Part 6: Resuscitation Education Science 2020 American Heart Association Guidelines For Cardiopulmonary Resuscitation And Emergency Cardiovascular Care

HomeCirculationVol. 142, No. 16_suppl_2Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUBPart 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Adam Cheng, MD, Chair, David J. Magid, MD, MPH, Marc Auerbach, MD, MSCE, Farhan Bhanji, MD, MEd, Blair L. Bigham, MD, MSc, Audrey L. Blewer, PhD, MPH, Katie N. Dainty, MSc, PhD, Emily Diederich, MD, MS, Yiqun Lin, MD, MHSc, PhD, Marion Leary, RN, MSN, MPH, Melissa Mahgoub, PhD, Mary E. Mancini, RN, PhD, Kenneth Navarro, PhD(c) and Aaron Donoghue, MD, MSCE, Vice Chair Adam ChengAdam Cheng Search for more papers by this author , David J. MagidDavid J. Magid Search for more papers by this author , Marc AuerbachMarc Auerbach Search for more papers by this author , Farhan BhanjiFarhan Bhanji Search for more papers by this author , Blair L. BighamBlair L. Bigham Search for more papers by this author , Audrey L. BlewerAudrey L. Blewer Search for more papers by this author , Katie N. DaintyKatie N. Dainty Search for more papers by this author , Emily DiederichEmily Diederich Search for more papers by this author , Yiqun LinYiqun Lin Search for more papers by this author , Marion LearyMarion Leary Search for more papers by this author , Melissa MahgoubMelissa Mahgoub Search for more papers by this author , Mary E. ManciniMary E. Mancini Search for more papers by this author , Kenneth NavarroKenneth Navarro Search for more papers by this author and Aaron DonoghueAaron Donoghue Search for more papers by this author Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000903Circulation. 2020;142:S551–S579Top 10 Take-Home MessagesEffective education is an essential contributor to improved survival outcomes from cardiac arrest.Use of a deliberate practice and mastery learning model during resuscitation training improves skill acquisition and retention for many critical tasks.The addition of booster training to resuscitation courses is associated with improved cardiopulmonary resuscitation (CPR) skill retention over time and improved neonatal outcomes.Implementation of a spaced learning approach for resuscitation training improves clinical performance and technical skills compared with massed learning.The use of CPR feedback devices during resuscitation training promotes CPR skill acquisition and retention.Teamwork and leadership training, high-fidelity manikins, in situ training, gamified learning, and virtual reality represent opportunities to enhance resuscitation training that may improve learning outcomes.Self-directed CPR training represents a reasonable alternative to instructor-led CPR training for lay rescuers.Middle school– and high school–age children should be taught how to perform high-quality CPR because this helps build the future cadre of trained community-based lay rescuers.To increase bystander CPR rates, CPR training should be tailored to low–socioeconomic status neighborhoods and specific racial and ethnic communities, where there is currently a paucity of training opportunities.Future resuscitation education research should include outcomes of clinical relevance, establish links between performance outcomes in training and patient outcomes, describe cost-effectiveness of interventions, and explore how instructional design can be tailored to specific skills.PreambleEach year, millions of providers receive basic and advanced life support training with the aim of improving patient outcomes from cardiac arrest.1 Resuscitation training programs incorporate evidence-based content while providing opportunities for learners to practice lifesaving skills in individual and team-based clinical environments. While resuscitation training is widespread, learners frequently fall short of achieving the desired performance outcomes, resulting in skills that do not consistently translate to clinical care with real patients.1,2The International Liaison Committee on Resuscitation Formula for Survival (Figure) emphasizes 3 essential components influencing survival outcomes from cardiac arrest: guidelines based on current resuscitation science, effective education of resuscitation providers, and local implementation of guidelines during patient care.3 Greater emphasis on effective education will improve provider performance, enhance local implementation of guidelines, and potentially increase survival rates from cardiac arrest.Download figureDownload PowerPointFigure. Formula for Survival in Resuscitation: Key Elements