skills three to six months after the SRT. Provide regular booster or refresher sessions three to six months after the SRT.

Box 1. Possible levels of outcome of articles (Modified from Kirkpatrick, 1994)

The Kirkpatrick system below was modified from Kirkpatrick's 1994 model of outcomes at four levels. Articles were allocated a Kirkpatrick level according to the outcomes described – some articles described outcomes relating to more than one level in which case they were included in the analysis for each outcome level.

Kirkpatrick Level 1 Reaction to learning experience

Evidence of learners’ views on the overall learning experience and its inter-professional nature including the training programme, rather than any specific learning outcomes.

Kirkpatrick Level 2a Modification of attitudes and perceptions

Evidence of documented changes in reciprocal attitudes or perceptions between participant groups and possible changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group.

Kirkpatrick Level 2b Acquisition of knowledge and skills

Evidence of knowledge and skills acquisition immediately following completion of a SRT.

Kirpatrick Level 2c

Evidence of the retention of knowledge and/or skills over a period of time after the SRT.

Kirkpatrick Level 3 Behavioural change

Evidence of transfer of learning to clinical practice.

Kirkpatrick Level 4a Change in organisational practice

Evidence of changes within the organisational practice and delivery of care after the SRT.

Kirkpatrick Level 4b Benefits to patients/clients, families and communities

Evidence of documented impacts in the health or well being of patients/clients, families and communities after the SRT.

Figure 1. Flow chart of the process for final inclusion of papers in the review.

Table

Criteria		Yes (2/good)	Partial (1/fair)	No (0/poor)	N/A
Study aims
1.	Is the hypothesis/aim/objective of the study clearly & sufficiently described?	Easily identified in introduction/method. Specifies: purpose, subjects/target population, and specific interventions/associations under investigation.	Vague/incomplete reporting or some info has to be gathered from parts of the paper other than intro/background/objective section.	Question or objective not reported/incomprehensible.
Study design & sample characteristics
2.	Is the study design well described and appropriate?(If study question not given, infer from conclusions).	Design easily identified, well described and appropriate.	Design and/or study question not clearly described, or design only partially addresses study question.	Design does not answer study question or design is poorly described.
3.	Is the method of intervention group selection described and appropriate?	Described and appropriate.	Selection methods not completely described, but no obvious inappropriateness. Or selection strategy likely introduces bias but not enough to seriously distort results.	No information/inappropriate information provided or selection bias, which likely distorts results.
4.	Are the characteristics of intervention group clearly described (i.e. age range, occupation)?	Sufficient relevant demographic information. Reproducible criteria used to categorise participants clearly defined.	Poorly defined criteria or incomplete demographic information.	No baseline/demographic info provided.
5.	Have the characteristics of participants lost to follow-up been described?	Losses adequately reported & not likely to affect results.	Losses not well reported, but small & not likely to affect results.	No information or losses large and likely to affect results.	No participants lost to follow-up.
6.	Are educational intervention(s) clearly described?	Defined and reproducible.	Partially defined, but insufficient detail to reproduce design.	Not described.
7.	Is method of delivery of educational intervention and subsequent follow-up clearly defined?	Sufficient relevant descriptive information. Reproducible criteria used to replicate intervention defined.	Poorly defined criteria or incomplete descriptive information.	No criteria/descriptive info provided.
Data analysis and results
8.	Are the main outcomes to be measured clearly described in the introduction/method?	Defined and measured according to reproducible criteria.	Definition leaves room for subjectivity, or not sure (i.e. not reported in detail, but probably acceptable). Or precise definition(s) are missing, but no evidence of major problems. Or instrument/mode of assessment(s) not reported.	Main outcomes first mentioned in results section. Or measures not defined/inconsistent/poorly defined.
9.	If possible, was an attempt made to blind those measuring the main outcomes of the intervention?	Assessor blind to intervention/study group.	Inadequate blinding: i.e. assessor may have been aware of group participant assigned to.	No attempt made to blind assessor.	Not possible/appropriate – e.g. observational/before & after study.
10.	Are population characteristics (if measured & described) controlled for and adequately described?	Appropriate control at design/analysis stage or randomised study with comparable baseline characteristics.	Incomplete control/description. Or not considered but unlikely to seriously influence results.	Not controlled for and likely to seriously influence results.
11.	Are the outcomes chosen to evaluate the intervention appropriate?	Appropriate outcomes selected and reported.	Some outcomes not relevant to assessing appropriateness of intervention.	Outcome measures do not evaluate intervention or poorly reported/not defined/inconsistent.
12.	Are the main findings clearly described?	Simple outcome data (e.g. mean/prevalence) reported for all major findings.	Incomplete or inappropriate descriptive statistics.	No/inadequate descriptive statistics.
13.	Are methods of analysis adequately described and appropriate?	Described and appropriate.	Not reported but probably appropriate or some tests appropriate, some not.	Methods not described and cannot be determined.
14.	Are estimates of variance reported for the main results?	Appropriate estimates provided (SD/SE, confidence intervals).	Undefined or estimates provided for some but not all outcomes.	No information.
15.	In trials/cohort studies, do analyses adjust for different lengths of follow-up, or in case-control studies, is the time between intervention and outcome the same for cases/controls?	Different lengths of follow-up adjusted for (e.g. survival analysis) and adequately described.	Different lengths of follow-up probably adjusted for but not adequately described.	Differences in follow-up ignored.	Cross-sectional design or same length of follow-up.
Conclusions
16.	Are the conclusions supported by the results?	All conclusions supported by data.	Some of the major conclusions are supported by the data; some are not. Or speculative interpretations are not indicated as such.	None/few of major conclusions supported by the data.

