Introduction
Sudden cardiac arrest is the third leading cause of death in Europe1,2 with an overall rate of 30-day survival of about 10% and a favourable neurological outcome at hospital discharge among survivors in only 2.8–18.2%.3 High-quality cardiopulmonary resuscitation (CPR) and guidelines compliance of rescuers have been associated with better outcomes after cardiac arrest. However, wide variability in attempting bystander CPR manoeuvres (ranging from 19 to 70%)2 has been reported.4 The widespread diffusion of the CPR guidelines and tailored training for laypeople and medical professionals are highly advisable in this context. Educational programmes have been demonstrated to improve the willingness to perform bystander CPR5,6 and increase overall survival.6 Moreover, the adoption of national laws supporting early education in CPR (among high-school students) increased the rate of intervention of bystanders in case of cardiac arrest.7
As a general rule, the medical personnel should be proficient in CPR and the lack of intervention is considered malpractice. However, the perception of having suboptimal skills in CPR is common among healthcare providers.8 A recent European survey showed great disparities among countries about formal education in Basic Life Support (BLS) during medical school and the overall perception of suboptimal training on rescue from courses provided by universities in about 42% of cases.9 A recent ERC guidance note recognizes the high disparity among European undergraduate students in BLS education and recommends the mandatory inclusion of competencies in CPR among medical schools in Europe.10
The Italian national core curriculum for medical students recommends formal education in Advanced Cardiopulmonary Life Support (ACLS/ALS) using internationally recognized educational protocols (International Liaison Committee on Resuscitation, ILCOR; European Resuscitation Council, ERC; American Heart Association, AHA) while, surprisingly, the document does not mention BLS courses.11 However, this approach seems unfeasible because advanced courses (ACLS/ALS) require previous basic training (BLS) due to the high costs and duration of ACLS/ALS courses (at least 2 days).
Cardiologists, anesthesiologists and Emergency Department doctors are the most exposed to cardiovascular emergencies (including cardiac arrest) and should systematically receive formal education in advanced cardiovascular support. However, there is no homogeneity regarding the CPR education offered by academic institutions12 and a wide variability is expected among the postgraduate schools.
Beyond formal recommendations, little is known about the real implementation of CPR education in Italian medical schools and cardiology fellowship programmes. The present statement analyses the current status of CPR education in Italian medical schools and postgraduate schools in cardiology and suggests some strategies to improve the spreading of the CPR culture among students and fellows.
The real world of cardiopulmonary resuscitation education in Italian medical schools and cardiology fellowship programmes
To assess the educational offer in CPR training among Italian medical schools and postgraduate schools in cardiology, we surveyed Italian medical students and fellows in cardiology in September 2022. The survey included two questionnaires (one exploring the educational offer and the other exploring the perceived educational needs) shared with the local representatives of the ‘Segretariato Italiano Studenti Medicina’ (SISM) and ICOT (Italian Cardiologists Of Tomorrow). These two nonprofit organizations are present in almost all Italian medical schools (SISM) and postgraduate schools in cardiology (ICOT) and collect a large number of Italian medical students and fellows in cardiology. Direct invitations have been sent to local referent students, fellows or postgraduate schools in cardiology directors whenever SISM and/or ICOT were not represented in some universities. Each local representative was asked to answer the questionnaire on the educational offer in his/her medical school/postgraduate school and share the questionnaire regarding the educational needs with the other students/fellows of the same institution. We finally collect data regarding the educational offer from 11 Italian medical schools and 29 postgraduate schools in cardiology, representing 26% and 70% of the total existing in Italy, respectively (Table 1). In addition, we collected the educational needs expressed by 208 medical students and 162 fellows in cardiology (Table 2).
