Basic life support: supporting safe practice

Field: Health Professions (Health Sciences)

Reflecting on my grandfather’s collapse last November in the presence of my mother, a non-health professional trained in Basic Life Support (BLS), I have wondered what evidence underpins the 3-year validity period of certification in BLS.1 Recall of the orderly approach to BLS is far easier in an assessment immediately following an intensive course and in the context of a classroom. In contrast, maintaining calm and confidence in an unexpected situation is a skill, and for my mother the additional stress of the casualty being her father and remembering training from over 2 years prior was both difficult and frightening. Similarly, I can confirm from my own experience that it is easy to fall into a false sense of security and assume you are competent because you have the certificate. I completed a BLS training course in secondary (high) school and joined the London Links St Johns Ambulance society at King’s College London in my first year of medical school. During the first Links session, the facilitator invited a volunteer to demonstrate how to approach an unresponsive casualty, and under the pressure of having an audience, I had doubts that I would do this correctly. A systematic review conducted into BLS training programmes delivered to adults in non-health professions found large variability in the time period selected to assess competence. Practical skill retention beyond 2 weeks of the initial training was only assessed in 52% of studies. Of these, the mean period was 14 weeks, and the longest duration after training was 48 weeks. This study found significant reductions in competence as time elapsed, whereby the practical simulation pass rate was just 19% for students who were assessed at 12 months, compared to those assessed after 3 months and 6 months, where average scores were 100% and 78.9% respectively.2 This is alarming considering 48 weeks is markedly shorter than the validity period awarded to BLS certification in the UK. The practical simulation pass rate was just 19% for students who were assessed at 12 months. NHS health care professionals are required to complete mandatory BLS training annually. The method of assessment is determined locally; however, a practical approach is recommended by the UK Resuscitation Council for clinical staff.3 It is interesting to contrast the requirements of health care staff with that of the layperson. The former expect to encounter unwell patients, and are prepared for the worst case scenario through regular training to ensure adequacy in both technical knowledge and confidence. Whereas, in the out of hospital setting, there is no such expectation, and therefore the responder is already at the disadvantage of feeling unprepared. As we have seen, there is decay in BLS knowledge as time passes since the day of certification, and therefore this heightened emotional response is likely to further reduce recall of the appropriate procedures to manage such an emergency. Alternative platforms to provide BLS training have been explored in recent studies. Video self-instruction (VSI) courses have been used as a substitute or adjunct to minimise face to face learning, wherein equal skill acquisition has been observed during examined practical simulations.4 Such training encompasses an educational videotape and accompanying manikin. It has many advantages: the course can be completed in an individual’s own time from the comfort of their own home; knowledge can be shared and skills practised with other household members (see Figure 1). Furthermore, since cardiac arrests are seven times more likely to take place at home compared to in a public location,5 the simulation becomes more realistic and transferable to real life. Video self-instruction (VSI) courses have been used as a substitute or adjunct. Cardiac arrests are seven times more likely to take place at home compared to in a public location. Considering the lack of evidence supporting skill retainment after 3 years in the research available, the duration of BLS certification for non-health professionals would appear arbitrary. At present the Health and Safety Executive (HSE) in the UK recommends people with a BLS qualification refresh their training annually; however, this is not mandatory. Perhaps the 3-year period was designed to incentivise attendance at BLS courses, and an annual renewal may be perceived as too great of a commitment. However, with the introduction of VSI, convenience is a unique selling point. Understandably, this may not be possible in resource poor countries, and without feedback from a professional on the practical skills, competence cannot be guaranteed. I recommend annual online renewal of the qualification by laypersons in the UK, following an initial in-person session to ensure adequate technical skill, akin to the requirements of health care staff. Moreover, we should be encouraging people to practice at home throughout the year in order to minimise the decline in skill and self-efficacy illustrated through both my family's anecdotal experience and in the literature, which will ultimately save a life.