Table A1.  Kirkpatrick 2A and 2B neonates

Author	Accredited training programme	Nature of the training	Tested knowledge at the end of the training	How was knowledge tested	Knowledge significantly improved at the end of the training	Tested skills at the end of the training	How were skills tested	Skills significantly improved at the end of the training	Confidence assessed (if so how)	Significant improvement in confidence at the end of the training
Cavaleiro et al. 2009	No	50 min Lecture then self study or Simulation (RCT)	Yes – after lecture and again after self study/simulation	MCQ	Yes after lecture (p < 0.0001) No after self study/simulation	No	N/A	N/A	No	N/A
Ergenekon et al. 2000	No	8 hours Lectures simulation	Yes	MCQ	Yes (mean score precourse 9.5 vs. post course 14.2) (p = 0.001)	No	N/A	N/A	Yes, assessed in evaluation form at the end of the course	72% felt more confident at the end
Trevisanuto et al. 2005	Yes NRP	2 courses 2 day Lectures Simulation	Yes	MCQ	Yes Both courses (52% to 85% and 64% to 94%) p ≤ 0.01	No	N/A	N/A	No	N/A

Notes: MCQ- multiple choice questionnaire, NRP- Neonatal Resuscitation Programme, N/A – Not applicable, RCT – randomised controlled trial.

Table A2.  Kirkpatrick 2A and 2B paediatrics

Author	Accredited training programme	Nature of the training	Tested knowledge at the end of the training	How was knowledge tested	Knowledge significantly improved at the end of the training	Tested skills at the end of the training	How were skills tested	Skills significantly improved at the end of the training	Confidence tested at the end of the training (if so how)	Significant improvement in confidence at the end of the training
Dobson et al. 2003	No	Six hours lectures simulation	No	Not tested	Not tested	No	Not tested	Not tested	Yes – Likert scale	Yes in all 13 areas tested (p ≤ 0.002)
Donoghue et al. 2009	No	Simulation – Hi fidelity vs low (RCT)	No	Not tested	Not tested	Yes	Simulation with two different manikins	Both groups improved scores but P value not stated (High fidelity group improved more than low fidelity) (P= 0.007)	No	N/A
Gerard et al. 2006	Yes PALS	Web based course vs traditional PALS	Yes	MCQ	Not stated	Yes	Video of performance	Not stated	Yes	Scores improved from 3.77 to 4.28 in one group and 3.57 to 4.24 in other group (p value not stated but 95% confidence intervals indicate significant)
Quan et al. 2001	Yes PALS	Two days Not stated	Yes	Written case scenarios	No	Yes	Video simulation	Yes P=<0.05 and <0.01 depending upon skill	Yes questionnaire	Mean confidence score increased from 1.9 to 6.2 (p value not stated but 95% confidence intervals indicate significant)
Waisman et al. 2002	Yes PALS	Not stated	Yes	MCQ	Yes – proportion passing exam increased from 62% to 84% (p ≤ 0.001)	No	N/A	N/A	No	N/A

Notes: MCQ – multiple choice questionnaires, PALS- Paediatric Advanced Life Support, RCT – randomised controlled trial.