Table 1 -
Educational offer among Italian schools of medicine and specialization schools in cardiology
|
Schools of medicine |
Specialization schools in cardiology |
| Number surveyed |
11 |
29 |
| Any BLS provider course, n (%) |
8 (72.7) |
10 (34.4) |
| BLS provider courses with final certification, n (%) |
3 (27.3) |
6 (20.7) |
| Any ACLS/ALS provider course, n (%) |
0 (0) |
8 (27.6) |
| ACLS/ALS provider courses with final certification, n (%) |
0 (0) |
5 (17.2) |
| BLS or ACLS/ALS provider course certification, if offered |
|
|
| American Heart Association, n (%) |
1 (33.3) |
7 (63.6) |
| Italian/European Resuscitation Council, n (%) |
1 (33.3) |
3 (27.3) |
| University of pertinence, n (%) |
0 (0) |
1 (9.1) |
| Multiple providers, n (%) |
1 (33.3) |
0 (0) |
| Instructor courses |
|
|
| BLS, n (%) |
0 (0) |
1 (3,5) |
| ACLS, n (%) |
0 (0) |
4 (13.8) |
| Both, n (%) |
0 (0) |
3 (10.3) |
| BLS or ACLS/ALS instructor course certification, if offered |
/ |
|
| American Heart Association, n (%) |
/ |
5 (45.5) |
| Italian/European Resuscitation Council, n (%) |
/ |
4 (36.3) |
| Not indicated, n (%) |
/ |
2 (18.2) |
| Global economical support by Universities for courses |
|
|
| BLS, n (%) |
1 (9.1) |
2 (6.9) |
| ACLS, n (%) |
0 (0) |
6 (20.7) |
| Both, n (%) |
0 (0) |
3 (7.5) |
| Partial economical support by Universities for courses |
|
|
| BLS, n (%) |
1 (9.1) |
0 (0) |
| ACLS, n (%) |
0 (0) |
1 (3.5) |
| Both, n (%) |
0 (0) |
1 (3.5) |
ACLS/ALS, Advanced (Cardiac) Life Support; BLS, Basic Life Support.
Table 2 -
Educational needs among Italian students in medicine and fellows in cardiology
|
Students in medicine |
Fellows in cardiology |
| Number surveyed |
208 |
162 |
| Year of study |
|
|
| 1, n (%) |
3 (1.44) |
65 (40.4) |
| 2, n (%) |
44 (21.2) |
51 (31.7) |
| 3, n (%) |
23 (11.6) |
27 (16.8) |
| 4, n (%) |
38 (18.3) |
18 (11.2) |
| 5, n (%) |
31 (14.9) |
/ |
| 6, n (%) |
69 (33.2) |
/ |
| Have you ever been a bystander of a cardiac arrest? |
|
|
| No, n (%) |
174 (83.6) |
13 (8.0) |
| Yes, once, n (%) |
17 (8.2) |
25 (11.4) |
| Yes, more than once, n (%) |
17 (8.2) |
124 (76.6) |
| How do you consider your proficiency in BLS (all years of study) |
|
|
| Low, n (%) |
80 (38.5) |
16 (9.9) |
| Intermediate, n (%) |
87 (41.8) |
85 (52.5) |
| High, n (%) |
41 (19.7) |
61 (37.6) |
| How do you consider your proficiency in BLS (only 4th and 5th years of study in medicine and 3rd and 4th years of study in cardiology) |
|
|
| Low, n (%) |
54 (39.1) |
5 (5.2) |
| Intermediate, n (%) |
57 (41.3) |
43 (44.3) |
| High, n (%) |
27 (19.6) |
49 (50.5) |
|
|
|
| How do you consider your proficiency in ACLS/ALS (all years of study) |
|
|
| Low, n (%) |
183 (88.0) |
67 (41.4) |
| Intermediate, n (%) |
23 (11.1) |
69 (42.6) |
| High, n (%) |
2 (0.9) |
26 (16.0) |
| How do you consider your proficiency in ACLS/ALS (only 4th and 5th years of study in medicine and 3rd and 4th years of study in cardiology) |
|
|
| Low, n (%) |
117 (84.8) |
21 (21.6) |
| Intermediate, n (%) |
19 (13.8) |
54 (55.7) |
| High, n (%) |
2 (1.4) |
22 (21.7) |
| How do you consider the relevance of BLS training? |
|
|
| Low, n (%) |
3 (1.4) |
8 (4.9) |
| Intermediate, n (%) |
6 (2.9) |
11 (6.8) |
| High, n (%) |
199 (95.7) |
143 (88.3) |
| How do you consider the relevance of ACLS/ALS training? |
|
|
| Low, n (%) |
1 (0.5) |
0 (0) |
| Intermediate, n (%) |
16 (7.7) |
2 (1.2) |
| High, n (%) |
191 (91.8) |
160 (98.8) |
| If not provided by your institution, did you attend as your initiative a CPR provider course? |
|
|
| No, n (%) |
141 (67.8) |
56 (34.6) |
| Yes, BLS, n (%) |
61 (29.3) |
54 (33.3) |
| Yes, ACLS/ALS, n (%) |
0 (0) |
30 (18.5) |
| Yes, Both, n (%) |
6 (2.9) |
22 (13.6) |
| If not provided by your institution, did you attend as your initiative a CPR instructor course? |
|
|
| No, n (%) |
195 (93.7) |
152 (93.8) |
| Yes, BLS, n (%) |
11 (5.3) |
2 (1.3) |
| Yes, ACLS/ALS, n (%) |
0 (0) |
7 (4.3) |
