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Improving the Efficiency of Advanced Life Support Training: A Randomized, Controlled Trial

Gavin D. Perkins, MD; Peter K. Kimani, PhD; Ian Bullock, PhD; Tom Clutton-Brock, MB; Robin P. Davies; Mike Gale, MSc; Jenny Lam, BA; Andrew Lockey, MMEd; Nigel Stallard, PhD, on behalf of the Electronic Advanced Life Support Collaborators
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From the University of Warwick, Warwick Medical School, Coventry; Heart of England NHS Foundation Trust, Birmingham; National Clinical Guideline Centre, Royal College of Physicians and Resuscitation Council (UK), London; University of Birmingham, Birmingham Medical School, Birmingham; and Calderdale Royal Hospital, Salterhebble, Halifax, United Kingdom, and Australian Resuscitation Council, Melbourne, Australia.

Acknowledgment: The authors thank Professor Ed Peile, who served as the independent chairman of the trial steering committee and provided sound advice and guidance throughout the conduct of the project. Dr. Peile declined authorship to maintain independent oversight of the trial. The authors also thank Teresa Melody (critical care research manager); Elizabeth Adey (research governance manager); and Ian Jacobs, Judith Finn, and Peter Morley (Australian Resuscitation Council) for their support in administering the trial and Sarah Mitchell, Sara Harris, and the Resuscitation Council (UK) ALS Subcommittee members for supporting the development of the e-learning material and the course centers, as well as Sultana Begum-Ali for providing the course staffing data.

Grant Support: The study was funded with a grant from the Resuscitation Council (UK). Dr. Perkins was supported by a National Institute of Health Research Clinician Scientist Award.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3019.

Reproducible Research Statement:Study protocol: Available at www.resus.org.uk/consent/eALSprcl.pdf. Statistical code: Available at https://files.warwick.ac.uk/nstallard/browse/e-ALS. Data set: Not available.

Requests for Single Reprints: Gavin D. Perkins, MD, University of Warwick, Warwick Medical School, Coventry CV4 7AL, United Kingdom; e-mail, g.d.perkins@warwick.ac.uk.

Current Author Addresses: Dr. Perkins: Heart of England NHS Foundation Trust, Birmingham, and University of Warwick, Warwick Medical School, Coventry CV4 7AL, United Kingdom.

Drs. Kimani and Stallard: University of Warwick, Warwick Medical School, Coventry CV4 7AL, United Kingdom.

Dr. Bullock: National Clinical Guideline Centre, Royal College of Physicians, 11 Saint Andrews Place, Regents Park, London NW1 4LE, United Kingdom.

Dr. Clutton-Brock: University of Birmingham, Birmingham Medical School, Birmingham B15 2TT, United Kingdom.

Mr. Davies: Heart of England NHS Foundation Trust, Birmingham B9 5SS, United Kingdom.

Mr. Gale: Australian Resuscitation Council, c/o Royal Australasian College of Surgeons, Spring Street, Melbourne 3000, Australia.

Ms. Lam: Resuscitation Council (UK), 5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR, United Kingdom.

Mr. Lockey: Calderdale Royal Hospital, Salterhebble, Halifax HX3 0PW, United Kingdom.

Author Contributions: Conception and design: G.D. Perkins, I. Bullock, T. Clutton-Brock, R.P. Davies, M. Gale, J. Lam, A. Lockey, N. Stallard.

Analysis and interpretation of the data: I. Bullock, P.K. Kimani, M. Gale, N. Stallard.

Drafting of the article: G.D. Perkins, M. Gale, N. Stallard.

Critical revision of the article for important intellectual content: I. Bullock, R.P. Davies, M. Gale, A. Lockey.

Final approval of the article: G.D. Perkins, P.K. Kimani, I. Bullock, T. Clutton-Brock, R.P. Davies, M. Gale, J. Lam, Andrew Lockey, MMEd; and Nigel Stallard, PhD.

Provision of study materials or patients: G.D. Perkins, T. Clutton-Brock, R.P. Davies, M. Gale, J. Lam.

Statistical expertise: P.K. Kimani, N. Stallard.

Obtaining of funding: G.D. Perkins, I. Bullock, N. Stallard.

Administrative, technical, or logistic support: R.P. Davies, M. Gale, J. Lam.

Collection and assembly of data: G.D. Perkins, R.P. Davies, M. Gale, J. Lam, N. Stallard.

Ann Intern Med. 2012;157(1):19-28. doi:10.7326/0003-4819-157-1-201207030-00005
Text Size: A A A

Background: Each year, more than 1.5 million health care professionals receive advanced life support (ALS) training.

Objective: To determine whether a blended approach to ALS training that includes electronic learning (e-learning) produces outcomes similar to those of conventional, instructor-led ALS training.

Design: Open-label, noninferiority, randomized trial. Randomization, stratified by site, was generated by Sealed Envelope (Sealed Envelope, London, United Kingdom). (International Standardized Randomized Controlled Trial Number Register: ISCRTN86380392)

Setting: 31 ALS centers in the United Kingdom and Australia.

Participants: 3732 health care professionals recruited between December 2008 and October 2010.

Intervention: A 1-day course supplemented with e-learning versus a conventional 2-day course.

Measurements: The primary outcome was performance in a cardiac arrest simulation test at the end of the course. Secondary outcomes comprised knowledge- and skill-based assessments, repeated assessment after remediation training, and resource use.