Table A3.  Kirkpatrick 2A and 2B adults

Author	Accredited training programme	Nature of the training	Tested knowledge at the end of the training	How was knowledge tested	Knowledge significantly improved at the end of the training	Tested skills at the end of the training	How were skills tested	Skills significantly improved at the end of the training	Confidence tested at the end of the training (if so how)	Significant improvement in confidence at the end of the training
Aboutanos et al. 2007	No	Lectures simulation	Yes	MCQ	Score increased from 72% to 79% (p = 0.032)	Yes	OSCE	Not known – no precourse score	No	N/A
Ali et al. 1995	Yes ATLS	Not stated (RCT of course vs not course)	Yes	MCQ	Improved compared with control group (p < 0.01)	Yes	OSCE	Improved compared with control group (p < 0.01)	No	N/A
Ali et al. 1996a,b	Yes ATLS	Not stated (RCT of course vs not course)	Yes	MCQ	Improved compared with control group and precourse scores (no p value)	Yes	OSCE	Improved compared with control group and precourse scores (p < 0.05)	No	N/A
Ali et al. 1998	No PHTLS	Not stated	yes	MCQ	Improved compared with control group and precourse scores (p < 0.05)	Yes	Simulation	Improved compared with control group and precourse scores (p < 0.05)	No	N/A
Bilger et al. 1997	Yes AHA	Model telephone simulation (RCT – phone vs no phone)	No	N/A	N/A	Yes	Use of phone	Improved in group taught with model phone (p < 0.01)	No	N/A
Cimrin et al. 2005	No	Lectures simulation	No	N/A	N/A	Yes	Simulation	Improved from score of 11.2 precourse to 15.6 postcourse (p < 0.001)	No	N/A
Azcona et al. 2002	Yes ATLS	Not stated	Yes	MCQ	Improved from 0% to 100% pass	Yes	Simulation	Improved from 5/16 to 16/16 passed	No	N/A
Dauphin et al. 2007	Yes ALSO	2 days Lectures simulation	Yes	MCQ	Improved from mean score of 55% precourse to mean 86% postcourse (p < 0.01)	No	N/A	N/A	Yes questionnaires	Eight of nine felt more confident
Dunning et al. 2006	No	Lectures simulation	No	N/A	N/A	Yes	Simulation	Improved times in most tasks (all p < 0.05)	No	N/A
Featherstone et al. 2005	Yes ALERT	Not stated	No	N/A	N/A	No	N/A	N/A	Yes questionnaires	Confidence improved in many areas (p < 0.01)
Girdley et al. 1993	Yes ATLS	Lectures simulation	Yes	MCQ	Improved from mean score of 28.3% precourse to mean 34.5% postcourse p = 0.0001	No	N/A	N/A	No	N/A
Greig et al. 1996	Yes BLS	Not stated	No	N/A	N/A	Yes	Simulation	Yes (six weeks later) – p value not stated	No	No
Devita et al. 2005	No	Lectures, simulation, debriefing	No	N/A	N/A	Yes – as a team	Simulation	Improved survival and task completion after training (p < 0.002)	No	N/A
Hoadley 2009	Yes ACLS	Lectures simulation	Yes	MCQ	Improved score from mean precourse of 80% to postcourse mean of 89% (p < 0.001)	Yes	Simulation	Not known	Yes	N/K
Jensen et al. 2009	Yes ALS	Lectures simulation RCT	Yes	MCQ	Improved scores of means of 73 and 70% precourse to 85 and 83 % postcourse (no p value reported)	Yes	Simulation	Yes (combined score with MCQ)	No	N/A
Mayo et al. 2004	No	Two groups – one received training the other not simulation	No	N/A	N/A	Yes	Simulation	Improved in most areas in group receiving training (p < 0.001)	No	N/A
Monsieurs et al. 2005	No	Not stated RCT two different bagging systems	No	N/A	N/A	Yes	Simulation	Not stated – automatic bagging system better than manual p = 0.0001)	No	N/A
Marshall et al. 2001	Yes ATLS	Not stated	No	Not sated	N/A	Yes	Simulation	Skills improved in all areas postcourse (p < 0.002)	Yes survey	Increased from mean score of 5.8 to 8.1 (p < 0.01)
Murphy & Fitzsimons 2004	Yes ILS	Not stated	No	N/A	N/A	No	N/A	N/A	Yes – qualitative	Improved (qualitative data)
Owen et al. 2006	No	Simulation	Yes	MCQ	Yes p = 0.001	Yes	simulation	Improved (p value not stated))	Yes – questionnaire	p ≤ 0.001
Rosenthal et al. 2006	No	Simulation	No	N/A	N/A	Yes	Simulation	Improved in nearly all areas (at 6 weeks after)from pre-course score (p<0.0001)	No	N/A
Tippet 2004	Yes ATLS	Not stated	Yes	Short answers	Improved from mean 61% to mean 83% (p = 0.006)	No	N/A	N/A	No	N/A
Wayne et al. 2005	No	Simulation RCT	No	N/A	N/A	Yes	Simulation	Improved scores – 38% higher than controls with no training (p<0.0001)	No	N/A

Notes: ACLS – Advanced Cardiac Life Support, AHA – American Heart Association, ALERT – Acute Life-Threatening Events: Recognition and treatment, ALSO – Advanced Life Support for Obstetrics, ATLS – Advanced Trauma Life Support, BLS – Basic Life Support, MCQ – multiple choice questionnaire, N/A – not applicable, OSCE – Objective Structured Clinical Examination, PHTLS – Prehospital Trauma Life support.