Contributing to Educational Efficiency. ACLS indicates advanced cardiovascular life support; and CPR, cardiopulmonary resuscitation.These guidelines contain recommendations for the design and delivery of resuscitation training for lay rescuers and healthcare providers. The provision of effective education is highly dependent on the instructional design of educational programs because this determines how content is delivered to the learner. In this Part, we explore the evidence informing different instructional design features and discuss how social determinants of health (eg, socioeconomic status [SES], race) and individual factors (eg, practitioner experience) may influence clinical performance and patient outcomes.References1. Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, Donoghue A, Duff JP, Eppich W, Auerbach M, Bigham BL, Blewer AL, Chan PS, Bhanji F; American Heart Association Education Science Investigators; and on behalf of the American Heart Association Education Science and Programs Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the American Heart Association.Circulation. 2018; 138:e82–e122. doi: 10.1161/CIR.0000000000000583LinkGoogle Scholar2. Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman JM, Sinz EH, Cheng A. Part 14: education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2015; 132(suppl 2):S561–e573. doi: 10.1161/CIR.0000000000000268LinkGoogle Scholar3. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JPUtstein Formula for Survival Collaborators. The formula for survival in resuscitation.Resuscitation. 2013; 84:1487–1493. doi: 10.1016/j.resuscitation.2013.07.020CrossrefMedlineGoogle ScholarIntroductionScope of GuidelineCardiac arrest remains a major public health problem, with more than 600 000 cardiac arrests per year in the United States.1,2 Survival rates of patients with cardiac arrest remain low despite advancements in resuscitation science.3 Each year, millions of people receive basic and advanced life support training in an effort to improve the quality of care delivered to cardiac arrest patients.4 Resuscitation training programs are designed to convey evidence-based content and provide opportunities for learners (ie, those enrolled in resuscitation training programs) to apply knowledge and practice critical skills. These programs, however, frequently fall short of achieving the desired learning outcomes (eg, knowledge and skill acquisition), with performance that does not consistently translate over to the real-world clinical environment.4,5 For example, cardiopulmonary resuscitation (CPR) skills that are acquired immediately after basic life support (BLS) training often show decay by as early as 3 months, resulting in many BLS-trained healthcare providers—such as physicians, nurses, respiratory therapists, and other healthcare professionals—struggling to perform guideline-compliant CPR during simulated and real cardiac arrests.6–14 Additionally, current research on lay rescuer CPR training is lacking evidence describing the optimal methods to train bystanders to recognize cardiac arrest, initiate CPR, and use automated external defibrillators appropriately.15–17 A dedicated focus on instructional design is essential to ensure that knowledge and skills acquired during training are applied when caring for patients in cardiac arrest.4Improving survival from cardiac arrest is highly dependent on the quality of resuscitative care. Many key determinants of survival, such as immediate recognition of cardiac arrest, early initiation of CPR, early defibrillation, and high-quality chest compressions, are variables that can be targeted by resuscitation training programs to improve patient outcomes. Instructional design features are the key elements, or “active ingredients,” of resuscitation training programs that determine how content is delivered to the learner.18 A better understanding of the impact of instructional design features on learning outcomes will enable educators to design training programs that translate into outstanding clinical performance during cardiac arrests. Furthermore, appreciating how social determinants of health (eg, SES, race) and individual factors (eg, practitioner experience) influence the downstream impact of resuscitation education will help inform future policy and implementation strategies. In this Part, we describe the evidence supporting key elements of resuscitation education and provide recommendations aimed at improving learner outcomes and patient outcomes from cardiac arrest.The following sections briefly describe the process