Katholieke Universiteit LeuvenGroup Biomedical SciencesFaculty of MedicineAcademic Department of General Practice

Doctoral thesis in Medical SciencesLeuven, 2011

in first aid

Stijn Van de Velde

Evidence-based practice

Copyright cover photo: Rode Kruis-Vlaanderen |Carl Vandervoort

Katholieke Universiteit Leuven

Group Biomedical Sciences

Faculty of Medicine

Academic Department of General Practice

Belgian Centre for Evidence-Based Medicine

Belgian Branch of the Dutch Cochrane Centre

EVIDENCE-BASED PRACTICE IN FIRST AID

Stijn Van de Velde

Jury: F. Buntinx, D. Knockaert, B. Nemery de Bellevaux, K. Vandewoude, J. Volmink

Promoter: B. Aertgeerts

Co-promoter: D. Ramaekers

Co-promoter: P. Vandekerckhove

Leuven, 30 June 2011

Doctoral Thesis in Medical Sciences

TABLE OF CONTENTS

1

CHAPTER 1 Introduction 5

The importance of first aid training 6

The role of evidence-based practice 7

Evidence-based practice and first aid 9

Specific objectives and outline of the thesis 10

CHAPTER 2 European first aid guidelines 13

CHAPTER 3 Effectiveness of nonresuscitative first aid training in

laypersons: a systematic review

27

CHAPTER 4 Does training on barriers to helping facilitate

emergency helping behaviour among laypersons

trained in first aid? A randomised deception trial

45

CHAPTER 5 Rapid reviews 67

BestBET 1: optimal body position in oral poisoning

cases

68

BET 2: Potato peel dressings for burn wounds 72

Medicinal use of potato-derived products:

conclusions of a rapid versus full systematic

review

76

CHAPTER 6 Rigour of development does not AGREE with

recommendations in practice guidelines on the use

of ice for acute ankle sprains

81

2

CHAPTER 7 Discussion 91

Contributions of this thesis 92

Current methodological perspectives on evidence-

based guidelines in general and on the European

first aid guidelines in particular

94

Potential solutions for drawing the line between

evidence-based and ‘evidence-biased’ guidelines

99

Suggestions for future research 100

Conclusions 103

REFERENCES 105

SUMMARY 113

SAMENVATTING 119

PROFESSIONAL CAREER 125

LIST OF PUBLICATIONS 129

ACKNOWLEDGEMENTS 133

APPENDICES

European first aid guidelines: search strategy 137

RCT: Questionnaires 157

RCT: Didactical plan experimental and control

intervention

167

3

4

INTRODUCTION

CHAPTER 1

5

1.1 The importance of first aid training

Injuries account for 8% of mortality and 13% of disability-adjusted life years

(DALY) in the European region.1 Incidence estimates for trauma from accidents

and violence equate to 1 death and 18 persons needing first aid treatment per

minute in Europe.1 The burden of injuries to health globally is considerable.

Many of these deaths are inevitable and occur before pre-hospital medical care

is available.2-4 However, post-mortem examinations of pre-hospital deaths

indicated that at least one third could have been prevented by means of simple

actions.4;5 Observational studies reported that in more than half of the cases

bystanders were at the accident site before the arrival of medical care.6;7 If

these bystanders are able and willing to provide aid, they have the potential to

save lives. The provision of such immediate help by laypeople to suddenly ill or

injured persons before the arrival of professional medical care is commonly

defined as first aid.8 From the above it has been advocated that as many people

as possible should be trained in first aid.

The concept of first aid training for laypeople exists since the 19th century. Henri

Dunant, the founder of the Red Cross, developed the idea after the bloody

battle of Solferino in 1859. He noticed that the wounded lacked medical

attention and organised local volunteers to provide care. Since its start, the

curricula have constantly been revised.9 In the past, first aid handbooks were

primarily based on experience and specialist knowledge. By the end of the 20th

century more importance was given to evidence-based curricula and to the

demonstration of educational efficacy.10 Since 2000 there have been

international guidelines for resuscitation which are evidence-based.11 The

guidelines are updated every five years12 and now form an important basis for

European first aid handbooks.

6

1.2 The role of evidence-based practice

While first aid aims to bridge the gap between an emergency and initiation of

medical care,8 the evidence-based movement seeks to bridge the gap between

scientific evidence and practice. In 1991 the term evidence-based medicine was

coined for the first time in published literature.13 In a key article, published in

1992, the evidence-based concept was presented as a new approach to

teaching and practising medicine.14 A common definition of evidence-based

medicine is “the conscientious, explicit, and judicious use of current best

evidence in making decisions about the care of individual patients”.15 The

evidence-based principles can be applied to diverse topics from astronomy over

psychology to zoology.16 As the evidence-based movement rapidly expanded to

areas outside medicine, this gave rise to the term evidence-based practice.

The evidence-based principle found its origin in the realisation that intuition,

experience and pathophysiological reasoning were insufficient grounds to

decide on medical care.14 New skills to acquire and appraise available evidence

were propagated. Evidence-based guidelines and systematic reviews evolved

from the explosion of clinical research as an instrument to translate evidence

into practice. A systematic review is “a review of a clearly formulated question

that uses systematic and explicit methods to identify, select, and critically

appraise relevant research, and to collect and analyse data from the studies

that are included in the review. Statistical methods (meta-analysis) may or may

not be used to analyse and summarise the results of the included studies.”17;18 A

difference with traditional or narrative reviews is that the latter lack systematic

strategies to reduce bias.19 Since 1980 the number of systematic reviews has

grown tremendously. An important milestone was the launch of the Cochrane

Collaboration in 1993 which develops and disseminates systematic reviews on

the effects of health care interventions. Today there are 4,500 Cochrane

7

reviews and 14,000 other systematic reviews in the Cochrane library. Eleven

new systematic reviews of trials are being published every day.20

The Institute of Medicine defined clinical practice guidelines as “systematically

developed statements to assist practitioner and patient decisions about

appropriate health care for specific clinical circumstances”.21 Regarding its

development three main types of guidelines can be distinguished: a) informal

consensus-based guidelines which are developed by a group of experts based

on their opinion and practical experience; b) formal consensus-based guidelines

which use systematic methods to translate expert opinion in recommendations;

and c) evidence-based practice guidelines which represent the best judgment of

a team of clinical and methodological experts taking into account findings from

a systematic literature review, practical experience, values, preferences and

circumstances for a specific topic.22 Evidence-based guidelines are generally

considered to produce more valid recommendations because they

systematically integrate the scientific evidence.23;24 Two important databases of

guidelines worldwide are the G-I-N Guideline Library (http://www.g-i-n.net/)

and the National Guideline Clearinghouse (http://www.guideline.gov/

The main objective of evidence-based guidelines is to improve the quality of

care. For those receiving care, this can imply improved health outcomes, and

consistency of care. For care providers, guidelines can address the risk of

performing interventions that are outdated, ineffective or even harmful. From

the policy perspective, guidelines have the potential to get the best value for

money. The gaps in literature identified in guidelines can also benefit

researchers in defining the future research agenda.23

). While

the latter database contained 700 guidelines in 2000, it now holds 2400

guidelines. Because many guidelines exist outside this database, it is not the

precise number which is important but rather the illustration of the growth

which has occurred.

8

1.3 Evidence-based practice and first aid

The case of first aid for burns provides an early example of how evidence-based

practice can contribute to first aid. In contrast to current first aid manuals, the

use of water for burns was not a standard procedure in initial first aid manuals.

Since 1928, experiments with boiled eggs and animals, and evidence from

humans have provided support for the use of water for burns.25 Thirty years

later this principle gradually diffused into first aid manuals.26

At the start of this thesis, the evidence regarding the effectiveness of first aid

procedures and training remained to be systematically assessed. Several areas

of controversy existed among experts on which first aid procedures were most

appropriate. This was reflected in unpublished surveys among Red Cross

National Societies in Europe and in scientific literature.5;27;28 While

cardiopulmonary resuscitation by laypeople was extensively studied29 and

evidence-based guidelines were published in 2000 and updated in 2005,11;12 the

field of non-resuscitative first aid lagged behind in applying evidence-based

practice.

Taking into account a) the considerable burden of injury, b) the life-saving

potential of first aid, c) the potential benefits of evidence-based practice, d)

areas of controversy in first aid, and e) the gaps in systematic analysis of first aid

evidence, it was the purpose of this thesis to introduce evidence-based practice

in the first aid training activities of the Belgian Red Cross-Flanders and to add

new empirical data to the research base.

9

1.4 Specific objectives and outline of the thesis

The scope of the research is non-resuscitative first aid training for laypeople

with no formal medical education. We focussed on the development of

evidence-based training curricula and on the evaluation of educational efficacy.

To realise this objective we performed multiple studies, which we describe in

chapters 2 to 6. Chapter 7 discusses the contributions, strengths and limitations

and implications of the studies in this thesis.

Chapter 2. European First Aid Guidelines

First aid training courses for the public in European countries often vary in

terms of the first aid procedures which they recommend.

We developed evidence-based guidelines to determine the most effective, safe,

and feasible first aid techniques and procedures, and to formulate

recommendations for training.

Chapter 3. Systematic review

The effectiveness of non-resuscitative first aid training remained to be critically

assessed. We systematically reviewed studies on the effects of non-resuscitative

first aid training with regard to acquisition and retention of competence or

modification of helping behaviour.

Chapter 4. Randomised controlled trial

The evidence on the effect of first aid training on helping behaviour is

incomplete and of low quality. Therefore, we measured the effects of a newly

developed training programme on first aid self-efficacy beliefs and helping

behaviour by means of a randomised controlled trial (RCT).

Chapter 5. Rapid reviews

10

Practitioners, especially in emergency care settings, often have a pressing need

for information. While evidence-based practice is an important goal, it can be

challenging to find a compromise between scientific rigour, transparency and

timeliness. This situation has given rise to the methodology of rapid reviews in

which methods for the search, appraisal, synthesis and analysis are determined

by time constraints.19 BestBETs is a database of such reviews with a main focus

on emergency medicine (www.bestbets.org). The Best Evidence Topic reports

(BETs) provide brief and structured summaries of the best available evidence for

very specific clinical questions. They are not systematic reviews, but rapid

reviews that can be performed by busy emergency physicians30. We conducted

a review of the best available evidence on 1) optimal body position in oral

poisoning cases and on 2) potato peel dressings for burn wounds, within a

limited timeframe and containing the essential elements of an evidence-based

literature review.

Although the concept of rapid review is rising, there is limited evidence

regarding its validity. Therefore, we compared the results of this rapid review

with a systematic review focusing on the same topic and produced

independently of each other within the same timeframe.

Chapter 6. Comparison of guidelines on ankle sprains

While the number of published evidence-based guidelines has grown rapidly in

many areas of medicine, conflicting and poorly constructed guidelines

sometimes lead to confusion. We tried to add to the research in the quality of

evidence-based guidelines by evaluating the content and rigour of development

of recommendations on the use of ice in guidelines for acute ankle sprains.

11

12

European first aid guidelines

CHAPTER 2

Van de Velde S, Broos P, Van Bouwelen M, De Win R, Sermon A, Verduyckt J,

Van Tichelen A, Lauwaert D, Vantroyen B, Tobback C, Van den Steene P, Villere

S, Mieres CU, Gobl G, Schunder S, Monsieurs K, Bierens J, Cassan P, Davoli E,

Sabbe M, Lo G, De Vries M, Aertgeerts B. European first aid guidelines.

Resuscitation. 2007;72(2):240-251.

13

Resuscitation (2007) 72, 240—251

TRAINING AND EDUCATIONAL PAPER

European first aid guidelinesq,qq

Stijn Van de Velde ∗, Paul Broos, Marc Van Bouwelen, Rudy De Win,An Sermon, Johann Verduyckt, Andre Van Tichelen, Door Lauwaert,Barbara Vantroyen, Christina Tobback, Patrick Van den Steene,Sarmite Villere, Carlos Urkia Mieres, Gabor Gobl, Susanne Schunder,Koenraad Monsieurs, Joost Bierens, Pascal Cassan, Enrico Davoli,Marc Sabbe, Grace Lo, Maaike De Vries, Bert Aertgeerts,

on behalf of the European First Aid Manual project by the Belgian RedCross­Flanders

Training Department, Belgian Red Cross­Flanders, Motstraat 40, 2800 Mechelen, Belgium

Received 26 August 2006; received in revised form 20 October 2006; accepted 20 October 2006

KEYWORDS

Emergency treatment;

Evidence­based

medicine;

First aid;

Guidelines;

Training

Summary

Aim: Our objectives were to determine the most effective, safe, and feasible firstaid (FA) techniques and procedures, and to formulate valid recommendations fortraining. We focussed on emergencies involving few casualties, where emergencymedical services or healthcare professionals are not immediately present at thescene, but are available within a short space of time. Due to time and resourceconstraints, we limited ourselves to safety, emergency removal, psychosocial FA,traumatology, and poisoning. Cardiopulmonary resuscitation (CPR) was not includedbecause guidelines are already available from the European Resuscitation Council(ERC). The FA guidelines are intended to provide guidance to authors of FA handbooksand those responsible for FA programmes. These guidelines, together with the ERCresuscitation guidelines, will be integrated into a European FA Reference Guide anda European FA Manual.

q A Spanish translated version of the summary of this article appears as Appendix in the final online version atdoi:10.1016/j.resuscitation.2006.10.023

qq Guidelines are not a substitute for the caregiver’s own judgment of a specific medical or health condition. Casualties shouldconsult a qualified health­care professional for advice about a specific condition. The authors disclaim any liability to any party forany damages arising out of the use or non­use of this material and any information contained therein, and all warranties, expressedor implied.∗ Corresponding author. Tel.: +32 15 44 34 76.