Table A4.  Kirkpatrick 2C neonates

Author	AP	Nature of the training	No of participants Followed up (D=doctors, N=nurses, S=students O=other)	When tested at follow-up	Components of ability tested		Knowledge change	Notes	p	Skill change	Notes	p
					K	S
Curran et al. 2004	No	Computer manikin	60 (D)	Four and eight months (one group with booster)	Yes MCQ	Yes Simulation	R then NC	RCT – Decreased knowledge at four months in both groups then remained same at eight months	<0.0001 then Not SIGNIF	R	RCT – Both groups at eight months	<0.0001
Dunn et al. 1992	No	One day Lectures Demo	166 (N)	Six months	Yes MCQ	Yes Simulation	NC	Mean MCQ score from 91% to 85%	Not SIGNIF	R	All passed after training – All failed at follow-up	N/K
Duran et al. 2008a,b	Yes NRP	Lectures Simulation	42 (D)	6 and 12 months	Yes MCQ	No	R	Mean MCQ score from 94.5% to 59.2% after 6 months and 93.2% to 58.3% after 12 months	N/K	N/A		N/A
Kuczorowski et al. 1999	Yes NRP	Video Practical	44 (D)	6–8 months	Yes MCQ	Yes Simulation	R	RCT – All passed after training –at follow-up 26 (56%) passed in control group and two other groups who had booster	N/K	R	All passed after training – all failed at follow-up	N/K
Levitt et al. 1996	Yes NRP	N/K	10 (D)	6–9 months	Yes MCQ	No	NC	Mean MCQ score from 86.4% to 75.4%	Not SIGNIF	N/A		N/A
Skidmore & Urquhart 2001	No	Lectures Simulation	62 (D and N)	6 months 12 months	Yes MCQ	Yes Simulation	NC		N/K	R	After six months (but not back to pretraining score)	N/K
Trevisanuto et al. 2005	Yes NRP	2 days Lectures Simulation	25 (D)	6 months	Yes MCQ	No	R	Mean MCQ score from 94.1% to 62.7%	<0.0001	N/A	N/A	N/A
West 2000	No	Two hours N/K	6 (N)	6 weeks	Yes MCQ	Yes Simulation	NC		N/K	NC		N/K

Notes: AP – Accredited programme, Knowledge change:, I – Increased, NC – No change, p – p value, MCQ – Multiple-Choice Questionnaires, Not SIGNIF – not significant, N/A – Not applicable, N/K – Not known, NRP – Neonatal Resuscitation Programme, R – Reduced.

Table A5.  Kirkpatrick 2C paediatrics

Author	AP	Nature of the training	No of participants Followed up (D = doctors, N = nurses, S = students, O = other)	When tested at follow-up	Components of ability tested		Knowledge change	Notes	p	Skill change	Notes	p
					K	S
Durojaiye and O’Meara 2002	Yes PLS	N/K	23 (D)	2 weeks and 2 and 4 months	Yes phone questions	No	NC		N/K	N/A		N/A
Nadel et al. 2000	No	Eight hours Lectures Simulation video – Then booster in one group	57 (D)	Approx 12 months	Yes MCQ	Yes Simulation video	N/K	Did not report change in knowledge but group who received booster did better than control group	N/K	N/K	Did not report change in skills over time but group who received booster did better than control group	N/K
Spaite et al. 2000	No	Self-study	11 (O)	Four months	Yes ‘test’	No	R	Mean score in test fell from 13.04 to 11.59	<0.01	N/A		N/A
Su et al. 2000	No	16 hours Lectures Simulation Subgroups had simulation or knowledge exam at 6 months	43 (O)	12 months	YesMCQ	Yes simulation	R	Scores in reduced between 19.7% and 22.3% at follow-up – no difference between groups randomised to have test at six months and controls	<0.05	N/K		N/K
Wolfram et al. 2003	Yes PALS	N/K	99 (O)	Mean 21 months	Yes MCQ	No	R	25% passed exam at follow-up	N/K	N/A		N/A

Notes: AP – Accredited programme, Knowledge and Skill change: I – Increased, NC – No change, MCQ – Multiple-Choice Questionnaires, N/A – Not applicable, N/K – Not known, p – p value, PALS – Paediatric Advanced Life Support, PLS – Paediatric Life Support, R – Reduced.

