Andrew Owen

Peer-led training and assessment in basic life support for healthcare students: Synthesis of literature review and fifteen years practical experience

BACKGROUNDnIn 1995, the University of Birmingham, UK, School of Medicine and Dentistry replaced lecture-based basic life support (BLS) teaching with a peer-led, practical programme. We present our 15-yr experience of peer-led healthcare undergraduate training and examination with a literature review.nnnMETHODSnA literature review of healthcare undergraduate peer-led practical skills teaching was performed though Pubmed. The development of the Birmingham course is described, from its inception in 1995-2011. Training methods include peer-led training and assessment by senior students who complete an European Resuscitation Council-endorsed instructor course. Student assessors additionally undergo training in assessment and communication skills. The course has been developed by parallel research evaluation and peer-reviewed publication. Course administration is by an experienced student committee with senior clinician support. Anonymous feedback from the most recent courses and the current annual pass rates are reported.nnnRESULTSnThe literature review identified 369 publications of which 28 met our criteria for inclusion. Largely descriptive, these are highly positive about peer involvement in practical skills teaching using similar, albeit smaller, courses to that described below. Currently approximately 600 first year healthcare undergraduates complete the Birmingham course; participant numbers increase annually. Successful completion is mandatory for students to proceed to the second year of studies. First attempt pass rate is 86%, and close to 100% (565/566 students, 99.8%) following re-assessment the same day. 97% of participants enjoyed the course, 99% preferred peer-tutors to clinicians, 99% perceived teaching quality as good or excellent, and felt they had sufficient practice. Course organisation was rated good or excellent by 91%. Each year 3-4 student projects have been published or presented internationally. The annual cost of providing the course is currently £15,594.70 (Eur 18,410), or approximately £26 (Eur 30) per student.nnnCONCLUSIONSnThis large scale, peer-led BLS course demonstrates that such programmes can have excellent outcomes with outstanding participant satisfaction. Peer-tutors and assessors are competent, more available and less costly than clinical staff. Student instructors develop skills in teaching, assessment and appraisal, organisation and research. Sustainability is possible given succession-planning and consistent leadership.

Sphingosine-1-Phosphate Prevents Egress of Hematopoietic Stem Cells From Liver to Reduce Fibrosis

Background & Aims There is growing interest in the use of bone marrow cells to treat liver fibrosis, however, little is known about their antifibrotic efficacy or the identity of their effector cell(s). Sphingosine-1-phosphate (S1P) mediates egress of immune cells from the lymphoid organs into the lymphatic vessels; we investigated its role in the response of hematopoietic stem cells (HSCs) to liver fibrosis in mice. Methods Purified (c-kit+/sca1+/lin-) HSCs were infused repeatedly into mice undergoing fibrotic liver injury. Chronic liver injury was induced in BoyJ mice by injection of carbon tetrachloride (CCl4) or placement on a methionine-choline–deficient diet. Some mice were irradiated and given transplants of bone marrow cells from C57BL6 mice, with or without the S1P antagonist FTY720; we then studied HSC mobilization and localization. Migration of HSC lines was quantified in Transwell assays. Levels of S1P in liver, bone marrow, and lymph fluid were measured using an enzyme-linked immunosorbent assay. Liver tissues were collected and analyzed by immunohistochemical quantitative polymerase chain reaction and sphingosine kinase activity assays. We performed quantitative polymerase chain reaction analyses of the expression of sphingosine kinase 1 and 2, sphingosine-1-phosphate lyase 1, and sphingosine-1-phosphate phosphatase 1 in normal human liver and cirrhotic liver from patients with alcohol-related liver disease (n = 6). Results Infusions of HSCs into mice with liver injury reduced liver scarring based on picrosirius red staining (49.7% reduction in mice given HSCs vs control mice; P < .001), and hepatic hydroxyproline content (328 mg/g in mice given HSCs vs 428 mg/g in control mice; P < .01). HSC infusion also reduced hepatic expression of α-smooth muscle actin (0.19 ± 0.007-fold compared with controls; P < .0001) and collagen type I α 1 chain (0.29 ± 0.17-fold compared with controls; P < .0001). These antifibrotic effects were maintained with infusion of lymphoid progenitors that lack myeloid potential and were associated with increased numbers of recipient neutrophils and macrophages in liver. In studies of HSC cell lines, we found HSCs to recruit monocytes, and this process to require C-C motif chemokine receptor 2. In fibrotic liver tissue from mice and patients, hepatic S1P levels increased owing to increased hepatic sphingosine kinase-1 expression, which contributed to a reduced liver:lymph S1P gradient and limited HSC egress from the liver. Mice given the S1P antagonist (FTY720) with HSCs had increased hepatic retention of HSCs (1697 ± 247 cells in mice given FTY720 vs 982 ± 110 cells in controls; P < .05), and further reductions in fibrosis. Conclusions In studies of mice with chronic liver injury, we showed the antifibrotic effects of repeated infusions of purified HSCs. We found that HSCs promote recruitment of endogenous macrophages and neutrophils. Strategies to reduce SIP signaling and increase retention of HSCs in the liver could increase their antifibrotic activities and be developed for treatment of patients with liver fibrosis.