of evidence review and guideline development. See “Part 2: Evidence Evaluation and Guidelines Development” in the 2020 ECC Guidelines for more details on this process.19Organization of the Resuscitation Education Science Writing GroupThe Resuscitation Education Science Writing Group comprised a diverse team of experts with backgrounds in resuscitation education, clinical medicine (ie, pediatrics, intensive care, emergency medicine), nursing, prehospital care, health services, and education research. Writing group members are American Heart Association (AHA) volunteers with an interest and recognized expertise in resuscitation and are selected by the AHA Emergency Cardiovascular Care (ECC) Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias and improper influence during development of the guidelines.20 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Disclosure information for writing group members is listed in Appendix 1.Methodology and Evidence ReviewThis Part of the 2020 AHA Guidelines for CPR and ECC is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation and affiliated International Liaison Committee on Resuscitation member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Each of these resulted in a description of the literature that facilitated guideline development.21–25 Reviews were limited to the resuscitation education science literature, but many of the concepts reviewed have origins within other fields (eg, medical education, psychology).Class of Recommendation and Level of EvidenceThe AHA Resuscitation Education Science Writing Group reviewed all relevant and current AHA Guidelines for CPR and ECC5,26–37 and the relevant 2020 International Consensus on CPR and ECC Science With Treatment Recommendations27 to determine if current guidelines should be reaffirmed, revised, or retired and whether new recommendations were needed. The writing group then drafted, reviewed, and approved recommendations (by majority vote among members), assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength; see Table 1, Applying COR and LOE to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care).Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).Classes of RecommendationCOR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit.Suggested phrases for writing Class 1 recommendations includeIs recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B.Suggested phrases for writing Class 2a recommendations includeIs reasonableCan be useful/effective/beneficialComparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Suggested phrases for writing Class 2b recommendations includeMay/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-establishedSuggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) includeIs not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/otherSuggested phrases for writing Class 3: Harm recommendations includePotentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/otherLevels of EvidenceFor LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO.Those categorized as Level A are derived fromHigh-quality evidence from more than 1 randomized clinical trial, or RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studiesThose categorized as Level B-R (randomized) are derived fromModerate-quality evidence from 1 or more RCTsMeta-analyses of moderate-quality RCTsThose categorized as Level B-NR (nonrandomized) are derived fromModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studiesThose categorized as Level C-LD (limited data) are derived fromRandomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjectsThose categorized as Level C-EO (expert opinion) are derived fromConsensus of expert opinion based on clinical experienceCOR and LOE are determined independently (any COR may be paired with any LOE).A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Importantly, applying Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)38 to educational studies yields greater challenges than its application to clinical studies. Specific considerations for studies involving educational outcomes (eg, improved “outcomes” in simulated patient settings or improved performance on summative assessment tools) are not provided in GRADE methodology; the writing group frequently assigned LOE to these studies according to a combination of a typical review of study quality, perceived importance of underlying constructs in the context of educational science, and (where possible) extrapolation of findings to analogous clinical phenomena (eg, outcomes in real patients as opposed to