Table A6.  Kirkpatrick 2C adults

Author	AP	Nature of the training	No of participants Followed up (D = doctors, N = nurses, S = students O = other)	When tested at follow-up	Components of ability tested		Knowledge change	Notes	p	Skill change	Notes	p
					K	S
Aboutanos et al. 2007	No	Lectures simulation	12 (D)	Two years	Yes MCQ	No	I	Mean score increased from 65% to 77%	<0.05	N/A		N/A
Ali et al. 2002	Yes ATLS	Lecture Simulation	144 (D)	Six months, 2, 4, 6 and 8 years	Yes MCQ	Yes OSCE Simulation	R	High and low trauma-exposed groups reduced scores from 83.9% to 74.8% and 81.9% to 74.6%, respectively, at six months. After this, no group passed MCQ	N/K	R		N/K
Ali et al. 1996a,b	Yes ATLS	N/K	60 (D)	Six months, 2,4 and 6 years	Yes MCQ	Yes OSCE	R	Scores after ATLS 85.3 – 87.7% in four groups. At six months = 77.8% (50%) pass, at two years 70.6% (0 passes), at four years 69.4% (0 passes), at six years 68.9% (0 passes)	N/K	R	Score after ATLS 16.6. Score at six months = 16.8, at two years = 13.9, at four years 12.0, at six years 11.9	N/K
Ander et al. 2004	No	Four hour lectures two hours and Simulation	40 (D)	Six and 12 months	No	Yes Simulation	N/A		N/A	I	Two of three skills improved at follow-up	N/K
Azcona et al. 2002	Yes ATLS	Not stated	59 (D)	Less than two years (38) and more than two years (21)	Yews MCQ	No	R	8/38 and 2/21 passed at follow-up	N/K	N/A		N/A
Beckers et al. 2007	No	15-minute lecture	59 (S)	Six months	No	Yes Simulation	N/A		N/A	R	Time to first shock elongated from mean of 56.5 seconds posttraining to 59.9 seconds at follow-up (but not back to pretraining level)	<0.01
Blumenfeld et al. 1998	Yes ATLS	N/K	220 (D)	Three to 60 months	Yes MCQ	No	R	Mean score 84% post-course and 66% at follow-up. 50% participants scored above 80% by 180 weeks	N/K	N/A		N/A
Boonmak et al. 2004	No	One-hour lecture, one-hour Simulation	30 (N)	Three months	Yes MCQ	Yes Simulation	R	Mean score fell from 75.4% to 60.5% at follow-up (back to pretraining levels)	N/K	N/C	(Mean skill score after training 79.7, at follow-up 75.7)	Not SIGNIF
Bradley et al. 1988	No	10-hour and four-hour lectures and Simulation	51 (O)	18 months (after Six month test at follow-up)	Yes MCQ And written	Yes Simulation	?R	RCT Proportion of failures may have increased in both groups at follow-up – no formal analysis	N/K	?R	Proportion of failures may have increased at follow-up – no formal analysis	N/K
Broomfield 1996	Yes ENB	Three hours Lectures Simulation	19 (N)	10 weeks	Yes MCQ	Yes Simulation	R	Mean score 23.9 postcourse and 19.4 at follow-up (higher than pretraining)	<0.0001	R	Mean score 7.2 postcourse and 5.1 at follow-up (higher than pretraining)	<0.0001
Coleman et al. 1991	No	Four hours of either lectures, discussion, handouts and simulation or e-learning	49 (S)	Three months	Yes MCQ	Yes Simulation	NC	Maintained scores in both groups	Not SIGNIF	NC	Maintained scores in both groups	Not SIGNIF
Cooper et al. 2007	Yes ILS	One-day lectures Simulation	29 (D, N, O)	Six months	Yes MCQ	Yes Simulation	N/C	Mean score 82% postcourse and 80% at follow-up	Not SIGNIF	R	Mean score 99% postcourse and 85% at follow-up (higher than pretraining)	0.02
Curry and Gas 1987	No	N/K	85 (D and N)	Six and 12 months	Yes MCQ	Yes Simulation	R	Doctors mean score 89.6% postcourse, 84% at 6 months and 83.4% at 12 months Nurses mean score 92.3% postcourse, 82% at 6 months and 79.4% at 12 months (Both back to pretraining levels)	N/K	R	Both for doctors and nurses – numerical data not reported (Both back to pretraining levels)	N/K
Curry and Gas 1983	Yes CPR	N/K	12(N) 13(D) 12(N) 6(D)	Six months 12 months	Yes MCQ	Yes Simulation	R	D and N had decreased after six months – back to pretraining levels by 12 months	<0.05	R	D skills decreased after six months, N by 12 months – both back to pretraining by 12 months	<0.01
De Regge et al. 2006	No	Simulation	Two groups of 16 (N)	Three and six months	No	Yes Simulation	N/A		N/A	N/C	Two groups with different resuscitation bags – Efficiency of ventilation stayed the same in both	Not SIGNIF
Erickson et al. 1996	No	30-minute lectures and Simulation	11 (D, N, O)	Two months	No	In clinical area	N/A		N/A	R	Airway and trauma skills decreased at follow-up (to pretraining levels)	N/K
Fabius et al. 1994	No	Computer demo and Simulation	54 (N, O)	Six months	No		N/A		N/A	?R	RCT – two groups – 1 person in each group ‘passed’ at follow-up compared with six and 34, respectively, immediately posttraining	N/K
Fossel et al. 1983	No	Simulation	41 (S)	One year and two years	Yes MCQ	Yes Simulation	R	Score lower at one and two years compared with those followed up at 2-3 weeks after training	<0.001	R	CPR performance lower at one and two years compared with those followed at 2-3 weeks after training	<0.05
Hammond et al. 2000	Yes ALS	Two days Lectures Simulation	40 (N)	18 months	Yes MCQ	Yes Simulation	N/C	Mean score 81.7% post course, 83.8% at follow-up	Not SIGNIF	R	75% percent passed at follow-up	N/K