E­mail address: stijn.vandevelde@rodekruis.be (S. Van de Velde).

0300­9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2006.10.023

14

European first aid guidelines 241

Methods: To create these guidelines we used an evidence­based guideline develop­ment process, based on the methodology of the Scottish Intercollegiate GuidelinesNetwork (SIGN).Results: The recommendations cover FA for bleeding, wounds, burns, spinal and headtrauma, musculoskeletal trauma, and poisoning, as well as safety and psychosocial FA.Conclusions: Where good evidence was available, we were able to turn science intopractice. Where evidence was lacking, the recommendations were consensus­based.These guidelines provide systematically developed recommendations and justifica­tions for the procedures and techniques that should be included in FA manuals andtraining programmes.© 2006 Elsevier Ireland Ltd. All rights reserved.

Introduction

Every year, thousands of people experience orwitness medical emergencies. When emergenciesoccur, family members, friends, colleagues, orbystanders often provide spontaneous help.1—3

Citizens can take safety precautions and helpothers until professional help arrives. First aid(FA) training is essential in preparing the gen­eral public for an initial response to suchsituations.

To improve the outcome of the casualty, firstaiders must be taught correctly; they must be giventraining in the right things. Incorrect training canresult in inadequate, even harmful, interventions.The procedures and techniques taught to the publicvary between European countries, but these dif­ferences cannot always be justified. Recently, theAmerican Heart Association published guidelinesfor resuscitation and FA,4 the European guide­lines that were published at the same time onlycovered resuscitation.5 European FA guidelines,which incorporate research and expert opinion sys­tematically and transparently, therefore are muchneeded.

Belgian Red Cross­Flanders initiated a project todetermine the most effective, safe, and feasibleFA techniques and procedures, and to formulatevalid recommendations. This project received sup­port from the European Commission. The guidelinescover emergencies involving few casualties, whereemergency medical services (EMS) or healthcareprofessionals are not present at the scene imme­diately, but are available within a short space oftime. Due to time and resource constraints, welimited ourselves to safety, emergency removal,psychosocial FA, traumatology, and poisoning. Car­diopulmonary resuscitation (CPR) is not included,because guidelines5 are already available from theEuropean Resuscitation Council (ERC).

We define FA as ‘immediate help provided to asick or injured person’. FA consists of proceduresand techniques, requiring minimal or no equip­

ment, that can be taught to the general public inbasic FA courses. FA is not only concerned with thetreatment of physical injury but also with providingother initial care to the individual, including psy­chosocial FA—–assistance given to people sufferingemotional distress caused by experiencing or wit­nessing a stressful event. A first aider is defined asa layperson trained in FA.

These guidelines have been designed to provideguidance to authors of FA handbooks and thoseresponsible for FA programmes. They are intendedto be a blueprint for local training programmes andto increase the usefulness, quality, impact, andharmonisation of training. This will improve boththe quality of FA provided and the outcome for thecasualty.

Together with the resuscitation guidelines ofthe ERC, these guidelines will be bundled intothe European Reference Guide for FA Instruction.This Reference Guide should be a helpful toolfor the dissemination of the guidelines throughoutEurope. To implement the new guidelines simplyand efficiently across Europe, we produced EFAMor European FA Manual. EFAM collates all the newguidelines for first aid and resuscitation into oneunique tool to update teaching material. It offersready­to­use digital texts and high quality photos ofall the latest techniques. The Reference Guide andEFAM can be requested from the European First AidManual website http://www.efam.be.

Methodology

The guideline development process was based onthe methodology of the Scottish IntercollegiateGuidelines Network (SIGN).6 This is a recognisedreference for the development of guidelines.7

Guideline Development Group

When composing the Guideline DevelopmentGroup, we ensured participation from all relevant

15

242 S. Van de Velde et al.

key groups and disciplines. The group consisted ofEuropean specialists in anaesthesiology, cardiology,traumatology, emergency medicine, disaster man­agement, psychosocial care, medical education,and FA training. The director of the Belgian branchof the Cochrane Collaboration, i.e. the BelgianCentre for Evidence­Based Medicine (CEBAM), gaveadvice on methodology. The experts who conductedthe systematic literature review participated intraining in evidence­based medicine.

Literature search and data sources

The objective of the search was to find all rele­vant studies using sensitive search strategies. Aninitial search was performed for guidelines and sys­tematic reviews (SR) in the Cochrane Database ofSystematic Reviews, the Guidelines InternationalNetwork database, the Health Evidence Network,the National Guideline Clearinghouse, the NationalElectronic Library for Health Guidelines Finder, andPubmed. A subsequent search for other studies wascarried out using Pubmed, Embase, and the Webof Science. Where eligible guidelines or SRs werefound, the subsequent search focussed on stud­ies published thereafter, up to December 2005.Hand searching and checking the reference listsof selected studies enabled the inclusion of stud­ies that were not retrieved in the initial search.The detailed search strategy is available uponrequest.

Selection of studies

Inclusion and exclusion criteria were defined beforethe selection procedure. There were no languagerestrictions or limits on study design. Studies wereselected from the titles and abstracts of all theretrieved references. Full texts were then screenedand irrelevant studies were excluded.

Quality assessment

All the selected studies were evaluated for method­ological quality using checklists. We used theAGREE instrument8 from the AGREE Collaborationfor assessing guidelines, and the SIGN checklist forreviewing SRs, randomised controlled trials (RCT),and cohort and case—control studies. We developedadditional checklists for other study designs.

Data extraction

The data from valid studies were tabulated in evi­dence tables and summarized by level of evidence.Evidence statements and recommendations were

formulated at a conference held in Riga, Latvia,in February 2006. If no relevant research evidencewas found, recommendations were based on a con­sensus of what was considered good practice. Foreach recommended FA technique or procedure, weassessed the effectiveness, safety, and feasibil­ity. In accordance with the SIGN grading system6

(Figure 1), our recommendations are graded fromA to D. These grades match the strength of thesupporting evidence, ranging from LOE 1 to 4.Where evidence was unavailable, the recommen­dation is based on a consensus of the GuidelineDevelopment Group as to what constitutes goodpractice.

Validation

External reviewers, including medical specialists,experts in psychosocial care, training managers,and trainers, made an initial assessment of eachguideline statement. They gave feedback on scope,quality, clarity, and usefulness. The GuidelineDevelopment Group then considered the responses.An independent expert committee, following theCEBAM external validation procedure, officially val­idated the final guidelines.

Evidence

Table 1 shows the number of studies identified,included, and excluded. In total we selected88 studies to support our recommendations. TheAmerican FA guidelines4 were included under mul­tiple topics, thus explaining why ‘total included’ inTable 1 amounts to 93 rather than 88.

We included 23 guidelines, 5 SRs, 2 RCTs,1 cohort study, 14 case reports or series, 2cross­sectional surveys, and 41 miscellaneousmanuscripts (narrative reviews, letters, comments,etc.). Five guidelines contained specific recom­mendations for FA.4,9—12 The other guidelines werefor use by healthcare professionals, but extrapola­tion to FA recommendations was possible. Twelveguidelines4,10,12—21 used systematic and transpar­ent methods for integrating research evidence,two guidelines9,11 were based on expert con­sensus, and for nine guidelines22—30 we couldnot retrace what method was used. Eight guide­lines included grades of recommendation. Whenappropriate guidelines or SRs were found, wefocussed the subsequent search on later pub­lications, up to December 2005. This was thecase for psychosocial FA, wounds, burns, spinaland head trauma, musculoskeletal trauma, andpoisoning.

16

European first aid guidelines 243

Figure 1 SIGN grading system.6

Safety measures

Findings

We included eight studies on road accidents,31—38

two on fire,39,40 and seven on electricalaccidents.40—46 Except for one cross­sectionalsurvey on fire safety (LOE 339), all the selectedstudies on safety measures are expert opiniondocuments (LOE 4). As to road accidents, there isdebate among specialists whether parking the carbefore or after the accident is important.

Recommendations (Grade D)

General principlesAlways make personal safety your first priority.Check the situation and identify any potential dan­

ger. Only approach the scene if it is safe foryou to do so. If possible, try to ensure safetyfor the casualty and bystanders. If it is unsafefor you to approach the casualty, alert the emer­gency services and wait at a safe distance for theirarrival.

Road accidentAlways act according to local laws.

When approaching a road accident, reduce speedand avoid sudden braking. Park your car in asafe place, off the road or at the side of theroad. Wear high visibility clothing. Use warn­ing signs (e.g. warning triangle) to alert passingtraffic. Do not run across busy travel lanes onmotorways.

Identify any downed electrical cables and ensurethat nobody touches or approaches them.

17

244 S. Van de Velde et al.

Tab

le1

Resu

lts

of

identi

fica

tion

and

sele

ctio

nof

studie

s

Safe

tyPsy

choso

cial

FAW

ounds

Ble

edin

gB

urn

sSp

inal,

head

traum

aM

usc

ulo

skele

tal

traum

aPois

onin

g

Incl

uded

guid

eli

nes

23

61

61

45

Incl

uded

SRs

01

12

00

10

Oth

er

pote

nti

all

yre

leva

nt

studie

s657

59

a463

a397

155

a40

a144

a28

a

Exc

luded

on

conte

nt/

quali

ty−

635

−51

−457

−358

−134

−35

−143

−26

Unlo

cata

ble

studie

s−

5−

1−

6−

12

−16

−3

−1

0O

ther

incl

uded

studie

s17

70

27

52

02

Tota

lno.

of

studie

sin

cluded

19

11

730

11

35

7

aIf

eli

gible

guid

eli

nes

or

SRs

were

found,

ati

me

lim

itw

as

use

dfo

roth

er

studie

s.

Prevent fire by switching off the ignition of vehi­cles involved in the accident, and ensuring thatnobody smokes. Be aware of the danger of airbags.If possible, apply the handbrake to stabilise thevehicles involved.

Fire at homeTry to warn everybody at risk without putting your­self at risk. Do not enter a burning house. Moveaway from the area to a safe distance. If you arein a burning building, leave the area immediatelyand help other people to leave, provided you cando this safely.

Electrical accident at homeConsider electrical devices and cables as ‘live’until proven to be disconnected. Do not touch acasualty connected to a power source. Remem­ber that liquids or objects in contact with thecasualty can potentially conduct electricity. Switchoff the current. If it is not possible to dis­connect the power, stand on insulating materialand push the power source away using non­conductive material. If this is not feasible, waitfor the fire brigade or specialised personnel toarrive.

Emergency removal of the casualty

Findings

Three expert opinion manuscripts are included onemergency removal of the casualty (LOE 44,23,47).There is no evidence on which technique of movinga casualty is best.

Recommendations (Grade D)

As a general rule, do not move a casualty fromthe scene of the accident. Only move a casualtyif he or she is in uncontrollable danger, and ifit is safe for you to do so. In that case movethe casualty to the nearest place of safety. Tryto shield the casualty from cold or heat, but onlymove a casualty if he or she has been exposedto cold for a long time. Explain to a consciouscasualty what you are going to do and ask forhis or her cooperation. Use a technique thatis safe for you and the casualty, is easily andquickly applied, without the need for special equip­ment. If possible, support the neck and avoidtwisting the head, neck, and body during the pro­cedure.

18

European first aid guidelines 245

Initial evaluation and calling for help

Findings

The recommendations below are based on a con­sensus of the Guideline Development Group as towhat constitutes good practice.

Recommendations (Grade D)

Introduce yourself and explain what you are goingto do. This will increase the casualty’s confidencein you. Evaluate the casualty’s condition. If help isneeded, alert the EMS or local emergency responsesystem, the Poison Control Centre (PCC) or otherhealthcare professionals as appropriate. Remem­ber that 112 is the recognised emergency telephonenumber in all countries of the European Union.Always refer to healthcare professionals or socialservices if you have any suspicion of non­accidentalinjury.

Psychosocial first aid

Findings

The focus of the literature tends to be onthe first weeks after an incident has occurred.Three guidelines on acute and post traumaticstress disorder,13,14,22 one systematic review ondebriefing,48 and seven expert opinion scripts49—55

were selected. Single session debriefing or activelyexploring emotions should not be done (LOE1+,14,48 LOE 413,22,49,53); this has proven tobe ineffective and potentially harmful. Singlesession debriefing is a psychological techniquefor a structured conversation about emotionaland cognitive experiences. Laypersons provid­ing initial psychosocial support need continuoustraining and assistance (LOE 451,54). Taking careof basic needs is part of psychosocial FA, butfood or drink should not be given because thiscomplicates professional care if anaesthesia isrequired.

Recommendations (Grade D)

Approach the casualty in a non­judgmental way. Lis­ten empathetically to the casualty, be supportive,and offer practical assistance. Do not give food ordrink to a sick or injured casualty, unless advisedotherwise by professional healthcare providers.Explain carefully to the casualty what has happenedand what is going to happen.

Infection control

Findings

We included three guidelines related to infectioncontrol.11,15,30 Cross­infection between first aiderand casualty must be avoided. Hand hygiene, byusing liquid soap and water, is an effective methodof preventing cross­infection (LOE 1+,15 LOE 430).The risk of cross­infection can be reduced by using abarrier (e.g. gloves) between the first aider and theblood or body fluids of the casualty (LOE 411,15,30).Careful handling and disposal of glass, needles, orother sharp objects that might cut, graze, or prickis essential in preventing infection (LOE 415,30).

Recommendations (Grades B and D)

Whenever possible, wash your hands with liquidsoap and water before and after giving FA (B). Usedisposable gloves if they are available (D); if not,a plastic bag may be used instead (D). Handle anddispose of sharp objects safely (D). If needles arepresent as a result of recreational drug use, thenthey should be identified and left to professionalsto handle (D).