| Yes, Both, n (%) |
2 (1.0) |
1 (0.6) |
The terms ‘low’, ‘intermediate’ and ‘high’ represent values of 1 to 3, 4 to 7, and 8 to 10 on a scale of 1 to 10.ACLS/ALS, Advanced (Cardiac) Life Support; BLS, Basic Life Support.
Most Italian schools of medicine offer BLS courses to their students, but fewer than 30% of them are certified by internationally recognized institutions (Table 1). Moreover, despite official recommendations, none of the medical schools offers advanced courses (ACLS/ALS). Conversely, about one-third of postgraduate schools in cardiology offer a BLS or ACLS/ALS course, but only a great minority are certified by internationally recognized institutions (20.7 and 17.2%, respectively). Very few postgraduate schools in cardiology and no medical schools offer the opportunity to achieve the role of instructor either in BLS or ACLS/ALS (Table 1).
Most medical students, as expected, have never witnessed a cardiac arrest, while more than 90% of fellows were involved at least once in this occurrence (Table 2). However, only 19.7% of students and 37.6% of fellows consider themselves highly proficient with basic CPR manoeuvres. Also considering only students and fellows who are in the last 2 years of their course of study, these figures do not change significantly. The perception of high proficiency in ACLS/ALS is even worse among students (0.9%) and fellows (16.0%), also restricting the analysis to those in the last 2 years (1.4 and 21.7%, respectively). Education in CPR is considered highly relevant by the great majority of students and fellows, and a considerable percentage of them attend CPR courses on their own initiative outside academic institutions (Table 2).
Strategies for cardiopulmonary resuscitation culture dissemination in medical and specialization schools
One size does not fit all
The data of our survey highlight the gap between the educational offer in CPR training and the perceived needs. However, although attending advanced courses (ACLS/ALS) is advisable as a general rule, it should be recognized that providing such courses to all medical students is not feasible nor appliable, as they do not have, at least during the first years of school, the necessary basic knowledge to approach the use of advanced interventions (i.e. electrical and pharmacological therapies). Moreover, a relevant number of ACLS/ALS courses are focused on teaching the role of team leader of an emergency team, but it is unlikely for a medical student to play this role before finishing medical school. As BLS and ‘high-quality CPR’ play a pivotal role in successful resuscitation, BLS courses are more appropriate for medical students provided that these courses include BLS for children and infants and appropriate training on automatic external defibrillator (AED) use. This kind of education should be extended to all postgraduate schools, in every discipline. BLS courses are relatively cheap and they can be provided with 6-h sessions, allowing a straightforward education for a large number of students in a reasonably short amount of time. We recommend that all students in medicine and all fellows of every postgraduate specialization school receive a formal BLS provider course (for adults, children and infants), following internationally recognized resuscitation guidelines, certified after a trackable assessment of practical skills and cognitive competencies (Table 3). The optimal timing for providing these courses should be the fourth year of medical school and the first year of a specialization school. As the certification validity usually lasts 2 years, the BLS courses offered to fellows could thus be reconducted to ‘refresher courses’ that should be provided in the first and third years of the fellowship programme. To hold CPR competencies as long as possible, we recommend a formal refresher BLS provider (for adults, children and infants) course every 2 years for all fellows (Table 3).