simulated ones).Guideline StructureThe 2020 guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.39 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. A brief introduction or short synopsis puts the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific supportive text clarifies the rationale and key study data supporting the recommendations. Hyperlinked references are provided to facilitate quick access and review.Document Review and ApprovalThese guidelines were submitted for blinded peer review to subject matter experts nominated by the AHA. Peer reviewer feedback was provided for guidelines in draft format and again in final format. The guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2.AbbreviationsAbbreviationMeaning/PhraseACLSadvanced cardiovascular life supportAHAAmerican Heart AssociationB-CPRbystander cardiopulmonary resuscitationBLSbasic life supportCORClass of RecommendationCPRcardiopulmonary resuscitationECCemergency cardiovascular careEMSemergency medical servicesEOexpert opinionLDlimited dataLOELevel of EvidenceNRnonrandomizedOHCAout-of-hospital cardiac arrestPALSpediatric advanced life supportRCTrandomized controlled trialROSCreturn of spontaneous circulationSESsocioeconomic statusVRvirtual realityReferences1. Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-hospital cardiac arrest: a review.JAMA. 2019; 321:1200–1210. doi: 10.1001/jama.2019.1696CrossrefMedlineGoogle Scholar2. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2019 update: a report from the American Heart Association.Circulation. 2019; 139:e56–e528. doi: 10.1161/CIR.0000000000000659LinkGoogle Scholar3. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, et al.; CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association.Circulation. 2013; 128:417–435. doi: 10.1161/CIR.0b013e31829d8654LinkGoogle Scholar4. Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, Donoghue A, Duff JP, Eppich W, Auerbach M, et al.; American Heart Association Education Science Investigators; on behalf of the American Heart Association Education Science and Programs Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the American Heart Association.Circulation. 2018; 138:e82–e122. doi: 10.1161/CIR.0000000000000583LinkGoogle Scholar5. Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman JM, Sinz EH, Cheng A. Part 14: education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2015; 132(suppl 2):S561–573. doi: 10.1161/CIR.0000000000000268LinkGoogle Scholar6. Lin Y, Cheng A, Grant VJ, Currie GR, Hecker KG. Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers - a randomized controlled trial.Resuscitation. 2018; 130:6–12. doi: 10.1016/j.resuscitation.2018.06.025CrossrefMedlineGoogle Scholar7. Anderson R, Sebaldt A, Lin Y, Cheng A. Optimal training frequency for acquisition and retention of high-quality CPR skills: a randomized trial.Resuscitation. 2019; 135:153–161. doi: 10.1016/j.resuscitation.2018.10.033CrossrefMedlineGoogle Scholar8. Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, et al.. ROC Investigators. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality–a report from the ROC epistry-cardiac arrest.Resuscitation. 2015; 93:150–157. doi: 10.1016/j.resuscitation.2015.04.010CrossrefMedlineGoogle Scholar9. Sutton RM, Niles D, French B, Maltese MR, Leffelman J, Eilevstjonn J, Wolfe H, Nishisaki A, Meaney PA, Berg RA, et al.. First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children.Resuscitation. 2014; 85:70–74. doi: 10.1016/j.resuscitation.2013.08.014CrossrefMedlineGoogle Scholar10. Sutton RM, Niles D, Nysaether J, Abella BS, Arbogast KB, Nishisaki A, Maltese MR, Donoghue A, Bishnoi R, Helfaer MA, et al.. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents.Pediatrics. 2009; 124:494–499. doi: 10.1542/peds.2008-1930CrossrefMedlineGoogle Scholar11. Stiell IG, Brown SP, Christenson J, Cheskes S, Nichol G, Powell J, Bigham B, Morrison LJ, Larsen J, Hess E, et al.. Resuscitation Outcomes Consortium (ROC) Investigators. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?Crit Care Med. 2012; 40:1192–1198. doi: 10.1097/CCM.0b013e31823bc8bbCrossrefMedlineGoogle Scholar12. Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest.Resuscitation. 1994; 28:195–203. doi: 10.1016/0300-9572(94)90064-7CrossrefMedlineGoogle Scholar13. Idris AH, Guffey D, Aufderheide TP, Brown S, Morrison LJ, Nichols P, Powell J, Daya M, Bigham BL, Atkins DL, et al.. Resuscitation Outcomes Consortium (ROC) Investigators. Relationship between chest compression rates and outcomes from cardiac arrest.Circulation. 