Bleeding

Findings

One guideline,4 2 SRs on control of arte­rial puncture56 and on femoral vessel injuriesin warfare,57 2 RCTs on control of arterialpuncture,58,59 11 case reports or series,60—70 and14 expert opinion scripts71—84 were selected.The effectiveness of controlling external bleedingthrough applying direct pressure or a compres­sion bandage to the site of bleeding is provenby high level of evidence (LOE 1+,4,56,58,59

LOE 3,61,62,65,67,68 LOE 44,71—78,80—83). There isinsufficient evidence about the effectiveness ofindirect pressure on pressure points and eleva­tion (LOE 44,72,74—76,80—82). Because of the possiblecomplications, the use of a tourniquet is con­traindicated for laypersons (LOE 360,63—66,68—70,LOE 44,57,72,75,76,79,80,82,84).

Recommendations (Grades B and D)

To control external bleeding, apply direct pressureor a compression bandage to the site of bleeding(B). If bleeding continues, apply more pressure oran additional bandage without removing the origi­nal dressing (D). Maintain pressure on the site of the

19

246 S. Van de Velde et al.

wound until the EMS arrives (D). Do not use indirectpressure on pressure points and elevation, and donot use a tourniquet to control bleeding (D).

Wounds

Findings

Three guidelines on wound management4,12,20 andone SR on water for wound cleansing85 wereselected. Irrigating wounds with water reducesinfection rates and improves healing rate (LOE1+85). Irrigation should be continued until thereappears to be no foreign matter left in the wound(LOE 44). Swabbing the wound can damage thewound tissue (LOE 420). There is debate amongstresearchers as to whether the potential toxiceffects of antiseptics and antibacterials on tis­sue may delay the healing of wounds; therefore,at present, use of antiseptics and antibacterialsshould be undertaken with caution (LOE 412,20).Wound dressings are necessary to protect thewound (LOE 420). Tetanus immunisation is neededfor all wounds.12 Many people do not know theirexact immunisation status. One guideline includedcriteria for referral to healthcare professionals.12

Recommendations (Grades B and D)

After controlling bleeding, irrigate wounds withclean, running, cold, tap water if available (B); ifnot, use any source of drinkable water (B). Irri­gate directly on the wound and continue until thereappears to be no foreign matter left in the wound(D). Do not swab a wound (D). After cleaning awound, cover it with sterile gauze if available (B);if not, use a clean dry cloth (D). Advise the casu­alty to seek medical advice to determine his/hertetanus immunisation status (D).

Do not remove an object that is embedded in awound (D). Instead, try to immobilise it (D), thencover the wound with sterile gauze if available, ora clean dry cloth (D).

Referral to healthcare professionals is indicatedif (D):

• an object is embedded in the wound;• there is uncontrollable bleeding;• an abrasion is larger than half the width of the

palm of the casualty;• bone, muscle, or other subcutaneous tissue is

exposed;• a wound involves the face, eyes, or genital area;• a wound cannot be cleaned properly;• a wound is caused by a bite.

Try to control bleeding until professional help is athand.

Burns

Findings

We included six guidelines,4,9,10,16,17,24 two casereports or series,86,87 one cross­sectional survey,88

and two expert opinion scripts89,90 on burns man­agement. Burns should be cooled as soon aspossible with tap­water (LOE 2++,4 LOE 3,86—88 LOE49,16,24,90). For some types of chemical burns, rins­ing with water is potentially harmful (LOE 49).The incidence of such burns, in a non­occupationalsetting, is low. This recommendation should, there­fore, apply to both types of burn to allow uniformand simple guidelines for first aiders. The evidencefor the optimum length of time a burn should becooled is inconclusive (LOE 387,88, LOE 44,9,16,89).When cooling, hypothermia in the casualty mustbe prevented (LOE 3,86—88 LOE 44,9,89). Clothingand jewellery can be removed, if they are notadhering to the skin (LOE 3,86,88 LOE 49,24,89,90).Intact burn blisters should not be opened (LOE 3,4

LOE 490). Antibiotic creams should not be used asFA.10 Wet wound dressings can protect the burn(LOE 3,88 LOE 49,10,24,89,90). Tetanus immunisationis needed for burns.10,16 Many people do not knowtheir exact immunisation status. Four guidelines(LOE 410,16,17,24) included criteria for referral tohealthcare professionals. The extent of a burncan be assessed with the Rule of Nines, the Lundand Browder chart, or with the palm of the casu­alty’s hand (LOE 410,16). The palm and fingers ofthe casualty’s hand is approximately 1% of theirtotal body surface area. There is no consensusin the research on the best method. The Rule ofNines should not be used for children under 16years old. Using the casualty’s hand is a feasiblemethod for estimating the size of a burn at thescene.

Recommendations (Grades B and D)

Cool burns as soon as possible with tap­water (B).Continue cooling for 15—20 min or until pain relief isachieved or until professional help arrives (D). Pre­vent hypothermia in the casualty by avoiding useof very cold water for cooling, protecting casual­ties from the wind, and using blankets to keep thecasualty warm (D). Remove clothing and jewelleryif they are not adhering to the skin (D). After cool­ing, apply wet wound dressings (D). Do not openintact burn blisters (D). Advise the casualty to seek

20

European first aid guidelines 247

medical advice to determine his/her tetanus immu­nisation status (D).

Referral to healthcare professionals is indicatedif (D):

• the casualty is a child under 5 years or an adultover 60 years;

• a burn involves face, ears, hands, feet, the gen­ital area, or joints;

• there is a circumferential burn of the limbs,torso, or neck;

• there are burns covering more than 5% of totalbody surface area in children under 16 years,or more than 10% in adults over 16 years. Thepalm and fingers of the casualty’s hand is approx­imately 1% of the total body surface area;

• there is a third­degree burn. If the deepest layerof the skin is burned, there is usually no painin the wound itself, because the nerves in thisarea have also been destroyed. The burn can lookblack, parchment­like or white and is dry. How­ever the skin around the wound, which is oftenless deeply burned, is painful;

• burns are electrical or chemical, or due to ioniz­ing radiation, or high pressure steam;

• there is an inhalation burn.

Spinal and head trauma

Findings

One guideline on head trauma,21 one cohort study91

and one case series92 on spinal trauma wereselected. Assessment of spinal or head trauma isdifficult; in children this is even more difficult. Allthree studies provide criteria for referral to health­care professionals (LOE 2++,21,91 LOE 392). Thereis no good evidence about when first aiders shouldexpect head injury in children. There is no evidencethat manual immobilisation in a non­moving victimis effective.

Recommendations (Grades B and D)

Initial evaluation of casualties who have an alteredmental state, or who are intoxicated or in greatpain is not very reliable. Alert the EMS if there isuncertainty about the nature of any injury (B).

Suspect head injury and alert the EMS if the casu­alty (B):

• is a victim of high­impact trauma such as from atraffic accident or a fall from higher than standingheight;

• is or becomes drowsy, sleepy, agitated, or uncon­scious;

• does not remember precisely what has happened;• has severe and persistent headache, nausea

and vomiting, irritability, or altered behaviour,seizure;

• has major lesions to the head.

Suspect spinal injury and alert the EMS if thecasualty (B):

• is a victim of high impact trauma such as from atraffic accident, or a fall from higher than stand­ing height;

• is or becomes drowsy, sleepy, agitated, or uncon­scious;

• does not remember precisely what has happened;• complains about numbness or tingling;• is not complaining about serious injuries of the

lower body or legs that would normally beexpected to be painful;

• has pain or tenderness in the neck or back.

Calm a casualty with spinal or head trauma andtry to convince him/her not to move (D). Onlyimmobilise the casualty if he or she is cooperative(D). If the casualty is agitated, do not immobilisethe head and neck against his/her will (D).

Musculoskeletal trauma

Findings

Four guidelines4,18,25,26 on musculoskeletal traumaand one SR93 about the use of ice in acute soft­tissue injury were selected. Initial evaluation oflimb injuries is difficult. Evidence is inconclusiveon the effectiveness of immediate post­injury cool­ing (LOE 1+4,18,93), and on the optimum duration ofcooling (LOE 1+93). No evidence was found aboutthe effectiveness of elevation and compression.Avoiding standing on an injured lower limb (LOE 44),or self immobilisation of an injured upper limb (LOE425,26), are often adequate and less painful thanputting the limb in a bandage or a sling.

Recommendations (Grade D)

In case of doubt about the severity, assume thata fracture has occurred and refer to healthcareprofessionals. Do not try to reduce angulated ordislocated limbs. Cool the injury with ice. Whencooling, use a barrier such as a towel between theice and the skin and do not use for a prolongedtime. Limit each period of cold application to amaximum of 20 min. Do not immobilise the injuredlimb if medical help is available within a short timespan. Advise the casualty not to stand on an injured

21

248 S. Van de Velde et al.

lower limb. In case of upper limb injury, ask thecasualty to immobilise the arm against the trunkhimself/herself. If there is major bleeding at thefracture site, apply direct pressure or a compres­sion bandage.

Poisoning through oral ingestion

Findings

Five guidelines4,19,27—29 and two expert opinionscripts94,95 were selected. Activated charcoal (LOE44,27,29,94), water, or milk (LOE 44,94) should onlybe used if this is advised by a PCC or a profes­sional healthcare provider. Ipecac syrup should notbe used (LOE 1+,4 LOE 3,19 LOE 427,28,28,94,95). Wedid not investigate whether body position has aneffect on poison absorption. Future investigationis needed to test the hypothesis that left lateraldecubitus decreases absorption.

Recommendations (Grade D)

Contact the PCC or professional healthcareproviders and follow their instructions.

Discussion

There was limited evidence addressing FA. It wassometimes possible to extrapolate research findingson professional healthcare to FA; the 21 guide­lines retrieved were very useful for this purpose.When evidence was available, we were able toturn science into practice. When evidence wasnot available, our recommendations are consensus­based. Effective and appropriate FA proceduresand techniques have been described, and interven­tions that are contraindicated have been identified.Even though the evidence base was limited, theseguidelines provide systematically developed rec­ommendations and justifications for the proceduresand techniques that should be included in FA man­uals and training programmes.

Customary practices are not always correct. Ifresearch shows that first aid can become better,one should not be blind to that fact. It is stronglyadvised that FA manuals and programmes bereviewed in the light of these guidelines and revisedwhere appropriate. The European Reference Guidefor FA Instruction and EFAM are handy tools toupdate or develop teaching material and can berequested at the website http://www.efam.be.

Until now, there has been no explicit descrip­tion of the status of research on FA. This studyillustrates the need for more research which isnecessary to ensure the quality of FA provision.Specifically, research is required on how well firstaiders can perform immobilisation techniques, andon the optimum duration of irrigation for burns andcooling after musculoskeletal trauma.

We hope these guidelines will encourage the sci­entific community to start new research effortsin FA. As new evidence becomes available, theseguidelines will need to be revised. A strategy mustbe developed to bring in wider European represen­tation and to include additional basic and advancedFA topics when these guidelines are updated.

Contributors

The Belgian Red Cross­Flanders is very grateful forthe work that has been done by the participatingexperts. S. Van de Velde, (Belgian Red Cross­Flanders) planned, coordinated, facilitated anddrafted the study report. P. Broos (University Hos­pital Gasthuisberg Leuven, Belgium) supervised thestudy and chaired the expert group. B. Aertgeerts(Belgian Centre for Evidence­Based Medicine) gavemethodological advice. The systematic literaturereview was done by: R. De Win (Belgian Red Cross­Flanders), D. Lauwaert (Academic Hospital FreeUniversity Brussels, Belgium), A. Sermon (Univer­sity Hospital Gasthuisberg Leuven, Belgium), C.Tobback (Poison Control Centre Belgium), M. VanBouwelen (Belgian Red Cross­Flanders), P. Van denSteene (Stressteam Federal Police Belgium), A. vanTichelen (Saint­Marie Hospital Halle, Belgium), B.Vantroyen (University Hospital Gasthuisberg Leu­ven, Belgium), J. Verduyckt (University HospitalGasthuisberg Leuven, Belgium). Advisors on special­ist topics were: J. Bierens (VU University MedicalCentre Amsterdam, Netherlands), P. Broos, P. Cas­san (European Reference Centre for First AidEducation, France), E. Davoli (World Health Organ­isation), M. De Vries (Impact Foundation, DutchKnowledge Centre for Post­Disaster PsychosocialCare), G. Gobl (Hungarian Red Cross), G. Lo (Inter­national Federation of the Red Cross and RedCrescent Societies, IFRC), C. Urkia Mieres (SpanishRed Cross), K. Monsieurs (European ResuscitationCouncil), M. Sabbe (University Hospital Gasthuis­berg Leuven, Belgium), S. Schunder (Austrian RedCross), and S. Villere (Latvian Red Cross). Externalvalidators were D. Ramaekers (Belgian Health CareKnowledge Centre), H. Van Brabant (Belgian HealthCare Knowledge Centre) and P. Vranckx (Virga JesseHospital Hasselt, Belgium).

22

European first aid guidelines 249

Conflict of interest statement

The Red Cross provides training in first aid.

Acknowledgements

We are grateful to the IFRC for their permission tocite from the First recommendations on life­savingtechniques report.11 We thank A. Handley (Colch­ester, UK) for reviewing and editing the manuscript.

Funding: The European Commission funded thisstudy. The Commission did not participate in theguideline development process and is not responsi­ble for any use that may be made of the informationin this publication.

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25

26

Effectiveness of nonresuscitative first aid training in

laypersons: a systematic review

CHAPTER 3

Van de Velde S, Heselmans A, Roex A, Vandekerckhove P, Ramaekers D,

Aertgeerts B. Effectiveness of nonresuscitative first aid training in laypersons: a

systematic review. Ann Emerg Med. 2009;54(3):447-457.