Table 3 -
Recommended education in cardiopulmonary resuscitation for medical students and fellows
| What |
To whom |
When |
Repeat |
| Basic Life Support (BLS) |
All medical students |
Starting from the fourth year of the school of medicine |
|
| Basic Life Support (BLS) |
All fellows |
In the first year of the specialization school |
Formal refresher course every 2 years (if advanced courses are not planned and/or provided) |
| Basic Life Support (BLS) |
All students of other healthcare-related disciplines |
Before the end of the school |
|
| Advanced Cardiac Life Support (ACLS/ALS) |
Fellows in specialties with a high probability of being exposed to cardiac arrest, such as
Anesthesiology
Cardiology
Emergency Medicine |
In the first year of the specialization school |
Formal refresher course every 2 years |
| Advanced Cardiac Life Support (ACLS/ALS) |
Fellows in specialties with a moderate probability of being exposed to cardiac arrest, such as
Internal medicine
Pulmonology
Geriatrics
General surgery |
Before the end of the school |
|
| Advanced Cardiac Life Support (ACLS/ALS) |
Fellows in specialties with a low probability of being exposed to cardiac arrest, such as
Dentistry
Ophthalmology
Dermatology |
Not recommended |
|
| Advanced Cardiac Life Support (ACLS/ALS) |
Medical students |
Not recommended |
|
| Nontechnical skills (didactic/low fidelity simulation) |
All medical students |
Last year of school |
|
| Nontechnical skills (didactic/low fidelity simulation) |
Fellows in specialties with a low probability of being exposed to cardiac arrest, such as
Dentistry
Ophthalmology
Dermatology |
Before the end of the school |
|
| Nontechnical skills (high-fidelity simulation) |
Fellows in specialties with a high or moderate probability of being exposed to cardiac arrest |
From the first to last year of school |
Preferably systematically repeated with different scenarios |
| Crisis Resources Management (CRM) course |
Fellows in specialties involved in critical care, such as
Anesthesiology
Cardiology
Emergency Medicine |
Before the end of the school |
|
As the CPR culture should attain all healthcare personnel, we also recommend that students of other healthcare-related disciplines (e.g. dentists, nurses and physiotherapists) receive a formal BLS provider course (for adults, children and infants), following internationally recognized resuscitation guidelines, certified after a trackable assessment of practical skills and cognitive competencies before the end of their schooling (Table 3).
Conversely, advanced skills are required among medical personnel (such as anaesthesiologists, cardiologists and Emergency Department doctors) exposed to patients with a high risk of developing cardiac arrest. These professional categories are also more likely to be involved as team leaders in emergency teams. Similar considerations could be made for specialists in the areas of internal medicine and surgery who can be involved, albeit less frequently, as members of emergency teams. On the contrary, specialists such as dermatologists and ophthalmologists are exposed very rarely to cardiac arrest and might have more difficulties holding their proficiency in ACLS/ALS. We thus recommend that all fellows in specialties with a high or intermediate probability to be directly involved in cardiac arrest management or as part of emergency teams receive a formal ACLS/ALS provider course following internationally recognized resuscitation guidelines, certified after a trackable assessment of practical skills and cognitive competencies (Table 3). Conversely, routine providing of ACLS/ALS courses to medical students and fellows in fields with a low probability of being exposed to cardiac arrest is not recommended (Table 3).
