Mandatory cardiopulmonary resuscitation competencies for undergraduate healthcare students in Europe: A European Resuscitation Council guidance note.

Cardiac arrest is one of the leading causes of death in high-resource countries, with a survival rate of 3 to 10%.1 Community response plays a pivotal role in improving survival following out-of-hospital cardiac arrest,2 something also highlighted by the European Resuscitation Council (ERC) 2015 Guidelines.3 Cardiopulmonary resuscitation [CPR is used in that statement as the general term for the competencies related to save the life of a person in cardiac arrest in a broad sense. The term basic life support (BLS) and advanced life support (ALS) instead describe the specific basic and advanced lifesaving competencies acquired in a course]. Training, starting within schools, has been suggested as a key factor in sustainably improving this response. Schoolchildren are demonstrably able to learn CPR better and faster than adults,4 perform CPR skills well after training5 and retain these skills6 with an increase in their sense of responsibility and self-confidence.7,8 This approach was introduced in Denmark in 2005 with the result that bystander CPR rates doubled in 10 years from 21 to 45%, with survival after out-of-hospital cardiac arrest increasing three-fold over the same period, from 8 to 22%.9 To support and promote children's education in CPR, the ERC promoted the ‘KIDS SAVE LIVES’ programme, which was supported by the WHO, with the aim of fostering CPR teaching in schools. The ERC position statement on ‘KIDS SAVE LIVES’ recommends 2 h of CPR education annually from the age of 12 years in all schools worldwide.10 The aim is that all students will know basic lifesaving CPR techniques by the end of their compulsory education. The ERC campaign promoting CPR education in schools has had positive outcomes over the last 4 years: legislation in six European countries has made such education mandatory, and in other countries a strong recommendation to teach CPR was issued by the respective authorities.11 However, very little is known about CPR teaching in higher education throughout Europe. Reports from different parts of the world have raised doubts about the CPR competencies of medical and other healthcare students.12,13 Lack of knowledge of cardiac arrest, CPR and other lifesaving manoeuvres is not an issue pertaining solely to healthcare students, it is also a longstanding problem with practising nurses and doctors, whose knowledge of BLS and ALS has been shown to be suboptimal, if not poor, in different parts of the world.14 The most recent survey, endorsed by the ERC Research NET, involved over 1000 medical students just before their graduation from 99 universities in 14 different European countries. It revealed a very diverse range of CPR competencies, overall knowledge about cardiac arrest epidemiology, awareness of algorithms for out-of-hospital cardiac arrest, use of automated external defibrillators and awareness of interventions for resolving choking.15 A major reason for this documented lack of CPR competencies seems to be that a considerable number of students in many countries have never attended a life support course (in some, not even BLS) before the end of their undergraduate education. Significantly, even in areas where almost all medical students participated in BLS courses, the study found that many did not adhere to current international guidelines and many students reported only didactic theory classes without any BLS skills practice.15 Many healthcare students also attend university as part of postgraduate programmes, presenting another opportunity to teach and assess their competence in CPR. This is a serious problem. The public, in general, assumes that healthcare professionals at the end of their undergraduate education are able to provide proper CPR skills and intervene effectively at cardiac arrest. Expectations and ideas about what such interventions are, or what can be achieved can be unrealistic due to the portrayal of these aspects in television series and films,16 but the idea that those trained in healthcare should be able to render basic skills in an attempt to save life remains entirely reasonable. The ERC would like to address this educational deficit. CPR competencies could be easily addressed at all levels of undergraduate healthcare education via mandated training. The different healthcare professions (including but not exclusive to medicine, nursing, physiotherapy and midwifery) teach their curricula with the aim that all students acquire the necessary skills to perform as a competent professional. That indicates the need for different roles in a critical situation such as cardiac arrest and therefore, each healthcare programme needs to decide which level of CPR competence beyond BLS is appropriate for their students when graduating. As BLS is considered a competency for every citizen, a stepwise approach over the graduation years seems reasonable to achieve the CPR competencies required in each profession. To guarantee an accepted European wide level of learning outcome, this ERC guidance note strongly recommends that all teaching