27

EVIDENCE-BASED EMERGENCY MEDICINE/CRITICALLY APPRAISED TOPIC

Effectiveness of Nonresuscitative First Aid Training in Laypersons:A Systematic Review

Stijn Van de Velde, MPH

Annemie Heselmans, MSc

Ann Roex, MD

Philippe Vandekerckhove, MD,

PhD

Dirk Ramaekers, MD, PhD

Bert Aertgeerts, MD, PhD

From the Belgian Red Cross–Flanders, Mechelen, Belgium (Van de Velde, Vandekerckhove); the

Centre for Evidence-Based Medicine, Katholieke Universiteit Leuven, Leuven, Belgium (Heselmans,

Ramaekers, Aertgeerts); and the Department of General Practice, Katholieke Universiteit Leuven,

3000 Leuven, Belgium (Roex).

Study objective: This study reviewed evidence on the effects of nonresuscitative first aid training on

competence and helping behavior in laypersons.

Methods: We identified randomized and nonrandomized controlled trials and interrupted time series on

nonresuscitative first aid training for laypersons by using 12 databases (including MEDLINE, EMBASE, and

PsycINFO), hand searching, reference checking, and author communication. Two reviewers independently

evaluated selected studies with the Cochrane Effective Practice and Organisation of Care Review Group quality

criteria. One reviewer extracted data with a standard form and another checked them. In anticipation of

substantial heterogeneity across studies, we elected a descriptive summary of the included studies.

Results: We included 4 studies, 3 of which were randomized trials. We excluded 11 studies on quality

issues. Two studies revealed that participants trained in first aid demonstrated higher written test scores

than controls (poisoning first aid: relative risk 2.11, 95% confidence interval [CI] 1.64 to 2.72; various first

aid cases: mean difference 4.75, 95% CI 3.02 to 6.48). Two studies evaluated helping responses during

unannounced simulations. First aid training improved the quality of help for a bleeding emergency (relative

risk 25.94; 95% CI 3.60 to 186.93), not the rate of helping (relative risk 1.13; 95% CI 0.88 to 1.45).

Training in first aid and helping behavior increased the helping rates in a chest pain emergency compared

with training in first aid only (relative risk 2.80; 95% CI 1.05 to 7.50) or controls (relative risk 3.81; 95% CI

0.98 to 14.89). Participants trained in first aid only did not help more than controls (relative risk 1.36; 95%

CI 0.28 to 6.61).

Conclusion: First aid programs that also train participants to overcome inhibitors of emergency helping behavior

could lead to better help and higher helping rates. [Ann Emerg Med. 2009;54:447-457.]

0196-0644/$-see front matter

Copyright © 2008 by the American College of Emergency Physicians.

doi:10.1016/j.annemergmed.2008.11.005

INTRODUCTION

In case of an accident, injury, or sudden illness, first aid

delivered by bystanders can save lives and limit damage until

professional help has arrived.1,2 Laypersons trained in first

aid can also potentially reduce delays in seeking medical

assistance. The latter is also potentially lifesaving because in

emergencies time may constitute a critical determinant of

victims’ outcomes. Recently, the potential value of first aid

training for laypersons has assumed a heightened importance

in the context of both manmade and natural mass casualty

incidents and disasters. When a sudden disaster strikes,

survivors often constitute the sole source of initial help to

others because professional help takes time to mobilize or isinsufficient.3,4

Reports from the recent bombings in New York and Londonstate that first aid by bystanders might have saved lives.5,6 In theMadrid bombings, 67% of the injured persons arrived at thehospital in nonambulance vehicles.7 Victim transport bybystanders occurs in many mass casualty disasters if ambulancetransport is lacking.3 First aid training can reduce the risks ofprivate victim transport and provide laypersons with guidanceabout when not to move a victim.3 After the Armenia and Kobeearthquakes, bystanders provided only minimal first aidefforts.5,8 Officials interviewed after the disaster strongly agreedthat first aid training for laypersons would likely decrease death

Volume , . : September Annals of Emergency Medicine 447

28

rates in similar events.8 Conversely, in disaster preparednessefforts, emergency personnel and authorities often disregard thepotential role of individual laypersons.3,4

Although laypersons rarely panic or develop psychologicalshock in disasters, the emotional stress of the situation cantemporarily limit their reasoning ability.9 Experts widelyadvocate layperson first aid training as a way of improving theinitial response in such situations. Recommendations rangefrom voluntary or mandatory first aid courses to be offered tothe community at large, to courses limited to target groups suchas workers, professional drivers, family members of high riskindividuals, or citizens living in disaster-prone areas.3,4,6,9-12

Given the increased premium on layperson first aid skillsunder conditions of disaster and the consequent likelihood ofsubstantial increase in resources devoted to training efforts, theevaluation of effectiveness of such training assumes paramountimportance. Such evaluations need to assess whether courseparticipants acquire appropriate attitudes, competences, andbehavior for first aid provision. This implies that courseparticipants demonstrate a positive attitude and helping reactiontoward emergencies, and furthermore that they can assess thesituation, ensure safety, assess the condition of the victim, gethelp if required, and administer first aid and provide emotionalsupport to victims.Published reports of effectiveness of first aid training are

scattered across a large array of biomedical journals published indifferent languages and in journals associated with differentpractice specialties, making it difficult to derive a validassessment of current knowledge in this area. The objective ofthis study was to systematically review primary studies on theeffects of nonresuscitative first aid training with regard toacquisition and retention of competence or modification ofhelping behavior.

MATERIALS AND METHODSWe reported this study in accordance with the QUOROM

statement for meta-analyses.13

Search StrategyWe developed the search strategy in consultation with an

information specialist and conducted a literature search ofMEDLINE (PubMed), EMBASE (EMBASE.com), theCochrane Central Register of Controlled Trials (Wiley), C2-SPECTR (Campbell Collaboration), Cinahl (EBSCOhost),British Nursing Index and Archive (OVID), SPORTDiscus(EBSCOhost), PsycINFO (WebSPIRS), and EducationResources Information Center database (EBSCOhost). A searchof the abovementioned databases took place from inceptionuntil May 2007. Appendix E1 (available online athttp://www.annemergmed.com) contains the description of theactual search strategies.We searched for grey literature reports14 about first aid

training in the Open Archives Initiative (OAIster) database andthe British Library Integrated Catalogue and consulted the

database of the Netherlands Institute for Health ServicesResearch (NIVEL) for Dutch-language reports on June 19,2007. We further searched for studies by communicating withthe authors of included studies, checking reference lists ofselected studies and of related systematic reviews,15-21 and handsearching. We hand searched conference proceedings andsupplement issues of the journals Resuscitation and Prehospitaland Disaster Medicine from January 1997 to April 2007.

Study SelectionIn anticipation of finding only a few studies with useful data,

we deliberately defined broad inclusion criteria. Systematicreviews with broad questions are valid on the condition thatthey do not generalize findings across differing conditions.22Weincluded randomized controlled trials, nonrandomizedcontrolled trials, controlled before-and-after trials, andinterrupted time series in our review.We defined a layperson as somebody who has never received

a formal health care education, and we included studiescovering first aid training for laypersons of all education levels.We included studies including participants with previousknowledge of first aid but excluded studies on patient educationand studies involving training for health care students andprofessionals. There were no restrictions on participants’ age,sex, ethnicity, motivation, learning potential, learning behavior,or education level. We defined first aid as immediate helpprovided to a suddenly ill or injured person, until that personhas recovered or medical care is available.We defined first aid training as a formal learning activity,

with learning goals defined in terms of skills and attitudespertaining to immediate help in case of accidents, injuries, orsudden illness. We did not include studies about the effect ofinformal learning activities, such as mass media awarenesscampaigns.We included studies that reported learning and behavior

outcomes relating to first aid training for bleeding, shock,wounds, injuries, poisoning, stroke, chest pain, asthmaticattacks, epileptic seizures, or diabetic crisis. We excluded studiesfocusing only on basic life support or the use of automatedexternal defibrillators. If studies covered both first aid andresuscitation training, we included only results of theeffectiveness of first aid training. We placed no restrictionsabout training methods, materials, duration, or delivery format.Primary outcomes of interest included measures of helping

behavior in real situations, including deception experiments. Indeception experiments, the study participants are unaware thatan emergency is being simulated and do not know that theirhelping behavior is being evaluated. This concept originatesfrom social psychology research and differs from customarysimulations in which participants know that it is an imitation ofan emergency. Secondary outcomes included measures oflearning gains in knowledge and skills. We did not includecourse participant views on the training or self-assessmentmeasures as outcome measures. There was no restriction on theoutcome assessment method or timing. Our interest focused

Effectiveness of Layperson First Aid Training Van de Velde et al

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both on the outcomes directly after completing the first aidtraining and outcomes in the weeks or months afterward.Because of time and resource constraints, we considered onlystudies reported in English, German, French, or Dutch.Two reviewers (S.V.D.V., A.H.) independently selected

studies from titles and abstracts. Interrater agreement wasevaluated with a Cohen’s k. The reviewers resolveddisagreements on the selection of studies by discussion and thenscreened full texts and excluded irrelevant studies.

Assessment of Risk of Bias in Selected StudiesTwo reviewers (S.V.D.V., A.H.) independently evaluated all

the selected studies for methodological quality. We used thequality criteria of the Cochrane Effective Practice andOrganisation of Care Review Group23 because they providevalidated checklists for every type of study design that wasincluded in our review. The quality criteria for randomizedcontrolled trials included concealment of allocation, participantfollow-up, blinded assessment, measurement of baseline data,reliability of outcome measures, and protection againstcontamination among study groups. Appendix E2 (availableonline at http://www.annemergmed.com) contains the actualchecklist for randomized controlled trials.We rated studies as having low risk of bias if all the quality

criteria were met and as having moderate risk of bias if 2 criteriawere not met, partially met, or not clear. Studies received a highrisk of bias rate when 3 or more criteria were not met, partiallymet, or not clear. Some quality issues about eligibility aroseduring the assessment process in studies in which bias wasexplicitly clear. The group of reviewers decided in agreement toset a cut point for inclusion between studies with a risk of biasand undoubtedly biased studies. This is one of the possibleapproaches to limit bias in a systematic review.22We consideredwhether to include studies with fewer than 10 participants anddecided not to do so because the allocation could not lead tobalanced groups. We decided to exclude studies if thecomparison groups had substantial differences at baselinebecause this made groups noncomparable. We excluded studieswith clear indications of exposure to the intervention in thecontrol group because this creates contamination bias anddilutes the effect of the intervention. We also discussed whetherto include studies with limited compliance with the interventionand decided not to do so because this raises serious concernsabout the representativeness of the data and might bemisleading. We contacted authors of selected studies if certaindata were not reported in the article, and if essential informationwas not forthcoming, we excluded the study from furtheranalysis. In cases of disagreement on the quality, a third reviewer(B.A.) resolved differences.

Data Extraction and SynthesisBecause there is no single data extraction form that fits all

uses, we adapted the Best Evidence Medical EducationCollaboration (BEME) coding sheet24 to the needs of ourreview. The extracted data related to methodology, participants,

setting, educational descriptors, assessment features, outcomes,and the study’s conclusions. We classified education levelsaccording to the International Standard Classification ofEducation (ISCED) levels.25

For the outcome measures, we entered indications of face,content, construct, concurrent, or predictive validity andreliability measures such as internal consistency, interraterreliability, or test-retest reliability in the data extraction form.One reviewer (S.V.D.V.) extracted data and another (A.H.)checked them. Disagreements were resolved by discussion.The group of reviewers (S.V.D.V., A.H., B.A.) assessed

clinical heterogeneity by evaluating the type of participants,intervention, and outcome for each study. In anticipation offinding only a few and very heterogeneous studies, there was noplan to conduct subgroup or sensitivity analysis, or meta-analysis methods. Instead, we conducted a descriptive review ofthe included studies. To present the outcomes uniformly acrossstudies, we used the Review Manager software version 4.2.10(The Nordic Cochrane Centre, The Cochrane Collaboration,Copenhagen, Denmark) to calculate mean differences forstudies with continuous data and relative risks for studies withdichotomous data.

RESULTSTrial FlowFigure 1 provides a flowchart of the identification and

selection of studies. The reviewers screened 7,644 citations,including 1,540 duplicates. Evaluation of titles and abstractsresulted in 146 citations. Agreement between the 2 reviewerswas high (Cohen’s k of 0.89). After full text evaluation, 15studies matched every selection criteria. The reviewers agreed

Figure 1. Flowchart of identification and selection ofstudies.

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30

unanimously to exclude 10 studies26-35 after the assessment ofprobable bias. One poorly reported study was excluded becauseit did not provide sufficient information to evaluate itsquality.36 Table 1 presents the results of the quality assessmentper included study; Table 2, per excluded study.

Study CharacteristicsTable 3 summarizes the characteristics of 4 included studies.