Alternative educational models
Sometimes, the availability of a sufficient number of instructors or the limited available time to provide courses may be a major issue.
Instructor-led teaching (ILT) is time-consuming, especially if the number of students is high. Self-directed CPR learning programmes, such as ‘HeartCode’ developed by the AHA, could represent a valid alternative to traditional courses without significant loss of efficacy.13 This ‘blended’ approach allows the simultaneous distribution of a self-directed standardized course to a large number of students. After successful completion of this part of the course, students access training and testing sessions with the assistance of certified instructors for completing all parts of the course. For a BLS course, this part lasts about 2.5 h instead of the 6 h of a traditional course. This way, several practice sessions can be provided on the same day. In practice, digital codes for accessing the self-directed part of the course could be distributed at the beginning of the academic year along with the dates for completing the course with the hands-on parts. The advantages are represented by the significant reduction in the time spent by a single instructor teaching the same number of students and the possibility for students to access the self-directed part of the course at their convenience. The shortcomings are related to the lesser time spent on interactions between students and instructors, which may somewhat impair the learning process and the higher cost of the teaching material. In addition, although this teaching programme has been developed both for BLS and ACLS/ALS (but an ACLS blended course is still not available in all languages, including Italian), it appears more easily applicable in BLS teaching.
Especially in a short-resources context, peer-assisted learning (PAL), that is student-to-student education, may be an additional option.14 PAL has been defined as ‘the development of knowledge and skill through active help and support among status equals or matched companions’15 and specifically involves individuals who are peers, not professional teachers, and who are also learning themselves through teaching.14 When correctly applied, this teaching method not only has several advantages but also raises relevant organizational issues.16 Jauregui et al.14 recently applied this approach for teaching specific ACLS/ALS-related topics using a low-cost setting, including a half-mannequin that can be intubated, airway supplies and a tablet-based app (SimMon). At the end of this experience, 135 medical students completed the course and a course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a five-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a well tolerated learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. On the contrary, faculty reported that students remained engaged and required minimal oversight.14 Although promising, this approach can however be considered for achieving specific knowledge and skills but not as a substitute for a comprehensive, certified course. We recommend considering alternative modalities to ILT to teach BLS or specific ACLS/ALS-related topics when the number of students is too elevated to provide adequate education in a relatively short amount of time.
CPR skill retention is a major issue after completion of a course. The standard approach is represented by repeating the course in a short version (‘refresher course’) after a certain time interval (usually 2 years). This implies the need for instructors’ time also for this activity. In this setting, alternative teaching methods include a ‘low dose’ (i.e. short sessions) of periodical training with self-directed learning activities monitored by an automated system.17 This approach appears to be promising in terms of skills retention and instructor/student time management. However, it needs additional logistics (dedicated skill station) and organizational resources.17 Similarly, ‘high-fidelity’ simulation,18,19 especially if combined with problem-based learning,20 improves long-term knowledge and skill retention but needs additional teaching and logistic resources.
We recommend considering low-dose repeated sessions or high-fidelity simulation for improving long-term knowledge and skill retention when logistics and organizational resources permit.
Logistic issues
Teaching a large number of students and fellows requires a structured organization for managing logistic and administrative issues. Correct manikin maintenance, certification card distribution and course materials management are all required for providing high-quality courses. Moreover, a specific budget is required for buying manuals and cards and reimbursing the instructors. We recommend that every school of medicine and correlated postgraduate schools have a structured logistic and financial organization for providing continuous education in CPR to medical students and fellows.
An adequate number of instructors is also needed to guarantee a regular turnover. Instructors are usually physicians or nurses employed in regular patient care tasks and an excessive CPR courses-related teaching load may impair the educational offer. Including medical students and fellows in the instructors’ pool may help in increasing the educational offer and improving knowledge21 and skill retention22 among students and fellows. The students and fellows who demonstrated optimal performance during BLS or ACLS/ALS courses and who have adequate didactic abilities should be addressed to follow certified instructor courses in the same discipline. We recommend the adoption of educational programmes to include selected medical students and fellows as instructors in BLS and ACLS/ALS courses.