Heidenreich et al. 2004	Yes AHA course	25 minutes Instruction Video Simulation	28 (S)	Six and 18 months	No	Yes Simulation	N/A		N/A	R and N/C	In standard CPR – reduction percentage correct chest compressions from 54 to 35 then 32. In uninterrupted chest compressions stayed the same	<0.02
Holden et al. 1996	No	N/K	55 (N)	Six months	Yes MCQ	Yes Simulation	N/C	Number achieving more than 50% correct answers did not deteriorate	N/K	? R	21 (38%) passed skills test at six months	N/K
Jensen et al. 2009	Yes ALS	Lectures simulation	Two groups (immedaitely and 6 months after qualification)	Six months	Yes composite	Yes composite with MCQ	N/K		N/A	N/K	Mean scores reduced from 85% and 83% post course to 82% and 78% at follow-up	N/K
Kovacs et al. 2000	No	One-hour lecture, five hours simulation and half-an-hour/week for three weeks	84 (S)	16, 25, and 40 weeks	No	Yes Simulation	N/A		N/A	N/C And R	RCT – groups with practice and feedback maintained skills. Control group and group receiving feedback alone deteriorated by 16 weeks (Mean score 45.2 to 34 and 45.2 to 35.4, respectively)	<0.05 in D groups
Leith 1997	No	‘Defibrillation training’	10 and 10 (N)	Six and 12 months	Yes write exam	Yes Simulation	R	Mean score reduced from 89% post course to 76% at 6 months and 70% at 12 months	N/K	R	Pass rate of practical test decreased from 70% to 0% at 6 and 12 months	N/K
Mancini & Kaye 1985	Yes AHA	N/K	33 (D)	Mean eight and 22 months	Yes Assessment and action	Yes Simulation	?R	Less than 100% of candidates responded correctly in all aspects except for assessing unresponsiveness (presume all needed to be correct immediately post-training)	N/K	?R	Less than 100% of candidates performed correctly in all aspects except for ventilating (presume all needed to be correct immediately post-training)	N/K
McKee et al. 1994	No	Lectures Simulation	50 (N)	One week, one, three and six months	No	Yes Simulation	N/A		N/A	R and N/C	Delay to defibrillation increased – resuscitation score deteriorated then improved to post training score at 6 months	<0.05 and Not SIGNIF
O’Donnell & Skinner 1993	No	20-minute lecture and Simulation	44 K 60 S	Six months	Yes Questionnaire	Yes Simulation	N/C and R	N/C in the 2 groups with refresher sessions and D in group with no refresher prior to follow-up	Not SIGNIF and <0.05	I	Group with monthly refresher sessions improved in ‘pass rate’ for performing cardiac massage from 39 to 69%	<0.05
O'steen et al. 1996	Yes ACLS	N/K	40 (N)	Mean 344 days (0–1034)	Yes MCQ	Yes Simulation	R	After 12 months – no further deterioration after	<0.05	R	After 12 months – no further deterioration after	<0.05
Plank & Steinke 1989	No	Two hours Lecture and simulation vs video	36(N)	6–8 weeks	Yes MCQ	Yes simulation	N/K	Pass score not stated	N/A	R	26 failed at follow-up	Not stated
Semeraro et al. 2006	Yes ALS	Lectures Simulation	47 (D)	Six months	Yes MCQ	Yes Simulation	R	Mean score 85.9% post-course and 79.5% at follow-up	<0.001	R	All passed postcourse and 30 passed at follow-up	<0.001
Smith et al. 2008	Yes ACLS BLS	N/K	133 (N)	Three, six, nine and 12 months	Yes MCQ	Yes Simulation	N/K	Results not reported	N/K	R	Four groups – all deteriorated – some to pretraining	N/K
Spooner et al. 2007	Yes BLS	eight hours Lectures simulation	66 (S) RCT standard vs feedback mannequin	Six weeks	No	Yes simulation	N/A		N/A	R	Fail rate increased from 16% and 25% to 10% and 38%, respectively	N/K
Stross 1983	Yes ACLS	N/K	132 (D)	One year	Yes ECG recognition and mock arrest	Yes Simulation	N/C and R	RCT. All three groups maintained ECG recognition but deteriorated in mock arrest – the two groups receiving booster sessions performed better at follow-up	N/K	R	39% performed successful ventilation and 47% external cardiac massage compared with all having passed ACLS course	N/K
Ten Eyck 1993	No	Four hours lectures and Simulation	48 (O)	Six months	No	Yes simulation	N/A		N/A	R	Five failed resuscitations and others did not perform other required aspects of simulation	N/K
Tippett 2004	Yes ATNC	21/2 days Lectures simulation	14 (N)	Three months	Yes Short answers	No	R	Mean score 83% postcourse and 73% at follow-up (back to precourse levels)	<0.05	N/A		N/A
Wayne et al. 2006	No	4 × 2 hours teaching and HI fidelity Simulation	38 (D)	Six and 14 months	No	Yes Simulation	N/A		N/A	N/C	In context of RCT previously over six months which involved three lots of testing	Not SIGNIF
Wenzel et al. 1997	No	Two hours Instruction Simulation	113 (S)	Six months	Yes MCQ	Yes Simulation	R	Mean score 6.4 postcourse and 6.2 at follow-up	<0.05	R	Five of nine skills deteriorated significantly	<0.0001
Yakel 1989	Yes 2 BLS courses	45 minutes or eight hours Lectures Simulation	81 then 86 (N)	Four months and eight months	No	Yes Simulation	N/A		N/A	R	Mean score 55 postcourse and 38 at 4 months. Improved to 42 at 8 months (p < 0.001) – four month test acted as booster (remedial training given). Longer course did better at follow-up (p < 0.05)	N/K
Young and King 2000	No	N/K	10 (N)	Six and 12 weeks	Yes Oral questions	Yes Simulation	R	Five failed at six weeks, five failed at 12 weeks	N/K	R	Five failed at six weeks, six failed at 12 weeks	N/K