institutions standardise their life support courses (from BLS to ALS) according to current ERC recommendations and course rules. Many students who are taught CPR during their initial undergraduate years do not undergo any subsequent refresher training. It is well known, however, that CPR skills rapidly deteriorate in just a few months. Frequent but low-intensity training, also called spaced learning, achieves higher retention of knowledge and skills performance: regular CPR refresher courses, perhaps annually, can maintain competence and establish a culture of lifelong learning to achieve a performance level that is able to deliver lifesaving CPR skills. Spaced learning, brief and higher frequency CPR training have all been shown to improve CPR skill retention by healthcare providers,17 and these are approaches that could be feasible for large institutions that have large numbers of students to teach and refresh each year. We would like to stress that this initiative is not only an educative one: far more important is improving patient outcome after cardiac arrest and CPR. There is strong evidence that better CPR competencies of healthcare providers can improve patient outcome after in-hospital cardiac arrest and those hospitals providing adequate resuscitation training have a better survival rate for their patients.18 Moreover, participation in ERC courses also improves outcomes.19 The ERC guidance note strongly promotes the implementation of a strategy to overcome the lack of CPR competence in undergraduate healthcare students both in Europe and beyond in the hope that, as a result, management and outcomes will improve. Educating all future healthcare providers to help others in life threatening emergencies supports the educational efforts of awareness campaigns for the wider population. The ERC guidance note proposes a stepwise approach to achieve these aims: (1) A mandatory CPR course during the first year of education, on the theory and practice of CPR following current ERC recommendations. This should be implemented at all higher education healthcare institutions with the aim of ensuring that undergraduates can perform competent BLS. (2) Higher education healthcare institutions should offer senior undergraduate students more ALS courses such as immediate life support, ALS for adults or European paediatric life support over the subsequent years of their health studies. As not all healthcare professionals will have the same role in a team treating cardiac arrest, the level of advanced courses should be aligned with their expected roles. In the same way adult, paediatric or neonatal life support should be taught depending on the professional needs of the students when they graduate from their studies. Therefore, the ERC suggests a stepwise resuscitation curriculum from basic to ALS training depending on the needs of the individual professions, for healthcare students. (3) Annual hands-on refresher CPR courses will maintain student competency in high-quality CPR. Therefore, the ERC recommends the implementation of a CPR refresher programme involving the entire degree course until graduation. (4) The instructing personnel of these courses need to teach according to international guidelines, and higher healthcare teaching institutions are advised to certify their instructors. The ERC, like other organisations, offers a comprehensive faculty development programme for CPR instructors and course directors for a variety of CPR courses based on standardised ERC course rules. (5) This teaching programme should become part of the general curriculum of each healthcare educational institution and include the assignment of sufficient resources. (6) Higher healthcare educational institutions implementing such a CPR policy should strongly consider peer-teaching programmes to facilitate these high-volume courses,20 as these provide effective and cost-effective life support skills teaching while enabling professional development opportunities for peer teachers that are otherwise difficult to achieve. (7) Peer-teaching healthcare students might support CPR school-teaching programmes and serve as multipliers in first responder community programmes. In doing so, healthcare educational institutions put their students into contact with prevention and health education programmes at the community level. (8) Healthcare educational institutions should acknowledge and accredit engagement in these CPR teaching programmes; teaching on such programmes should count as academic achievements for the teachers at these institutions. (9) Finally, the corresponding governmental institutions in the different European countries should legislate to make all higher healthcare educational institutions include CPR education in their curricula, or integrate these programmes in the national professional curricula and include the assignment of sufficient resources. The guidance note provides the necessary goals for healthcare students seeking to understand and deliver life-saving competencies to their patients, and others who collapse within their community. This guidance note is supported by the ERC Board Directors of Science and Research, and of Education and Training.