Mesenchymal stromal cell therapy in liver disease: opportunities and lessons to be learnt?

End-stage liver disease is responsible for 30,000 deaths per year in the United States alone, and it is continuing to increase every year. With liver transplantation the only curative treatment currently available, new therapies are in great demand. Mesenchymal stem cells (MSC) offer an opportunity to both treat liver inflammatory damage, as well as reverse some of the changes that occur following chronic liver injury. With the ability to regulate both the innate and adaptive immune system, as well as both inhibit and promote apoptosis of effector inflammatory cells, there are numerous therapeutic opportunities for MSC in acute and chronic liver disease. This article critically appraises the potential therapeutic roles of MSC in liver disease, as well as the barriers to their adoption into clinical practice.

A randomised control trial comparing two techniques for locating chest compression hand position in adult Basic Life Support

INTRODUCTIONnChest compressions performed correctly have the potential to increase survival post cardiac arrest. The 2005 European Resuscitation Council (ERC) guidelines altered and simplified instructions for hand position placement to increase the number of chest compressions performed. This randomised controlled trial compares chest compression efficacy (hand position and number of effective chest compressions) after training using the 2005 guidelines or the 2005 guidelines with a hand position modification based on 2000 ERC guidelines.nnnMETHODSnFirst year healthcare students at the University of Birmingham, United Kingdom, were randomly allocated to either 2005 or intervention group immediately after passing a Basic Life Support (BLS) assessment to ERC standards. The 2005 group performed 2 min of BLS on a SkillReporter™ manikin (Laerdal Medical, Stavanger, Norway). The intervention group received training on hand placement using landmark techniques from the 2000 ERC guidelines; emphasising rapid hand positioning. This group also performed 2 min of BLS on a SkillReporter™ manikin.nnnRESULTSn82 students were assessed; 41 in the 2005 group and 41 in the intervention group. Average compression rate was 102 in the 2005 group and 104 in the intervention group (p=0.29). Average number of incorrect hand placements was 24 in the 2005 group and 9 in the intervention group (p=0.03).nnnCONCLUSIONSnThe use of landmark measurement techniques in hand placement for external chest compressions does not have a detrimental effect on the number of chest compressions performed during BLS and increases correct hand positioning.

A systematic review and meta-analysis of perioperative oral decontamination in patients undergoing major elective surgery

BackgroundOral antiseptics reduce nosocomial infections and ventilator-associated pneumonia in critically ill medical and surgical patients intubated for prolonged periods. However, the role of oral antiseptics given before and after planned surgery is not clear. The aim of this systematic review and meta-analysis is to determine the effect of oral antiseptics (chlorhexidine or povidone–iodine) when administered before and after major elective surgery.MethodsSearches were conducted of the MEDLINE, EMBASE and Cochrane databases. The analysis was performed using the random-effects method and the risk ratio (RR) with 95xa0% confidence interval (CI).ResultsOf 1114 unique identified articles, perioperative chlorhexidine was administered to patients undergoing elective surgery in four studies. This identified 2265 patients undergoing elective cardiac surgery, of whom 1093 (48.3xa0%) received perioperative chlorhexidine. Postoperative pneumonia and nosocomial infections were observed in 5.3 and 20.2xa0% who received chlorhexidine compared to 10.4 and 31.3xa0% who received a control preparation, respectively. Oral perioperative chlorhexidine significantly reduced the risk of postoperative pneumonia (RRu2009=u20090.52; 95xa0% CI 0.39–0.71; pu2009<u20090.01) and overall nosocomial infections (RRu2009=u20090.65; 95xa0% CI 0.52–0.81; pu2009<u20090.01), with no effect on in-hospital mortality (RRu2009=u20091.01; 95xa0% CI 0.49–2.09; pu2009=u20090.98).ConclusionsPerioperative oral chlorhexidine significantly decreases the incidence of nosocomial infection and postoperative pneumonia in patients undergoing elective cardiac surgery. There are no randomised controlled studies of this simple and cheap intervention in patients undergoing elective non-cardiac surgery.Trial RegistrationThis systematic review was registered with the International prospective register of systematic reviews (PROSPERO). The registration number is CRD42015016063.