Results: 440 of the 1843 participants randomly assigned to the blended course and 444 of the 1889 participants randomly assigned to conventional training did not attend the courses. Performance in the cardiac arrest simulation test after course attendance was lower in the electronic advanced life support (e-ALS) group compared with the conventional advanced life support (c-ALS) group; 1033 persons (74.5%) in the e-ALS group and 1146 persons (80.2%) in the c-ALS group passed (mean difference, −5.7% [95% CI, −8.8% to −2.7%]). Knowledge- and skill-based assessments were similar between groups, as was the final pass rate after remedial teaching, which was 94.2% in the e-ALS group and 96.7% in the c-ALS group (mean difference, −2.6% [CI, −4.1% to 1.2%]). Faculty, catering, and facility costs were $438 per participant for electronic ALS training and $935 for conventional ALS training.

Limitations: Many professionals (24%) did not attend the courses. The effect on patient outcomes was not evaluated.

Conclusion: Compared with conventional ALS training, an approach that included e-learning led to a slightly lower pass rate for cardiac arrest simulation tests, similar scores on a knowledge test, and reduced costs.

Primary Funding Source: National Institute of Health Research and Resuscitation Council (UK).


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Figure 1.

Study flow diagram.

c-ALS = conventional advanced life support; e-ALS = electronic advanced life support.

* More data are missing for the conventional group because of a computer system error that occurred during the first 3 courses (1 e-learning and 2 conventional courses).

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Figure 2.

Differences (95% CIs) in pass rates for the CASTest and other outcomes.

The pass rates are predictive margins that account for clustering within courses, stratification by center, and adjustment for age and profession. If all values in the 95% CI are greater than −5% (dashed line), e-ALS training is considered noninferior to c-ALS training. For the CASTest results, the 95% CI crosses the 5% margin and is inconclusive. For the overall pass rate, initial assessment and resuscitation test, and instructor potential, e-ALS training is noninferior to c-ALS training. c-ALS = conventional advanced life support; CASTest = cardiac arrest simulation test; e-ALS = electronic advanced life support; MCQ = multiple-choice question.

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Figure 3.

CASTest domain scores.

Data shown are the proportion of scores for individual performance criteria grouped by the 3 domains: initial assessment and resuscitation, management of pulseless electrical activity, and management of a shockable rhythm. ABCDE = Airway, Breathing, Circulation, Disability, Exposure approach; c-ALS = conventional advanced life support; CASTest = cardiac arrest simulation test; CPR = cardiopulmonary resuscitation; e-ALS = electronic advanced life support; IM = intramuscular; IV = intravenous; VF = ventricular fibrillation.

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Submit a Comment/Letter
Effectiveness of Advanced Life Support Training
Posted on July 31, 2012
Diane B. Wayne, MD, Aashish K. Didwania, MD, William C. McGaghie, PhD
Northwestern University Feinberg School of Medicine
Conflict of Interest: None Declared

We read the article by Perkins et al about e-learning for advanced life support (ALS) education (1) with interest. In their paper, they studied education provided to 3734 health care professionals at 31 centers in the UK and Australia. We commend the authors for their large trial regarding ALS education but are not surprised by the finding that learners randomized to the e-learning arm performed worse on the cardiac arrest simulation test. Deliberate practice with feedback from a skilled instructor is a critical component of skill mastery. This has been shown by K. Anders Ericsson in a number of areas including the development of expertise in medicine and related domains.(2) Therefore, we believe removing deliberate practice from ALS education and replacing it with e-learning lead to the decrease in performance on the simulation test. Current training in ALS has already been shown to be deficient because skills deteriorate rapidly after training.3 By contrast, simulation-based education featuring deliberate practice has been shown to boost ALS skills with improvement lasting up to 14 months.(4) These skills have also been shown to transfer to the clinical setting resulting in improved quality of care.(5)We commend the authors for their sophisticated study showing that costs can be reduced through e-learning. However, the ultimate goal is to design ALS courses that result in highly qualified ALS providers. We believe that more, not less, deliberate practice of simulated scenarios is required to achieve this aim.

Diane B. Wayne, MD, Aashish K. Didwania, MD, William C. McGaghie, PhDNorthwestern University Feinberg School of MedicineChicago, IL


1. Perkins GD, Kimani PK, Bullock I, et al. Improving the efficiency of advanced life support training. Ann Intern Med. 2012; 157: 19-28

2. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004; 79(10 Suppl): S70-S81.

3. Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation. 2008; 78:59-65

4. Wayne DB, Siddall VJ, Butter J, A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills. Acad Med. 2006;81(10 Suppl):S9-S12.

5. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61

Author's Response
Posted on August 22, 2012
Gavin D. Perkins, MD, Andrew Lockey, MMEd, Ian Bullock, PhD
University of Warwick, Coventry, Great Britain
Conflict of Interest: None Declared

We thank Dr Wayne and colleagues for their comments on our paper. We agree with their view that simulation training is central to successful advanced life support (ALS) training. This is consistent with international guidelines for ALS training (1). In our blended learning trial the amount of cardiac arrest simulation sessions was identical between the two groups (2). Face to face content from the two day course replaced with e-learning material were lectures and small group teaching, and not skill focused simulation teaching. By improving the efficiency and reducing the overall cost of ALS training, opportunity presents for money saved to be re-invested in further simulation and deliberate self practice to reduce the impact of skill decay which is known to occur within months initial training (3).

Gavin D Perkins

Andrew Lockey

Ian Bullock


1. Soar J, Monsieurs KG, Ballance JH, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation. Resuscitation 2010;81:1434-44.

2. Perkins GD, Kimani PK, Bullock I, et al. Improving the Efficiency of Advanced Life Support Training: A Randomized, Controlled Trial. Ann Intern Med 2012;157:19-28.

3. Soar J, Mancini ME, Bhanji F, et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e288-330.

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