Three studies37-39 were randomized controlled trials, and one40

was a nonrandomized controlled trial.Kelly et al37 tested a 9-minute video clip about first aid for

poisoning, combined with the distribution of pamphlets andstickers. Participants were parents of young children who visiteda women, infant, and children clinic. Outcome measuresincluded knowledge about first aid for poisoning. The authorscarried out the assessment by means of written and oralinterviews.Moore38 evaluated the effects of assertion training and first

aid instruction for primary school children. This program wasintended to increase the children’s autonomy and ability to takecare of their own health. The training consisted of anoncompulsory course within the school setting, with randomallocation of participants to one of 4 comparison groups. Thegroups received either 6 hours of assertion training, 6 hours offirst aid training, 3 hours of assertion training, and 3 hours offirst aid training or received no training but watched 6 hours ofscience films without health education content. The first aidtraining covered bleeding, injuries, burns, shock, poisoning, andother topics outside the review. Assertiveness training focusedon developing assertive behavior so that participants couldbecome more autonomous health care consumers. Thisconsisted of learning how to express feelings, ask forinformation, and make requests or refusals. The authors used awritten test to assess first aid knowledge and skills.Shotland and Heinold39 evaluated the change in first aid

practice among university students after first aid training. Thefirst aid training was part of a program organized by the healtheducation department. The duration of the training course isunclear. Passing the final examination would lead to anAmerican Red Cross certificate in advanced first aid andemergency care. This study evaluated the helping responses of

participants during unannounced simulations. The participantswere deceived and the simulations carefully staged so that theyactually believed it was a real accident.The simulated accident was that of a fallen worker who was

bleeding severely. The influence of training was tested againstthe presence of bystanders and level of ambiguity. The numberof bystanders was either none or 2. In ambiguous conditions,there was only the sound of the falling worker; in unambiguousconditions, there was also a moan for help. Participant responseswere categorized as providing no help, calling for help, orproviding direct help.Hawks and Egan40 evaluated the effect of training at a

university during a health and wellness education course open toall university students. The majority of students were from thefaculty of education. Students took part in the course forreasons of personal interest or because it was a compulsorylesson or an elective. The trainers randomly allocatedparticipants to one of 4 comparison groups: first aid trainingcomplemented with training in overcoming the inhibitors ofemergency helping behavior, training that mentioned theinhibitors, training without focus on inhibitors, or no training.The training in the inhibitors of emergency helping behaviorstressed during the lectures that bystanders often are held backfrom helping when there are other bystanders or when there isambiguity about the gravity of the emergency. The participantsdiscussed how to deal with these barriers to providing help andexercised this in simulations with situational ambiguity andpresence of bystanders. The only difference between the 3training programs was the amount of time spent on theinhibitors of emergency helping behavior. The exact duration ofthe training courses is unclear.As in the previously described study, the participants were

deceived and unexpectedly confronted with a simulatedemergency. The simulation was chest pain in a middle-agedand overweight worker. Four actors played bystanders in theroom with the casualty who was urgently in need of help.The study recorded whether the participants provided help.No data were available on the type of help provided. Thisstudy also carried out a preliminary test in the interventiongroups of first aid knowledge and skills by means of a writtenand a practical test.

Table 1. Assessment of quality criteria about risk of bias among the 4 included studies meeting quality and nonquality eligibility

criteria for inclusion.

Included Study by

First Author

Concealment of

Allocation

Participant

Follow-up

Blinded or Objective

Assessment

Baseline

Measurement

Reliable

Outcome(s)

Protection Against

Contamination Global Assessment

Kelly, 200337 Partially done Done Done Partially done Unclear Done Included study with

a high risk of bias

Moore, 198738 Not done Done Not done Done Partially done Done Included study with

a high risk of bias

Shotland, 198539 Partially done Partially done Unclear Not done Done Unclear Included study with

a high risk of bias

Hawks, 199840 Not done Done Done Done Partially done Done Included study with

a moderate risk of

bias

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450 Annals of Emergency Medicine Volume , . : September

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Table 2. Assessment of quality criteria about risk of bias among 11 excluded studies meeting nonquality eligibility criteria for

inclusion.

Excluded Study by

First Author

Concealment

of Allocation

Participant

Follow-up

Blinded or

Objective

Assessment

Baseline

Measurement

Reliable

Outcome(s)

Protection

Against

Contamination Global Assessment

Marchand-Martella,

199226

Not done Done Not done Unclear Done Unclear Study excluded because the

sample size was less than

10 and the allocation could

not lead to balanced groups

Peterson, 198427 Not done Done Unclear Done Done Unclear Study excluded because the

sample size was less than

10 and the allocation could

not lead to balanced groups

Timko, 199928 Not

applicable

Done Unclear Not done Done Not done Study excluded because the

sample size was less than

10 and the allocation could

not lead to balanced

groups, and the controls

were exposed to the

intervention

McKenna, 198229 Not done Partially

done

Unclear Not done Unclear Unclear Study excluded because the

comparison groups had

substantial differences at

baseline, which made

groups noncomparable

Stern, 199930 Not done Unclear Unclear Not done Unclear Done Study excluded because the

comparison groups had

substantial differences at

baseline, which made

groups noncomparable

Frederick, 200031 Partially done Done Partially done Not done Partially

done

Unclear Study excluded because the

comparison groups had

substantial differences at

baseline, which made

groups noncomparable

Campbell, 200132 Partially done Partially

done

Done Done Partially

done

Not done Study excluded because there

was insufficient compliance

with the intervention

(overall 57% attendance at

the sessions), and the

controls were exposed to

the intervention

Engeland, 200233 Partially done Not done Not done Done Partially

done

Done Study excluded because only

26% of the participating

schools complied with the

intervention, which raises

serious concerns about the

representativeness of the

data

Capone, 200034 Partially done Done Done Done Partially

done

Not done Study excluded because the

controls were exposed to

the intervention

Raynal, 199135 Not done Done Done Done Unclear Not done Study excluded because the

controls were exposed to

the intervention

Breivik, 198036 Unclear Unclear Unclear Unclear Unclear Unclear Study excluded because of

insufficient information to

evaluate the quality

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All studies measured the final outcomes within 1 month ofthe intervention.37-40

Risk of BiasTable 1 summarizes the methodological quality of the 4

included studies.

Kelly et al37 allocated the participants at random to thecomparison groups but did not report on procedures forconcealment. Eighty-nine percent of the enrolledparticipants completed the study. Researchers, blind to groupstatus, recorded the outcomes. The study obtained baselinemeasurements of first aid knowledge. There was no reporting

Table 3. Characteristics of included studies.

Study by

First Author Education Level Setting Participants Intervention Outcome

Kelly, 200337 Higher

(nonuniversity)

Training at 2

women, infant,

and children

clinics.

Parents of young

children who visited

the clinic.

N: 323

Age: u

I5video (9 min),

pamphlets, and stickers

about first aid for

poisoning

C5educational class on

immunizations and

healthy snacks

Assessment of knowledge about

first aid for poisoning with

written and oral interviews

Moore,

198738

Primary Training in primary

school as a

noncompulsory

course.

Pupils from 2 primary

schools.

N: 92

A: 10–11 y

I(1)5training to develop

assertive behavior to

become a more

autonomous health care

consumer (6 h)

I(2)5first aid training on

bleeding, injuries, burns,

shock, poisoning, and

other topics outside the

review (6 h)

I(3)5assertion training (3

h) and first aid training

on abovementioned

topics (3 h)

C5viewing science films

without health education

content (6 h)

Assessment of first aid

knowledge and skills on first

aid for bleeding, broken

bones, burns, head injuries,

poisoning, and heat stroke

with a written test

Shotland,

198539

Higher (university) Training at university

during a first aid

program organized

by the health

education

department.

Participants from the

usual enrollments for

the training program.

Passing the

examination led to an

American Red Cross

certificate.

N: 209

A: u

I5first aid training on

bleeding, wounds, and

other undefined topics

(duration5u)

C5receiving same training

as I but took tests

before lesson on

bleeding control

(duration5u)

Assessment of helping behavior

during a deception experiment

with a simulated arterial

bleeding emergency

Hawks,

199840

Higher (university) Training at university

during a health

and wellness

education course

open to all

university

students.

Recruitment through the

normal university

registration process.

Reasons for

participation in the

training included

personal interest, as

a compulsory lesson,

or as an elective.

N: 98

A: 18-53 y

I(1)5first aid training that

also addressed 2

inhibitors of emergency

helping behavior, ie,

situational ambiguity

and bystander effect

(duration5u)

I(2)5first aid training that

mentioned inhibitors of

helping behavior

(duration5u)

I(3)5first aid training

without focus on

inhibitors of helping

behavior (duration5u)

C5no first aid training

Assessment of first aid

knowledge and skills with a

written and a practical test

(no data reported in study)

Assessment of helping rates

during a deception experiment

with a simulated chest pain

emergency

u, Unclear; I, intervention group; C, control group.

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of reliability data. Protection against contamination wasadequate. The study did not provide indications of facevalidity and did not report whether content experts hadreviewed the test instrument before the trial. However, wecould derive content validity indications from the providedtest descriptions. We assessed the study to have a high risk ofbias.Moore38 did not use concealment of randomization. All the

enrolled participants completed the study. The study failed toblind the researchers. Baseline measurements recorded first aidknowledge and skills with a written test. The test instrumenthad a satisfactory internal consistency (Crohnbach’s a of 0.67).Protection against contamination was adequate. Face validitywas evaluated by asking the children for feedback on the testinstruments in a pilot study with another primary school.Content experts had reviewed the test instrument before thetrial, and the provided test descriptions showed content validity.Participants who received more training also performed betteron the test, which indicates construct validity. We assessed thestudy to have a high risk of bias.Shotland and Heinold39 allocated the participants at random

to the comparison groups but did not describe procedures forconcealment. Seventy-eight percent of the enrolled participantscompleted the study. The study failed to report on blinding andprotection against contamination. The study did not recordbaseline measurements of outcomes. Video recordings allowedverifying the helping behavior data of participants obtained bythe researcher’s observations. No data collection errors weredetected. Demonstrating a high credibility with suspicion scoresabout the induced deception provided an indirect indication offace validity. It was unclear whether content experts hadreviewed the test instrument before the trial, but the providedtest descriptions showed content validity. We assessed the studyto have a high risk of bias.Hawks and Egan40 allocated the participants to the

comparison groups through the normal universityregistration process. All the enrolled participants completedthe study. Researchers, blind to group status, recorded theoutcomes. Baseline measurements recorded first aidknowledge and skills. Video recordings allowed verifying thehelping behavior data of participants obtained by theresearcher’s observations. No data collection errors weredetected. Protection against contamination was adequate.The study did not report whether content experts hadreviewed the test instrument before the trial, but the testdescriptions provided in the article showed content validity.It was unclear whether the study obtained suspicion scores,but this study did report high credibility of the test in apreceding experiment. Participants who received moretraining also performed better on the test, which indicatesconstruct validity. In relation to concurrent and predictivevalidity, the study compared scores on a written and practicaltest with scores during the helping behavior test. The 3groups trained in first aid had comparable scores on the

written knowledge test and practical skills test. The controlgroup did not take the written and practical test. Therefore,no actual comparison between scores on both tests waspossible. We assessed the study to have a moderate risk ofbias.

Effect of InterventionTable 4 gives a summary of the most important study results.

Without statistical pooling, forest plots graphically represent the

Table 4. Summary of main findings.

Study by

First Author Outcome Measure Main Results

Kelly, 200337 Written and oral test

on first aid

knowledge for

poisoning

Trained persons have a

significantly better

knowledge of Poison

Control Center telephone

number (RR 3.35; 95% CI

2.33 to 4.81) and of first

aid in case of household

bleach ingestion (RR 2.11;

95% CI 1.64 to 2.72)

Moore,

198738

Written test on first aid

knowledge and skills

for multiple cases

Significantly better

knowledge and skills

among those with 6 h first

aid training vs controls

(MD 4.75; 95% CI 3.02 to

6.48) and among those

with 3 h first aid training

vs controls (MD 2.56;

95% CI 0.99 to 4.13)

Shotland,

198539

Deception experiment

on helping behavior

Trained participants provided

significantly better first aid

for an arterial bleeding

emergency (RR 25.94;

95% CI 3.60 to 186.93).

Helping response for an

arterial bleeding

emergency did not occur

significantly more in

trained participants (RR

1.13; 95% CI 0.88 to

1.45)

Hawks,

199840

Deception experiment

on helping behavior

Helping response for a chest

pain emergency did not

significantly differ between

people trained in first aid

only and controls (RR

1.36; 95% CI 0.28 to

6.61). Helping response

occurred significantly more

among those trained in

first aid and helping

behavior than among

those trained in first aid

only (RR 2.80; 95% CI

1.05 to 7.50) or than in

controls (RR 3.81; 95% CI

0.98 to 14.89)

RR, relative risk; MD, mean difference.

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34

main findings of the 2 deception experiments (Figure 2).Appendix E3 contains the data used to calculate relative risk andmean difference for each comparison (available athttp://www.annemergmed.com).The study by Kelly et al37 on first aid for poisoning revealed

significantly better knowledge of the Poison Control Centerwork and its telephone number in trained participants (relativerisk 3.35; 95% confidence interval [CI] 2.33 to 4.81). In thecase of household bleach ingestion, participants receiving theintervention responded twice more that they would call thePoison Control Center (relative risk 2.11; 95% CI 1.64 to2.72).The study by Moore38 with first aid training for primary

education children revealed significantly greater knowledge andskills in the groups receiving first aid instruction. The highestdifference in scores occurred between the group receiving 6hours of first aid training and the control group (meandifference 4.75; 95% CI 3.02 to 6.48; range of scores possible 0to 20).The study by Shotland and Heinold39 that unexpectedly

confronted university students with an arterial bleedingemergency revealed that some type of help was provided by64% of participants in the intervention group and by 57% ofthe controls. The chances of helping were not significantlydifferent when comparing the 2 groups (relative risk 1.13; 95%CI 0.88 to 1.45). The number of respondents was significantlyhigher in unambiguous situations (relative risk 1.86; 95% CI1.40 to 2.46) and when individuals were alone with the casualty

(relative risk 1.29; 95% CI 0.99 to 1.66). Untrainedparticipants limit their helping response significantly more to acall for help only. Trained participants applied significantlymore direct pressure to control the bleeding than untrained andperformed much better in the combination of calling for helpand applying direct pressure (relative risk 25.94; 95% CI 3.60to 186.93).The study by Hawks and Egan40 about university students’

helping response to a chest pain emergency found a 45%helping rate in the group trained in first aid and helpingbehavior. Some type of help was provided by 26% of theparticipants in the group addressing helping behavior in smallmeasure, 16% in the group receiving first aid training withouthelping behavior, and 12% among controls. Levels ofsignificance were reached when helping behavior in the groupbeing trained in first aid and helping behavior with thosetrained in first aid only were compared (relative risk 2.80; 95%CI 1.05 to 7.50) or with controls (relative risk 3.81; 95% CI0.98 to 14.89). The group addressing helping behavior in smallmeasure did not help significantly more than controls (relativerisk 2.20; 95% CI 0.52 to 9.39), nor did the group receivingfirst aid training without focus on helping behavior (relative risk1.36; 95% CI 0.28 to 6.61).