Structured training in assessment increases confidence amongst basic life support instructors

AIMnAssessment skills are often neglected in resuscitation training and it has been shown that the ERC BLS/AED instructor course may be insufficient to prepare candidates for an assessment role. We have introduced an Assessment Training Programme (ATP) to improve assessors decision making. In this article we present our ATP and an observational study of candidates confidence levels upon completing both an ERC BLS/AED instructor course and our ATP.nnnMETHODSnForty-seven candidates undertook the ERC instructor course and 20 qualified ERC BLS/AED instructors undertook the ATP. Pre- and post-course questionnaires were completed. Confidence was assessed on ten-point Visual Analogue Scales (VAS).nnnRESULTSnOverall confidence on the ERC BLS/AED instructor course rose from 5.9 (SD 1.8) to 8.7 (SD 1.4) (P < 0.001). A more modest improvement was witnessed on the ATP, rising from 8.2 (SD 1.4) to 9.6 (SD 0.5) (P < 0.001). Upon completion of their respective courses, assessors (mean 9.6, SD 0.5) were significantly more confident at assessing than instructors (mean 8.7, SD 0.5) (P<0.001). Confidence in assessing individual algorithm components was similar on both courses. On the post-course questionnaire those on the ATP remained significantly more confident at assessing borderline candidates compared to instructors (P < 0.001), with no difference for clear pass (P = 0.067) or clear fail (P = 0.060) candidates.nnnCONCLUSIONnThe ATP raises the confidence of assessing BLS/AED candidates to a level above that of the ERC instructor course alone. We advocate that resuscitation organisations consider integrating an ATP into their existing training structure.

Use of the learning conversation improves instructor confidence in life support training: An open randomised controlled cross-over trial comparing teaching feedback mechanisms

AIMSnFeedback is vital for the effective delivery of skills-based education. We sought to compare the sandwich technique and learning conversation structured methods of feedback delivery in competency-based basic life support (BLS) training.nnnMETHODSnOpen randomised crossover study undertaken between October 2014 and March 2015 at the University of Birmingham, United Kingdom. Six-hundred and forty healthcare students undertaking a European Resuscitation Council (ERC) BLS course were enrolled, each of whom was randomised to receive teaching using either the sandwich technique or the learning conversation. Fifty-eight instructors were randomised to initially teach using either the learning conversation or sandwich technique, prior to crossing-over and teaching with the alternative technique after a pre-defined time period. Outcome measures included skill acquisition as measured by an end-of-course competency assessment, instructors perception of teaching with each feedback technique and candidates perception of the feedback they were provided with.nnnRESULTSnScores assigned to use of the learning conversation by instructors were significantly more favourable than for the sandwich technique across all but two assessed domains relating to instructor perception of the feedback technique, including all skills-based domains. No difference was seen in either assessment pass rates (80.9% sandwich technique vs. 77.2% learning conversation; OR 1.2, 95% CI 0.85-1.84; p=0.29) or any domain relating to candidates perception of their teaching technique.nnnCONCLUSIONS & RELEVANCEnThis is the first direct comparison of two feedback techniques in clinical medical education using both quantitative and qualitative methodology. The learning conversation is preferred by instructors providing competency-based life support training and is perceived to favour skills acquisition.

Comparison of the errors in basic life support performance after training using the 2000 and 2005 ERC guidelines

The importance of immediate cardiopulmonary resuscitation (CPR) and defibrillation after cardiac arrest is established. The 2005 European Resuscitation Council (ERC) guidelines were altered to try to improve survival after cardiac arrest. This observational study compares the errors in basic life support (BLS) performance after training using the 2000 or 2005 guidelines. First-year healthcare students at the University of Birmingham, United Kingdom, were taught adult BLS in a standardised 8-h course: an historical group with previous ERC guidelines (Old), the other with 2005 ERC guidelines (New). 2537 (Old 1773; New 764) students were trained and assessed in BLS. There was no difference in overall error rate between Old and New (5.53% vs. 6.70% (p>0.05)) or adherence to the sequence of the respective BLS algorithm. The New group (hands in centre of the chest) had significantly more erroneous hand positions compared to the Old group (5.23% vs. 1.64%, p<0.001). The 2005 ERC guidelines do not significantly improve correct BLS performance. Removal of hand placement measurement results in a significant increase in hand position errors. The clinical benefit of an increased number of compressions impaired by worsened hand positioning is unknown and requires further study.