Nontechnical skills
Nontechnical skills are defined as ‘the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.23 In recent years, nontechnical skills emerged as pivotal for reducing medical errors24 and improving teamwork.25 Effective teamwork requires authoritative leadership and clear communication among the resuscitation team. However, although teaching team management is part of ACLS/ALS courses, leadership capabilities are often lost with time26 and need to be reinforced by specific training. Medical schools and fellowship programmes should provide the resources to achieve nontechnical skills. However, a recent survey among European young cardiologists showed a substantial lack of training not only in CPR technical but also in nontechnical skills.12
Situational awareness, decision-making, communication and teamworking are typical teaching/learning areas to reduce medical error-related failures27 and can be taught using different approaches.28–30 Combined didactic and simulation teachings, high-fidelity simulation and Crisis Resources Management (CRM)31 courses could be provided to different audiences, from medical students to trainees (Table 3). We recommend the inclusion of formal teaching of nontechnical skills to medical students and fellows, according to the expected exposure to critical care and team leadership.
Perspectives
Providing effective, stable and long-lasting education in technical and nontechnical skills in CPR to medical students and fellows is a tremendous challenge. The large number of learners conflicts with the very few teachers in this field. Moreover, very few universities and educational institutions currently seem ready to approach such an enormous educational load. However, maximal effort should be spent to fill this gap to improve the quality of the assistance provided by future medical generations. A paradigm shift already started to take place, recognizing the role of teaching by simulation in medical education. CPR is the most evident field of application, but almost every medical discipline can take advantage of this methodology. Virtual teaching hospitals (i.e. simulation centres wherein medical students and fellows practice before approaching real patients) should be a standard reality in every medical and specialization school. Universities and governments should invest more intellectual and financial resources in this field in the future.
Acknowledgements
The authors are grateful to the representatives and members of the ‘Segretariato Italiano Studenti Medicina’ and ‘Italian Cardiologists of Tomorrow’ for their invaluable support in the survey deployment.
Conflicts of interest
There are no conflicts of interest.
References
1. Gräsner J-T, Herlitz J, Tjelmeland IBM, et al. European Resuscitation Council Guidelines 2021: epidemiology of cardiac arrest in Europe.
Resuscitation 2021; 161:61–79.
2. Kiguchi T, Okubo M, Nishiyama C, et al. Out-of-hospital cardiac arrest across the World: first report from the International Liaison Committee on Resuscitation (ILCOR).
Resuscitation 2020; 152:39–49.
3. Gräsner J-T, Lefering R, Koster RW, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe.
Resuscitation 2016; 105:188–195.
4. Cheskes S, Schmicker RH, Rea T, et al. The association between AHA CPR quality guideline compliance and clinical outcomes from out-of-hospital cardiac arrest.
Resuscitation 2017; 116:39–45.
5. Son JW, Ryoo HW, Moon S, et al. Association between public cardiopulmonary resuscitation education and the willingness to perform bystander cardiopulmonary resuscitation: a metropolitan citywide survey.
Clin Exp Emerg Med 2017; 4:80–87.
6. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest.
JAMA 2013; 310:1377–1384.
7. Vetter VL, Griffis H, Dalldorf KF, et al. Impact of state laws: CPR education in high schools.
J Am Coll Cardiol 2022; 79:2140–2143.
8. Cernuda Martínez JA, Castro Delgado R, Ferrero Fernández E, Arcos González P. Self-perception of theoretical knowledge and practical skills by primary healthcare physicians in life-threatening emergencies.
Prehosp Disaster Med 2018; 33:508–518.
9. Baldi E, Contri E, Bailoni A, et al. Final-year medical students’ knowledge of cardiac arrest and CPR: we must do more!.
Int J Cardiol 2019; 296:76–80.