LIMITATIONSAnalyzing the references obtained per source shows that the

search strategy can be improved. Searching MEDLINE(PubMed), EMBASE (EMBASE.com), PsycINFO

Figure 2. Forest plots without statistical pooling for the main findings of the 2 deception experiments first sorted bycomparison and then by outcome. The squares display the effect sizes and the horizontal lines represent the CIs. If the CIcrosses the vertical line, it means there is no statistically significant difference.

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454 Annals of Emergency Medicine Volume , . : September

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(WebSPIRS), and Education Resources Information Centerdatabase (EBSCOhost) would have been sufficient to retrieve allrelevant studies. Dropping key words such as “emergencymedicine” and “emergency nursing” that did not add anyrelevant studies for laypersons can increase the specificity of thesearch formula. Inserting a set of terms describing the criteriafor study designs is recommended. Adding search terms onspecific first aid topics to the intervention terms and adding thekey words “helping behavior” with OR to the outcome termscould be meaningful. As a result of checking the reference listsof all relevant studies and related systematic reviews andcommunication with authors of included studies, it is highlyunlikely that any studies were missed. As a safeguard, weperformed the search again after completion of the review,adding the key words “helping behavior,” but this did not revealany new relevant studies.A limitation in our study is that we excluded studies from

our review if they were not reported in English, German,French, or Dutch. Because emergency and disaster preparednessis a topic of major interest in Europe and elsewhere, it ispossible that important studies were not included in our reviewbecause of their choice of language.Another potential source of bias is incomplete reporting of

results in the published reports of the studies included in thereview. We contacted the authors of the 4 included studies witha request for more information, and 2 replied with more details.The research question in this systematic review was broadly

defined and included 4 studies that vary by either participants oroutcomes, making it difficult to make generalizations.

DISCUSSIONWe know of 3 previous reviews on the effectiveness of

cardiopulmonary resuscitation training for cardiac arrest.15-17

We believe that ours is the first systematic review of effectivenessof nonresuscitative first aid training in laypersons.All 4 of the studies we included found statistically significant

effects of first aid training on either competence or helpingbehavior of laypersons.37-40 The identification of 2 studies thatmeasured the change in practice39,40 is an important finding ofthis review.Although first aid training appeared to improve the quality

of first aid procedures for a bleeding emergency, it did not leadto an increased helping rate.39 The presence of bystanders andambiguity of situations emerged as barriers to providing help.39

A training program that focused both on first aid proceduresand on inhibitors of emergency helping behavior was closelyassociated with higher helping rates in a chest pain emergency.40

Although it is difficult to generalize from the 4 included studies,it nonetheless appears likely that traditional first aid trainingimproves objectively measured skill competences more than itdevelops a positive attitude and a likely helping reaction towardemergencies on the part of trainees.The evidence available to answer our question about the

effects of first aid training is of low quality and incomplete. The

studies provided little evidence to demonstrate validity andreliability of the outcome measures. Data are available only forsingle-victim emergencies. The findings are also limited totraining at a few educational levels and to observation ofeffectiveness of training within 1 month of the intervention.Furthermore, the evidence is too limited to take into accounteither the variability across cases or across components ofcompetence.New rigorous randomized controlled trials on the acquisition

and retention of competence and the modification of helpingbehavior are needed to explore the provisional findings of oursystematic review. The key challenge is to gain a betterunderstanding of actual helping behavior. The study by Hawksand Egan40 found that 45% of the participants trained in firstaid and helping behavior demonstrated helping behavior.Participants in this group helped almost 3 times more thanthose trained in first aid only. Nevertheless, 55% of trainees didnot provide any type of help. Many social psychologyexperiments have studied the influence of different contextual,personal, group, and victim factors in medical emergencies. Asystematic review of these studies might help to determinewhich factors are likely to be important for enhancement of theeffectiveness of first aid training.Deception experiments seem potentially useful means of

testing behavioral effectiveness. However, there are some ethicalconsiderations. Researchers may only use deception as part of astudy if the research question is important and deception is theonly way to obtain valid data. Participants should be informedabout the risks involved in the research and should not beexposed to harmful stress levels. At the end of the study,participants should be fully debriefed.41 Caution is alsorecommended to prevent harm to simulation participants.First aid covers assistance for a variety of situations. It is

important for the validity of the outcome measures to gather abroad sample of performance when possible. When newrandomized controlled trials are designed, it is essential tocarefully consider the reliability and validity of the outcomesthat will be measured. Apart from the recommendation above,we refer readers to the International Handbook of Research inMedical Education, by Norman et al,42 for an elaboratediscussion on obtaining valid and reliable outcomemeasurements.In conclusion, on the basis of 2 studies with university

students, programs for first aid that also train participants toovercome inhibitors of emergency helping behavior could leadto better help and higher helping rates for single-victimemergencies. Because the overall completeness and quality of theevidence is low, full confidence in this conclusion should beconsidered to be contingent on further research.

The authors are grateful to J. Collins, P. Donceel, M. VanNuland, for their critical reflections on this review. They thank J.Vlayen for his advice on composing the search strategy. The authorswould also like to thank the following authors for providing

Van de Velde et al Effectiveness of Layperson First Aid Training

Volume , . : September Annals of Emergency Medicine 455

36

additional information: K. Frederick, J. Moore, G. Smedslund,J.C. Lane, H. Breivik, S. Hawks, and D. Kendrick.

Author contributions: This review was made on behalf of

Belgian Red Cross-Flanders. SVDV, BA, and DR conceived and

designed the study. SVDV implemented and wrote the review.

AH was the second reviewer and screened retrieved papers

against inclusion criteria, appraised the methodological quality

of studies, and checked if data extraction was accurate. BA

and DR gave methodological advice. AR provided a medical

education perspective. PV provided general advice on the

review. B Aertgeerts was the guarantor of the study.

Funding and support: By Annals policy, all authors are required

to disclose any and all commercial, financial, and other

relationships in any way related to the subject of this article

that might create any potential conflict of interest. See the

Manuscript Submission Agreement in this issue for examples

of specific conflicts covered by this statement. This study was

funded by the Belgian Red Cross–Flanders. Belgian Red

Cross–Flanders is one of the 186 National Societies of the

International Red Cross and Red Crescent Movement. First aid

training is an important activity of the organization. To further

improve the quality and effectiveness of the first aid

programs, the Belgian Red Cross–Flanders aims at the

establishment of evidence-based practice in first aid. S Van de

Velde and P Vandekerckhove are in employment at the Belgian

Red Cross-Flanders, which provides training in first aid.

Publication date: Available online January 21, 2009.

Reprints not available from the authors.

Address for correspondence: Stijn Van de Velde, Belgian Red

Cross-Flanders, Motstraat 40, 2800 Mechelen, Belgium; 32-0-

15-44-34-76, fax 32-0-15-44-33-08; E-mail

stijn.vandevelde@rodekruis.be.

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datacollectionchecklist.pdf. Accessed June 11, 2007.

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26. Marchand-Martella NE, Martella RC. Teaching a first aid skill to

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effect of first aid training. J Occup Accidents. 1982;4:47-59.

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30. Stern EB, Berman M, Thomas JJ, et al. Community education for

stroke awareness: an efficacy study. Stroke. 1999;30:720-723.

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aid and home safety program for Hispanic migrant adolescents.

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in junior high schools. Inj Control Saf Promot. 2002;9:99-106.

34. Capone PL, Lane JC, Kerr CS, et al. Life supporting first aid

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to increase use of poison control centers by low-income and

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38. Moore JB. Effects of assertion training and first aid instruction on

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39. Shotland RL, Heinold WD. Bystander response to arterial bleeding:

helping skills, the decision-making process, and differentiating the

helping response. J Pers Soc Psychol. 1985;49:347-356.

40. Hawks SR, Egan M. The impact of three different first aid

curricula on emergency helping among college students. J Health

Educ. 1998;29:289-293.

41. American Psychological Association. Ethical principles of

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http://www.apa.org/ethics/code2002.html. Accessed June

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Handbook of Research in Medical Education. Dordrecht, The

Netherlands: Kluwer Academic Publishers; 2002.

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Volume , . : September Annals of Emergency Medicine 457

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APPENDIX E1. Search formulas.This file contains further details of methods to accompany

the paper Effectiveness of non-resuscitative first aid training forincreasing competence and helping behaviour in laypersons: Asystematic review by Stijn Van de Velde, Annemie Heselmans,Ann Roex, Philippe Vandekerckhove, Dirk Ramaekers and BertAertgeerts.Below we describe the search formula per consulted database.

We consulted the databases on 4 June 2007.MEDLINE (Pubmed)1. “First Aid”[mh] OR “Emergency

Treatment”[mh:NoExp] OR “EmergencyMedicine”[mh] OR “Emergency Nursing”[mh] OR“first aid”[tw] OR “first response”[tw] OR “prehospitalcare”[tw] OR “prehospital management”[tw] ORlifesupport*[tw] OR “life support*”[tw] ORlifesaving[tw] OR “life saving”[tw] OR “wildernessmedicine”[tw] OR “mountain rescue*”[tw]

2. ”Education”[mh] OR “Learning”[mh] OR educat*[tw]OR train*[tw] OR teach*[tw] OR instruct*[tw] ORlearn*[tw]

3. 1 AND 24. “Educational Measurement”[mh] OR “Health

Knowledge, Attitudes, Practice”[mh] OR“Knowledge”[mh] OR “Psychomotor Performance”[mh]OR “Competency-Based Education”[mh] ORknowledge[tw] OR attitude*[tw] OR skill*[tw] ORcompetenc*[tw] OR perform*[tw] OR abilit*[tw]

5. ”Retention (psychology)”[mh] OR retention[tw] ORretain*[tw] OR recall*[tw] OR maintenance[tw] ORmaintain*[tw] OR remember*[tw]

6. 4 OR 57. 3 AND 6EMBASE (EMBASE.com)1. (‘first aid’/de OR ‘emergency treatment’/de OR

‘emergency medicine’/de OR ‘emergency nursing’/deOR ‘first aid’:ab,ti OR ‘first response’:ab,ti OR‘prehospital care’:ab,ti OR ‘prehospital management’:ab,ti OR lifesupport*:ab,ti OR ‘life support*’:ab,ti ORlifesaving:ab,ti OR ‘life saving’:ab,ti OR ‘wildernessmedicine’:ab,ti OR ‘mountain rescue*’:ab,ti)

2. (‘Education’/exp OR ‘Learning’/exp OR educat*:ab,tiOR train*:ab,ti OR teach*:ab,ti OR instruct*:ab,ti ORlearn*:ab,ti)

3. 1 AND 24. (‘attitude to health’/de OR ‘knowledge’/exp OR

‘psychomotor performance’/exp OR knowledge:ab,ti ORattitude*:ab,ti OR skill*:ab,ti OR competenc*:ab,ti ORperform*:ab,ti OR abilit*:ab,ti)

5. long term memory’de OR retention:ab,ti OR retain*:ab,ti OR recall*:ab,ti OR maintenance:ab,ti ORmaintain*:ab,ti OR remember*:ab,ti

6. 4 OR 57. 3 AND 6

COCHRANE CENTRAL (Wiley)1. MeSH descriptor Emergency Treatment, this term

only2. MeSH descriptor First Aid, this term only3. MeSH descriptor Emergency Medicine explode all

trees4. MeSH descriptor Emergency Nursing explode all trees5. first aid OR “first response” OR “prehospital care” OR

“prehospital management” OR lifesupport* OR “lifesupport*” OR lifesaving OR “life saving” OR“wilderness medicine” OR “mountain rescue*”

6. OR 1-57. MeSH descriptor Education explode all trees8. MeSH descriptor Learning explode all trees9. educat* OR train* OR teach* OR instruct* OR

learn*10. OR 7-911. 6 AND 1012. MeSH descriptor Educational Measurement explode all

trees13. MeSH descriptor Health Knowledge, Attitudes,

Practice explode all trees14. MeSH descriptor Knowledge explode all trees15. MeSH descriptor Psychomotor Performance explode all

trees16. MeSH descriptor Competency-Based Education

explode all trees17. MeSH descriptor Retention (Psychology) explode all

trees18. knowledge OR attitude* OR skill* OR competenc* OR

perform* OR abilit* OR retention OR retain* ORrecall* OR maintenance OR maintain* OR remember*

19. OR 12-1820. 11 AND 19C2-SPECTR (Campbell Collaboration)1. {first aid} OR {first response} OR {prehospital care}

OR {prehospital management} OR {lifesupport} OR{life support} OR {lifesaving} OR {life saving} OR{wilderness medicine} OR {mountain rescue} OR{Emergency Treatment} OR {Emergency Medicine}OR {Emergency Nursing} [SEARCH ALL INDEXEDFIELDS]

2. {first aid} OR {first response} OR {prehospital care} OR{prehospital management} OR {lifesupport} OR {lifesupport} OR {lifesaving} OR {life saving} OR {wildernessmedicine} OR {mountain rescue} OR {EmergencyTreatment} OR {Emergency Medicine} OR {EmergencyNursing} [SEARCH ALL NON-INDEXED FIELDS]