Notes: AP – Accredited programme, ACLS – Advanced Cardiac Life Support, AHA – American Heart Association, ALS – Advanced Life Support, ATLS – Advanced Trauma Life Support, BLS – Basic Life Support, CPR – Cardio-pulmonary Resuscitation, ILS – Immediate Life Support, Knowledge and Skill change D – Decreased, MCQ – Multiple-Choice Questionnaires, N/A – Not applicable, NC – No change, N/K – Not known, Not SIGNIF – not significant, p – p value, R – Reduced.

Table A7.  Kirkpatrick 4 neonates

Author	Accredited programme	Nature of the training	Period studied	Significant impact on patient outcome	Nature of the impact on patients (data)	Significant increase in survival rates (data)	Significant improvement in clinical management	Nature of the improvement (data)
Boo 2009	Yes NRP	Lectures Simulation	Five years pretraining and 8 years posttraining	Not stated	Numerical decline in perinatal and neonatal mortality but no p values	? Less mortality	Not stated	Not stated
Duran et al. 2008a,b	Yes NRP	Not stated	Over three-year period including pre and post implementation of training	Yes	After training: significant increase in one minute Apgar score (5.43–6.5 – p = 0.01) Babies with ischaemic changes on CT reduced from 91% to 62% (p = 0.02) Reduction in inpatient stay from 12 to 6.1 days p ≤ 0.05	No statistically significant difference	Not stated	Not stated
Patel et al. 2001	Yes NRP	Not stated	Before training (1985–1988), during transition (1989–1990) and after training (1991–1995)	Yes	Fewer babies with low one and five minutes Apgar scores posttraining p ≤ 0.001	Not stated	Not stated	Not stated
Patel & Piotrowski 2002	Yes Neonatal resuscitation programme (NRP)	Not stated	Before NRP – 1985–1988, after 1991–1995.	Yes	Higher one minute Apgar score (7–10) (24% pre vs 31% post NRP – p = 0.001) and higher five minute (53% vs 65% – p < 0.001). More changed from low one minute to high five minute after NRP (39% to 49% – p < 0.001)	Not stated	Not stated	Not stated
Ryan et al. 1999	Yes NRP	Lectures Simulation	51 deliveries before and 51 deliveries after the training (1994–1995)	Not stated	Not stated	Not stated	Yes	Improvement in delivery room preparation (p = 0.01), management (p = 0.01) assessment (p = 0.02) and interventions (p = 0.02)
Singh et al. 2006	Yes NLS	Lectures simulation	Data collected precourse in 1990–1994 and postcourse in 1997 and 2003	Not stated	Not stated	Not stated	Yes for par of findings	Inappropriate use of naloxone fell from 75% to 10 % (p = 0.0001). Total use of naloxone fell from 13% to 0.5%, incidence of hypothermia fell from 9% to 2.3% (both not statistically significant)
Zhu et al. 1997	Yes NRP	Not stated	Pretraining 1992, posttraining 1993 to 1995	Yes	3× reduction in neonatal mortality (9.9 to 3.4 per 1000) p < 0.001	Yes

Notes: NLS – Neonatal life support, NRP – Neonatal Resuscitation Programme.

Table A8.  Kirkpatrick 4 paediatrics

Author	Accredited programme	Nature of the training	Period studied	Significant impact on patient outcome	Nature of the impact on patients (data)	Significant increase in survival rates (data)	Significant improvement in clinical management	Nature of the improvement (data)
Lo et al. 2009	No	Simulation Weekly scenarios	23 weekly training sessions of approximately 30 minutes	Not documented	N/A	Not documented	No	Median time for chest reopening significantly longer- p = 0.002. Longer to give medication p = 0.002
Losek et al. 1994	No (PALS for emergency medicine in State)	Lectures as before but with additional supervised practice from 1986	Patients 0–18 years from January 1990 to December 1991 compared with data from January 1983 to June 1985	Not documented	N/A	Not documented	Yes	<18-month-old improved intubation p = 0.000008 and vascular access p = 0.000003 Older child improved vascular access p < 0.05

Notes: N/A – not applicable, PALS – Paediatric Life Support.