2012; 125:3004–3012. doi: 10.1161/CIRCULATIONAHA.111.059535LinkGoogle Scholar14. Cheng A, Hunt EA, Grant D, Lin Y, Grant V, Duff JP, White ML, Peterson DT, Zhong J, Gottesman R, et al.. International Network for Simulation-based Pediatric Innovation, Research, and Education CPR Investigators. Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions.Resuscitation. 2015; 97:13–19. doi: 10.1016/j.resuscitation.2015.08.024CrossrefMedlineGoogle Scholar15. Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review.Resuscitation. 2013; 84:415–421. doi: 10.1016/j.resuscitation.2012.12.008CrossrefMedlineGoogle Scholar16. Todd KH, Heron SL, Thompson M, Dennis R, O’Connor J, Kellermann AL. Simple CPR: a randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation.Ann Emerg Med. 1999; 34:730–737. doi: 10.1016/s0196-0644(99)70098-3CrossrefMedlineGoogle Scholar17. Castrén M, Nurmi J, Laakso JP, Kinnunen A, Backman R, Niemi-Murola L. Teaching public access defibrillation to lay volunteers–a professional health care provider is not a more effective instructor than a trained lay person.Resuscitation. 2004; 63:305–310. doi: 10.1016/j.resuscitation.2004.06.011CrossrefMedlineGoogle Scholar18. Cook DA, Hamstra SJ, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hatala R. Comparative effectiveness of instructional design features in simulation-based education: systematic review and meta-analysis.Med Teach. 2013; 35:e867–898. doi: 10.3109/0142159X.2012.714886CrossrefMedlineGoogle Scholar19. Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, et al.. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2020; 142:(suppl 2):S358–S365. doi: 10.1161/CIR.0000000000000903LinkGoogle Scholar20. American Heart Association. Conflict of interest policy.https://www.heart.org/en/about-us/statements-and-policies/conflict-of-interest-policy. Accessed December 31, 2019.Google Scholar21. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, et al.. PRISMA Extension for Scoping Reviews (PRISMAScR): checklist and explanation.Ann Intern Med. 2018; 169:467–473. doi: 10.7326/M18-0850CrossrefMedlineGoogle Scholar22. International Liaison Committee on Resuscitation. Continuous evidence evaluation guidance and templates.https://www.ilcor.org/documents/continuous-evidence-evaluation-guidance-and-templates. Accessed December 31, 2019.Google Scholar23. Institute of Medicine (US) Committee of Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S, eds. Washington, DC: The National Academies Press; 2011.Google Scholar24. PRISMA. PRISMA for scoping reviews.http://www.prisma-statement.org/Extensions/ScopingReviews. Accessed December 31, 2019.Google Scholar25. International Liaison Committee on Resuscitation (ILCOR). Continuous evidence evaluation guidance and templates: 2020 evidence update process final.https://www.ilcor.org/documents/continuous-evidence-evaluationguidance-and-templates. Accessed December 31, 2019.Google Scholar26. Bhanji F, Mancini ME, Sinz E, Rodgers DL, McNeil MA, Hoadley TA, Meeks RA, Hamilton MF, Meaney PA, Hunt EA, et al.. Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2010; 122(suppl 3):S920–S933. doi: 10.1161/CIRCULATIONAHA.110.971135LinkGoogle Scholar27. Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh M-J, Iwami T, et al.; on behalf of the Education, Implementation, and Teams Collaborators. Education, implementation, and teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.Circulation. 2020; 142(suppl 1):S222–S283. doi: 10.1161/CIR.0000000000000896LinkGoogle Scholar28. Atkins DL, de Caen AR, Berger S, Samson RA, Schexnayder SM, Joyner BL, Bigham BL, Niles DE, Duff JP, Hunt EA, et al.. 2017 American Heart Association focused update on pediatric basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2018; 137:e1–e6. doi: 10.1161/CIR.0000000000000540LinkGoogle Scholar29. Kleinman ME, Goldberger ZD, Rea T, Swor RA, Bobrow BJ, Brennan EE, Terry M, Hemphill R, Gazmuri RJ, Hazinski MF, et al.. 2017 American Heart Association focused update on adult basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2018; 137:e7–e13. doi: 10.1161/CIR.0000000000000539LinkGoogle Scholar30. Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabañas JG, Link MS, Kurz MC, Chan PS, Morley PT, et al.. 2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2019; 140:e881–e894. doi: 10.1161/CIR.0000000000000732LinkGoogle Scholar31. Panchal AR, Berg KM, Cabañas JG, Kurz MC, Link MS, Del Rios M, Hirsch KG, Chan PS, Hazinski MF, Morley PT, et al.. 2019 American Heart Association focused update on systems of care: dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2