10. Baldi E, Savastano S, Contri E, et al. Mandatory cardiopulmonary resuscitation competencies for undergraduate healthcare students in Europe.
Eur J Anaesthesiol 2020; 37:839–841.
11. Conferenza permanente dei presidenti dei CLM di Medicina e Chirurgia. Core curriculum. 2018.
http://presidenti-medicina.it/core-curriculum/. [Accessed 13 October 2022].
12. Czerwińska-Jelonkiewicz K, Montero S, Bañeras J, et al. Current status and needs for changes in critical care training: the voice of the young cardiologists.
Eur Heart J Acute Cardiovasc Care 2021; 10:94–101.
13. Roppolo LP, Heymann R, Pepe P, et al. A randomized controlled trial comparing traditional training in cardiopulmonary resuscitation (CPR) to self-directed CPR learning in first year medical students: the two-person CPR study.
Resuscitation 2011; 82:319–325.
14. Jauregui J, Bright S, Strote J, Shandro J. A novel approach to medical student peer-assisted learning through case-based simulations.
West J Emerg Med 2018; 19:193–197.
15. Topping K, Ehly S. Peer-assisted learning. New York: Routledge; 1998.
16. Wadoodi A, Crosby JR. Twelve tips for peer-assisted learning: a classic concept revisited.
Med Teacher 2002; 24:241–244.
17. Panchal AR, Norton G, Gibbons E, Buehler J, Kurz MC. Low dose- high frequency, case based psychomotor CPR training improves compression fraction for patients with in-hospital cardiac arrest.
Resuscitation 2020; 146:26–31.
18. McCoy CE, Rahman A, Rendon JC, et al. Randomized controlled trial of simulation vs. standard training for teaching medical students high-quality cardiopulmonary resuscitation.
West J Emerg Med 2019; 20:15–22.
19. Langdorf MI, Strom SL, Yang L, et al. High-fidelity simulation enhances ACLS training.
Teaching Learn Med 2014; 26:266–273.
20. Berger C, Brinkrolf P, Ertmer C, et al. Combination of problem-based learning with high-fidelity simulation in CPR training improves short and long-term CPR skills: a randomised single blinded trial.
BMC Med Educ 2019; 19:180.
21. Blanco MA, Maderer A, Oriel A, Epstein SK. How we launched a developmental student-as-teacher (SAT) program for all medical students.
Med Teacher 2014; 36:385–389.
22. Veloso SG, Pereira GS, Vasconcelos NN, Senger MH, de Faria RMD. Learning by teaching basic life support: a nonrandomized controlled trial with medical students.
BMC Med Educ 2019; 19:67.
23. Flin R, O’Connor P. Safety at the sharp end: a guide to nontechnical skills. London: CRC Press; 2008.
24. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000.
25. Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N. The impact of nontechnical skills on technical performance in surgery: a systematic review.
J Am Coll Surg 2012; 214:214–230.
26. Robinson PS, Shall E, Rakhit R. Cardiac arrest leadership: in need of resuscitation?
Postgrad Med J 2016; 92:715–720.
27. Casali G, Lock G, Novoa NM. Teaching nontechnical skills: the patient centered approach.
J Thorac Dis 2021; 13:2044–2053.
28. Gordon M, Darbyshire D, Baker P. Nontechnical skills training to enhance patient safety: a systematic review.
Med Educ 2012; 46:1042–1054.
29. Ounounou E, Aydin A, Brunckhorst O, Khan MS, Dasgupta P, Ahmed K. Nontechnical skills in surgery: a systematic review of current training modalities.
J Surg Educ 2019; 76:14–24.
30. Lynch A. Simulation-based acquisition of nontechnical skills to improve patient safety.
Semin Pediatr Surg 2020; 29:150906–1150906.
31. Lei C, Palm K. Crisis resource management training in medical simulation. 2022.
https://www.ncbi.nlm.nih.gov/books/NBK551708/. [Accessed 13 October 2022].