Table A9.  Kirkpatrick 4 adults

Author	Accredited programme	Nature of the training	Period studied	Significant improvement in patient outcome	Nature of the impact on patients (data)	Significant increase in survival rates (data)	Significant improvement in clinical management	Nature of the improvement (data)
Arreola et al. 2004	Yes PHTLS, BLS and ALS (some in house)	Not stated	Three ambulance services October to December 1994, pretraining and January to June 1995 posttraining. January to September 2000 pretraining and October 2000 to June 2001 posttraining	Yes	Not stated	Improvement in survival in those patients transported in one intervention centre (p = 0.04)	Yes	Improved airway management in the two intervention centres (p < 0.001) Improved spinal immobilisation in one intervention centre p < 0.001 Some improved iv fluid administration in two intervention centres (p < 0.001)
Camp et al. 1997	ACLS	Not stated	1980 to 1984 pretraining and from 1985 to 1990 posttraining	Yes	Increased ‘death events’ reversed by intervention increased from 2% to 11% (p < 0.001) posttraining	Yes	Yes	Increased intervention at ‘death events’ posttraining (from 5% to 37% – p < 0.001)
Curry and Gas 1987	No	Not stated	1981–1985 – one hospital received training – the other did not	No		No	No	No difference in death rates between trained and untrained staff
Dane et al. 2000	Yes ACLS	Not stated	1996 and 1997 Compared resuscitation outcome of nurses ACLS trained with those not	Yes	4× more likely to survive when treated by trained nurses (38% to 10%) p = 0.02	Yes	Not stated	Not stated
Makker et al. 1995	Yes ACLS	Not stated	1991 – 225 cardiac arrests	No		No	Yes	Certified doctors made less errors in first semester after training (5.9%) compared with second semester (14.7%) (p = 0.05)
Moretti et al. 2007	Yes ACLS	Two-day course Lectures Simulation	January 1998 to March 2001 Compared resuscitation outcome of personnel ACLS trained with those not	Yes	Increase in return of spontaneous circulation with trained versus non-trained (49/113 vs 16/59 p = 0.04)	Better survival in ACLS trained group: at 30 days (27% versus 6% – p = 0.02) and 1 year (22% vs 0% p = 0.002)	Not stated	Not stated
Murphy & Fitzsimons 2004	Yes ILS	Not stated	1999–2000 and 2001–2002	Not stated	Not stated	Not stated	No	No difference in personnel who inserted mask or defibrillated
Seidelin & Bridges 1993	No	Six hours simulation	Six month period Aug 1987 to January 1987 compared with 1985	No		No	No
Spearpoint et al. 2009	Yes ILS	One day Lectures simulation	January 2002 to December 2007 – training ongoing during this period	Yes	Increase in survival to return of spontaneous circulation p ≤ 0.005	Reduced deaths at cardiac arrest over time period (p < 0.0002) Survival to discharge after emergency call increased to 39% (2007) from 28% (2004) p < 0.005	Not stated	Not stated
Van Olden et al. 2004	Yes ATLS	Not stated	May 1996 to September 1997 precourse and December 1997 to April 1999 postcourse	Yes	Significant reduction in mortality 24.2% to 0% in first 60 minutes following resuscitation	Yes	Not stated	Not stated
Van Olden et al. 2004	Yes ATLS	Not stated	Compared period pretraining (June 1996 to November 1997) to posttraining (January 1998 to July 1999)	Not stated	Not stated	Not stated	Yes	10 (of 14) procedures were performed better posttraining and management scores increased from 4.2 pretraining to 5.8 posttraining (p < 0.0001)
Vestrup et al. 1988	Yes ATLS	Not stated	Compared periods of pretraining (April 1983 to March 1984) to post training (April 1985 to 1986)	Not stated	Not stated	Not significantly different	yes	Significant increase in rectal examinations for trauma patients p = 0.03
Woodall et al. 2007	Yes ACLS	Lectures clinical placement	January 2000 to December 2002 Compared resuscitation outcome of paramedics ACLS trained with those not	Yes	Pulse on admission more likely in ACLS trained (21%) compared with nontrained (8.5%) p = 0.0001	Yes Increased survival to discharge in ACLS trained (6.7%) versus nontrained (4.66%) p = 0.03	Yes	Quicker mean time to first shock in ACLS trained (9.44 minutes) vs nontrained (10.07 minutes)

Notes: ACLS – Advanced Cardiac Life Support, ATLS – Advanced Trauma Life Support, ILS – Immediate Life Support, BLS – Basic Life Support, PHTLS – Pre-Hospital Trauma Life Support Course

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