3. 1 OR 2CINAHL (EBSCOhost)1. (MH “First Aid”) or (MH “First Aid (Iowa NIC)”) or

“first aid” or “first response” or lifesupport* or “lifesupport*” or lifesaving or “life saving” or “wildernessmedicine” or “mountain rescue*”

457.e1 Annals of Emergency Medicine Volume , . : September

39

2. (MH “Education1”) or (MH “Learning1”) or educat*OR train* OR teach* OR instruct* OR learn*

3. 1 AND 24. (MH “Educational Measurement1”) or (MH“Knowledge1”) or (MH “Health Knowledge andBehavior (Iowa NOC) (Non-Cinahl)1”) or (MH“Education, Competency-Based”) or (MH “PsychomotorPerformance1”) or (MH “Student PerformanceAppraisal1”) OR knowledge OR attitude* OR skill* ORcompetenc* OR perform* OR abilit*

5. (MH “Skill Retention”) OR retention OR retain* ORrecall* OR maintenance OR maintain* OR remember*

6. 4 0R 57. 3 AND 6

BRITISH NURSING INDEX AND ARCHIVE (OVID)1. first aid/ or “accident and emergency nursing”/ or (”firstaid” or “first response” or “prehospital care” or“prehospital management” or lifesupport$ or lifesupport$ or lifesaving or life saving or wildernessmedicine or mountain rescue$).mp. [mp5title, abstract,heading words]

2. (educat$ or train$ or teach$ or instruct$ or learn$).mp.[mp5title, abstract, heading words]

3. 1 AND 24. knowledge OR attitude$ OR skill$ OR competenc$ OR

perform$ OR abilit$5. retention OR retain$ OR recall$ OR maintenance OR

maintain$ OR remember$6. 4 OR 57. 3 AND 6

SPORTSDISCUS (EBSCOhost)1. (DE “FIRST aid in illness & injury”) or (DE

“EMERGENCY medicine”) or “first aid” OR “firstresponse” OR “prehospital care” OR “prehospitalmanagement” OR lifesupport* OR “life support*” ORlifesaving OR “life saving” OR “wilderness medicine”OR “mountain rescue*”

2. DE “EDUCATION” OR DE “HEALTH education”OR DE “OUTDOOR education” OR DE “PHYSICALeducation & training” OR DE “SPECIAL education” orDE “TRAINING” or DE “TEACHING” OR educat*OR train* OR teach* OR instruct* OR learn*

3. 1 AND 24. DE “PERFORMANCE” OR DE “JOB performance”

OR knowledge OR attitude* OR skill* OR competenc*OR perform* OR abilit*

5. retention OR retain* OR recall* OR maintenance ORmaintain* OR remember*

6. 4 OR 57. 3 AND 6PsycINFO (WebSPIRS)1. ”first aid” or “first response” or “prehospital care” or

“prehospital management” or lifesupport* or “life

support*” or lifesaving or “life saving” or “wildernessmedicine” or “mountain rescue*”

2. (explode “Teaching-” in MJ,MN) or (explode “Training-” in MJ,MN) or (explode “Learning-” in MJ,MN) or(explode “Education-” in MJ,MN) or (educat* or train*or teach* or instruct* or learn*)

3. 1 AND 24. (knowledge or attitude* or skill* or competenc* orperform* or abilit*) or ((explode “Ability-1” in MJ,MN)or (explode “Competence-” in MJ,MN) or (explode“Performance-1” in MJ,MN)) or (explode “Knowledge-Level” in MJ,MN) or ((”Health-Attitudes” in MJ,MN)or (”Health-Behavior” in MJ,MN) or (”Health-Knowledge” in MJ,MN)) or (explode “Educational-Measurement” in MJ,MN)

5. ”Retention (psychology)”[mh] OR retention[tw] ORretain*[tw] OR recall*[tw] OR maintenance[tw] ORmaintain[tw] OR remember*[tw]

6. 4 OR 57. 3 AND 6ERIC (EBSCOhost)1. DE “First Aid” OR “first aid” OR “first response” ORlifesupport* OR “life support*” OR lifesaving OR “lifesaving” OR “wilderness medicine” OR “mountainrescue*”

2. (DE “Education” OR DE “Academic Education” ORDE “Adult Education” OR DE “After SchoolEducation” OR DE “Aging Education” OR DE “AlliedHealth Occupations Education” OR DE “CitizenshipEducation” OR DE “Coeducation” OR DE“Community Education” OR DE “ComparativeEducation” OR DE “Compensatory Education” ORDE “Competency Based Education” OR DE“Compulsory Education” OR DE “CorporateEducation” OR DE “Correctional Education” OR DE“Distance Education” OR DE “Driver Education” ORDE “Early Childhood Education” OR DE “ElementarySecondary Education” OR DE “Family LifeEducation” OR DE “Health Education” OR DE“Industrial Education” OR DE “Informal Education”OR DE “Inservice Education” OR DE “IntergroupEducation” OR DE “Leisure Education” OR DE“Migrant Education” OR DE “NoncategoricalEducation” OR DE “Nondiscriminatory Education”OR DE “Nonformal Education” OR DE“Nontraditional Education” OR DE “OpenEducation” OR DE “Outcome Based Education” ORDE “Outdoor Education” OR DE “Patient Education”OR DE “Physical Education” OR DE “PoliceEducation” OR DE “Popular Education” OR DE“Population Education” OR DE “PostsecondaryEducation” OR DE “Process Education” OR DE“Professional Education” OR DE “ProgressiveEducation” OR DE “Public Education” OR DE “Rural

Volume , . : September Annals of Emergency Medicine 457.e2

40

Education” OR DE “Safety Education” OR DE“Special Education” OR DE “SupplementaryEducation” OR DE “Urban Education” OR DE“Values Education” OR DE “Vocational Education”OR DE “Womens Education”)

3. (DE “Learning” OR DE “Active Learning” OR DE“Adult Learning” OR DE “Associative Learning” ORDE “Aural Learning” OR DE “Cooperative Learning”OR DE “Discovery Learning” OR DE “DiscriminationLearning” OR DE “Experiential Learning” OR DE“Incidental Learning” OR DE “Intentional Learning”OR DE “Lifelong Learning” OR DE “MasteryLearning” OR DE “Multisensory Learning” OR DE“Nonverbal Learning” OR DE “ObservationalLearning” OR DE “Prior Learning” OR DE “ProblemBased Learning” OR DE “Rote Learning” OR DE“Sequential Learning” OR DE “Serial Learning” ORDE “Transfer of Training” OR DE “TransformativeLearning” OR DE “Verbal Learning” OR DE “VisualLearning”)

4. (DE “Instruction” or DE “Assignments” OR DE“College Instruction” OR DE “Concept Teaching” ORDE “Group Instruction” OR DE “Home Instruction”OR DE “Individual Instruction” OR DE “MassInstruction”)

5. (DE “Training” OR DE “Caregiver Training” OR DE“Industrial Training” OR DE “Job Training” OR DE“Laboratory Training” OR DE “Military Training” ORDE “Professional Training” OR DE “Retraining” ORDE “Volunteer Training”)

6. OR 2-57. 1 AND 68. DE “Knowledge Level” or DE “Ability” OR DE

“Cognitive Ability” OR DE “Competence” OR DE“Skills” or DE “Performance” OR DE “JobPerformance” OR DE “Attitudes” OR knowledge ORattitude* OR skill* OR competenc* OR perform* ORabilit*

9. DE “Recall (Psychology)” or DE “Retention(Psychology)” OR retention OR retain* OR recall* ORmaintenance OR maintain* OR remember*

10. 8 OR 911. 7 AND 10

APPENDIX E2. EPOC quality criteria for randomizedcontrolled trials.This file contains further details of methods to accompany

the paper Effectiveness of non-resuscitative first aid training forincreasing competence and helping behaviour in laypersons: Asystematic review by Stijn Van de Velde, Annemie Heselmans,Ann Roex, Philippe Vandekerckhove, Dirk Ramaekers and BertAertgeerts.Below we list the EPOC Quality criteria for randomised

controlled trials. (Extract from the following reference :

Cochrane Effective Practice and Organisation of Care Group.The data collection checklist. Available at:http://www.epoc.uottawa.ca/checklist2002.doc.)Seven standard criteria are used for randomised controlled

trials and controlled clinical trials included in EPOC reviews:a) Concealment of allocation (protection against selection bias)Score DONE if the unit of allocation was by institution,

team or professional and any random process is describedexplicitly, e.g. the use of random number tables or coin flips; theunit of allocation was by patient or episode of care and therewas some form of centralised randomisation scheme, an on-sitecomputer system or sealed opaque envelopes were used.Score NOT CLEAR if the unit of allocation is not described

explicitly; the unit of allocation was by patient or episode of careand the authors report using a ‘list’ or ‘table’, ‘envelopes’ or‘sealed envelopes’ for allocation.Score NOT DONE if the authors report using alternation

such as reference to case record numbers, dates of birth, day ofthe week or any other such approach (as in CCTs);the unit of allocation was by patient or episode of care and

the authors report using any allocation process that is entirelytransparent before assignment such as an open list of randomnumbers or assignments; allocation was altered (by investigators,professionals or patients).b) Follow-up of professionals (protection against exclusion bias)Score DONE if outcome measures obtained for 80-100% of

subjects randomised. (Do not assume 100% follow up unless statedexplicitly.); Score NOT CLEAR if not specified in the paper; ScoreNOTDONE if outcome measures obtained for less than 80% ofsubjects randomised.c) Follow-up of patients or episodes of careScore DONE if outcome measures obtained for 80-100% of

subjects randomised or for patients who entered the trial. (Do notassume 100% follow up unless stated explicitly.) Score DONE ifthere is an objective data collection system; Score NOT CLEAR ifnot specified in the paper; Score NOTDONE if outcomemeasures obtained for less than 80% of subjects randomised or forless than 80% of patients who entered the trial.d) Blinded assessment of primary outcome(s)* (protection

against detection bias)Score DONE if the authors state explicitly that the primary

outcome variables were assessed blindly OR the outcomevariables are objective, e.g. length of hospital stay, drug levels asassessed by a standardised test; Score NOT CLEAR if notspecified in the paper; Score NOT DONE if the outcome(s)were not assessed blindly.* Primary outcome(s) are those variables that correspond to

the primary hypothesis or question as defined by the authors. Inthe event that some of the primary outcome variables wereassessed in a blind fashion and others were not, score eachseparately and label each outcome variable clearly.e) Baseline measurementScore DONE if performance or patient outcomes were

measured prior to the intervention, and no substantial differences

457.e3 Annals of Emergency Medicine Volume , . : September

41

were present across study groups; Score NOT CLEAR if baseline

measures are not reported, or if it is unclear whether baseline

measures are substantially different across study groups; Score

NOTDONE if there are differences at baseline in main outcome

measures likely to undermine the post intervention differences (e.g.

are differences between the groups before the intervention similar

to those found post intervention).

f) Reliable primary outcome measure(s)*

Score DONE if two or more raters with at least 90% agreement

or kappa greater than or equal to 0.8 OR the outcome is obtained

from some automated system e.g. length of hospital stay, drug

levels as assessed by a standardised test; Score NOT CLEAR if

reliability is not reported for outcome measures that are obtained

by chart extraction or collected by an individual; Score NOT

DONE if agreement is less than 90% or kappa is less than 0.8.

* In the event that some outcome variables were assessed in a

reliable fashion and others were not, score each separately on the

back of the form and label each outcome variable clearly.

g) Protection against contamination

Score DONE if allocation was by community, institution or

practice and it is unlikely that the control received the intervention;

Score NOT CLEAR if professionals were allocated within a clinic

or practice and it is possible that communication between

experimental and group professionals could have occurred;

Score NOT DONE if it is likely that the control group

received the intervention (e.g. cross-over trials or if patients

rather than professionals were randomised).

APPENDIX E3. Data and comparisons.This file contains further details of methods to accompany

the paper Effectiveness of non-resuscitative first aid training for

increasing competence and helping behaviour in laypersons: A

systematic review by Stijn Van de Velde, Annemie Heselmans,

Ann Roex, Philippe Vandekerckhove, Dirk Ramaekers and Bert

Aertgeerts.

Below we describe the comparisons and data used to calculate

RR or MD.

Kelly 2003

Knowledge of the Poison Control Center telephone number

(First aid training versus Controls)

Intervention

n

Intervention

N

Control

n

Control

N

91 145 27 144

Knowledge of first aid for ingestion of household bleach

(First aid training versus Controls)

Intervention

n

Intervention

N

Control

n

Control

N

102 145 48 144

Moore 1987

Knowledge of first aid for multiple cases (First aid training

versus Controls)

Intervention

N

Intervention

Mean

Intervention

SD

Control

N

Control

Mean

Control

SD

22 11.92 3.43 23 7.17 2.35

Shotland 1985

Helping rates for bleeding (First aid training versus Controls)

Intervention

n

Intervention

N

Control

n

Control

N

51 80 47 83

Helping rates for bleeding (Unambiguous versus Ambiguous

situation)

Unambiguous

n

Unambiguous

N

Ambiguous

n

Ambiguous

N

64 82 34 81

Helping rates for bleeding (Alone versus Group situation)

Alone n

Alone

N

Group

n

Group

N

56 83 42 80

Adequate first aid for bleeding (First aid training versus

Controls)

Intervention

n

Intervention

N

Control

n

Control

N

25 80 1 83

Hawks 1998

Helping rates for chest pain (Training in first aid and helping

behaviour versus Controls)

Intervention

n

Intervention

N

Control

n

Control

N

13 29 2 17

Helping rates for chest pain (Training in first aid and helping

behaviour (small measure) versus Controls)

Intervention

n

Intervention

N

Control

n

Control

N

7 27 2 17

Volume , . : September Annals of Emergency Medicine 457.e4

42

Helping rates for chest pain (First aid training only versusControls)

Intervention

n

Intervention

N

Control

n

Control

N

4 25 2 17

Helping rates for chest pain (Training in first aid and helpingbehaviour versus First aid training only)

Intervention

n

Intervention

N

Intervention

(3) n

Intervention

(3) N

13 29 4 25

457.e5 Annals of Emergency Medicine Volume , . : September

43

44

CHAPTER 4

Does training on barriers to helping facilitate emergency

helping behaviour among laypersons trained in first aid?

A randomised deception trial

Stijn Van de Velde, Ann Roex, Karoline Vangronsveld, Lidewij Niezink, Koen Van

Praet, Annemie Heselmans, Peter Donceel, Philippe Vandekerckhove, Dirk

Ramaekers, Bert Aertgeerts. Does training on barriers to helping facilitate

emergency helping behaviour among laypersons trained in first aid? A

randomised deception trial. Article submitted.

45

Abstract

Objective To investigate the effect of conventional first aid training versus

conventional training plus a supplementary training module to decrease

barriers to helping.

Design A randomised controlled trial with deception where the participants

were unaware that an acute myocardial infarction was simulated and did not

know that their helping behaviour was being evaluated.

Setting Ten training courses organised by six local Red Cross branches.

Participants 144 participants, from 18 years onwards, without formal medical

education or profession.

Interventions All participants first received 24 hours conventional first aid

training. According to random number lists, participants then either attended

an experimental lesson with a training module to reduce barriers to helping or

followed an active control lesson. Both the experimental and control training

lasted two hours.

Main outcome measures During the deception test we assessed how much

time elapsed between the start of the simulation and seeking help (primary

outcome). Other main outcomes measured were the rate of helping actions,

and first aid self-efficacy beliefs. Two persons, blinded towards group status,

independently extracted data from the video recordings of the deception test.

Results We randomised 72 participants to both the experimental and control

group. 22 participants were included in the analysis for the experimental group

and 36 in the control group. We found no statistically or clinically significant

differences between the experimental and control group for any of the

measures. The time until seeking help (geometrical mean and 95% confidence

46

interval) was 55.5 seconds (42.9 to 72.0) in the experimental group and 56.5

(43.0 to 74.3) in the control group. All participants showed some kind of helping

reaction. About 57% (n=33) of the participants asked a bystander to seek help,

40% (n=23) left the victim to seek help themselves, and 3% (n=2) did not seek

any help within the allocated 3 minutes. Participants indicated a mean self-

efficacy score of 25.2 (23.9 to 26.6) in the experimental group and 24.4 (23.0 to

25.8) in the control group. The self-efficacy score did not correlate with the

time-related outcomes.

Conclusion Supplementary training on dealing with barriers to helping did not

alter the time or rate of helping in an acute myocardial infarction emergency.

Despite the very high helping rates, there is still a need to increase the

timeliness and appropriateness of the aid provided. First aid self-efficacy beliefs

did not appear to be a useful predictor of performance.

Trial registration Clinical Trials NCT00954161

Introduction

Training laypersons in first aid is widely advocated to save lives. To achieve this

goal the training must improve knowledge, attitudes, and skills, and the trainees

must use these abilities appropriately in case of emergency. Despite the general

belief in the potential of first aid training, a systematic review of the

effectiveness of non-resuscitative first aid training showed that it does not

always translate into helping behaviour.1 Three trials used deception

experiments to evaluate the helping behaviour for bleeding and heart attack

emergencies after first aid training.2-4 The deception implied that the

participants were unaware of any simulation and did not know that their

helping behaviour was being evaluated. These trials showed that laypersons

trained in first aid provided better help,2 but did not help more often than

47

untrained laypersons.2;4 These trials also found that conventional first aid

training was less effective than training supplemented by a training module that

concentrated on the obstacles to action.3;4 The systematic review concluded

that conventional first aid training improved competences but not performance,

and that supplementary training on dealing with barriers to helping might

enhance helping behaviour.1 The conclusions are only tentative because the

evidence was of low quality and are limited to university student populations in

the U.S.1

Social-psychological research has extensively documented the role of different

factors such as individual differences, victim characteristics, presence of other

bystanders, and situational ambiguity on bystander helping behaviour.5-7

Barriers to helping identified in surveys among laypersons include fear of

causing further harm, legal consequences, disease transmission, and increasing

the burden on the emergency medical services without good reason.8-10

We integrated the information on bystander helping behaviour in a training

module to decrease barriers to helping. This module can be given in addition to

conventional first aid training. This study aimed to investigate the effect of

conventional first aid training versus conventional training plus this

supplementary training module in a community-based randomised controlled

trial. Our primary hypothesis was that the time until seeking help is shorter

among people trained with the supplementary intervention.

Having the confidence to provide first aid may influence helping barriers. We

therefore also measured the participants’ self-efficacy beliefs11;12 and related

these to the performance demonstrated in the deception. While deception is a

useful instrument to test first aid performance, this technique runs the potential

risk of creating mistrust or harm from high stress levels.13 For that reason this

study also evaluated the impact of the deception on the participants.

48

Methods

Participants

Belgian Red Cross-Flanders provides first aid training at almost 300 local

branches which are supported and coordinated by its central services. Red Cross

staff recruited study participants from September 2009 until October 2010

during the first lesson of 10 first aid training courses organised by six branches

(Mechelen, Muizen, Duffel, Kampenhout-Herent, Sint-Katelijne-Waver, Lier).

The selection of branches was based on proximity to the headquarters of the

Belgian Red Cross-Flanders. Participants had a minimum age of 18 years and

were not allowed to follow additional first aid training outside the study. We

excluded health care students and professionals from the study. Participants

that completed the full study protocol received a gift coupon to the value of

€40. The follow-up ended in January 2011.

Informed consent

At the start of the study, we obtained informed consent for a study to test first

aid self-efficacy after attending one of two new training lessons and for an

apparently separate study on driving proficiency. Immediately after the

deception test we provided a third informed consent form in which we notified

participants about the deception.

Design

An investigator, who was not involved in the enrollment of study participants,

used random number lists obtained from www.randomisation.com to allocate

participants. The randomisation was done per branch, assuring an equal

number of enrolled participants per group (if the number of participants was

even). All participants first received conventional first aid training. Participants

then either attended an experimental lesson with a training module to reduce

barriers to helping or followed an active control lesson. We informed

participants that both lessons were newly developed and had to be evaluated.

49

They received no information about the scope of these lessons until they

started.

The conventional first aid training programme was a 24-hour course which

covered first aid procedures for the most important emergencies including

acute myocardial infarction. Teaching methods included lectures, skills practice

on manikins or other participants, and exercises with simulated patients. No

more than 20 participants were allowed per course. The participants were able

to take a written and practical exam to assess competence, but this was not

obligatory. Volunteer trainers gave the programme over two to three month

periods. All trainers were trained in facilitation learning and assessment.

Intervention

The experimental training module aimed to sensitise participants towards a

helping reaction and to reduce barriers to helping. Instructional methods

included: a) Group work and discussion on the likelihood of witnessing an emergency

situation; personal experiences with emergencies; moral aspects of helping;

feelings and perspectives of the victim and bystanders; barriers to helping

behaviour, and how to deal with them.

b) Role play for specific situations where barriers to helping are present.

c) Formulation and writing down of personal helping goals.

In addition, the participants received a booklet containing information on

barriers to helping and how to deal with them.

The active control training focussed on first aid for alcohol and drug incidents

and was an extension of the conventional first aid training.

Both the experimental and control training lasted two hours and took place one

week after completion of the conventional training programme. The maximum

number of participants per group was ten. One professional first aid trainer

gave all the experimental and control lessons.

50

Deception test

Within one month of the experimental or control training, we assessed each

study participant individually during a deception test at the headquarters

(Mechelen) of the Belgian Red Cross-Flanders. We deceived participants by

making them believe that they were participating in a driving proficiency test.

Upon arrival, participants placed their mobile phones in a locker and went to

the test room. This room contained four chairs placed side by side in front of a

games computer with a steering wheel, and accelerator and brake pedals. The

study participant took a seat in the middle next to the imminent ‘victim’. Two

actors in the role of passive bystanders sat at the sides. The actors were blinded

towards group status. The test supervisor left the room while the participants

practised on the computer game. Shortly after this the victim started the

simulation by grabbing his chest and imitating shortness of breath. The victim

also had a pale and sweaty appearance. The other actors reacted as if they were

concerned but did not know what to do. When a help-seeking reaction

occurred, or after 3 minutes without a help-seeking reaction, the test supervisor

informed the participant about the deception and the reasons for the test. A

hidden camera filmed the assessment. A counsellor specialised in supporting

people involved in distressing situations facilitated a defusing immediately after

the test.13 Content experts and researchers in medical education, experimental

psychology and social psychology evaluated the test scenario before the trial.

Outcomes

At baseline, we collected data on socio-demographic factors and scores on a

multiple choice test measuring the knowledge about procedures for various first

aid situations.

Outcomes measured directly after the experimental or control training

comprised first aid self-efficacy beliefs and satisfaction. The satisfaction

questionnaire consisted of seven statements relating to novelty,

comprehensibility, clarity, applicability of the information, teaching quality,

group dynamics, and overall satisfaction.

51

During the deception test we assessed the primary outcome, i.e. the time until

seeking help. The time was measured between the start of the simulation and a

person leaving the room to get help. This person could either be the study

participant or an actor who had been instructed by the participant to get help.

When no help-seeking action occurred after three minutes, the test was

aborted. Post hoc, we decided to explore how much time elapsed between a)

the start of the simulation and visual notice of the emergency by the

participant: detection delay, b) notice and any helping response: response

delay, and c) notice and seeking help: help-seeking delay. A helping response

was defined as either assessing the victim, seeking help, or providing direct help

to the victim. Two persons, blinded towards group status, independently

extracted data from the video recordings. Any differences were discussed and

verified on the recordings.

Other outcomes measured during the deception test were the rate of helping

actions, credibility and impact of the deception, and state of positive and

negative mood after being told about the deception. For the state of mood

participants indicated how they felt in relation to five positive and five negative

mood items: nervous, enthusiastic, confused, strong, ashamed, determined,

anxious, proud, angry, and inspired. The latter scale was based on the Positive

And Negative Affect Schedule.14

The participants rated self-efficacy, satisfaction, credibility, impact of deception,

and state of positive and negative mood on a Likert scale.

Sample size and statistical analysis

We estimated that we would need 25 participants in both the experimental and

control group to detect a difference in mean delay time for seeking help of 30

seconds for a power of 80 % at a 5% level of significance, a standard deviation

of 37 seconds and a control/experimental patient ratio of 1. We based the

52

estimated data required for the sample size calculation on the raw data from a

study published by Hawks3. We periodically monitored whether the target

number of participants for the analysis had been reached and then decided if

new participants had to be enrolled.

Responses to items regarding self-efficacy, satisfaction, and positive and

negative mood were summed up per scale to yield composite scores. When a

specific item was not answered, we imputed the mean individual score for the

other completed items in the scale. For the time-related variables we applied a

logarithmic transformation (natural logarithm) to obtain a symmetric

distribution of the model residuals. We reported the geometric mean values

and 95% confidence intervals in both groups after back-transforming

(exponential function) to the original scale.

We used descriptive statistics for the baseline variables, rate of helping, various

types of helping actions, credibility scores, the impact of event, the state of

mood, and satisfaction. We used Cronbach's alpha to evaluate the reliability of

the self-efficacy and training satisfaction scale. To evaluate the time-related

variables and the self-efficacy scores, we used a two-way ANOVA. The first

factor was the training branch; the second factor was the comparison group.

Since the training branch was not an effect modifier, we reported the effect for

all the training branches together. By calculating the Spearman’s correlation

coefficient we evaluated the relationship between scores on the self-efficacy

beliefs and the time-related variables. We initially planned to compare the rate

of helping in both groups and to evaluate the relationship between scores on

the self-efficacy beliefs and the rate of helping. Since all participants showed

some type of helping reaction this was no longer relevant.

We analysed the data per protocol. This means that we analysed the

participants according to the group they actually attended. Because suspicion

about the deception test might influence helping behaviour, we excluded

participants that reported credibility scores below four. An intention-to-treat

analysis was not considered, since participants only switched groups when the

timeslot was not convenient for them.

53

P-values are two-sided and considered significant if smaller than 0.05. We used

PASW Statistics 18 (SPSS) for the statistical analysis.

Results

The median (IQR) number of days between the experimental or control training

and the deception test was 7 (5.5 to 11.5) days. Figure 1 illustrates the

participant flow in the trial. We randomised 72 participants to both the

experimental and control group. Fifteen participants switched from group

because the timeslot of the allocated group was inconvenient for them. The

most important reason for dropping out before the interventions was lack of

time. More participants dropped out in the experimental arm versus the

controls. Time-related factors and bad weather with heavy snowfall were the

main cause of this imbalance. We excluded two participants because they had

prior knowledge of the deception. Nine participants were not included in the

analysis because they did not find the deception sufficiently credible. One

person who did not notice the emergency was also excluded.

54

Figure 1: Flow of participants in the trial.

55

Table 1 presents the baseline data for the randomised participants per allocated

group, and for the participants included in the analysis per attended group.

Baseline data are similar per allocated and per analysed group. Participants that

switched groups were mainly female, in a relationship, and older.

Experimental group (n=72)

Active control group (n=72)

Analysed in experimental group (n=22)

Analysed in active control group (n=36)

Sex (female) 48 (66.7%) 48 (66.7%) 17 (77.3%) 25 (69.4%)

Age (years) 32.9 (24.4 – 41.6)

31.8 (23.3 – 42.9)

27.0 (22.5 - 40.8)

26.7 (21.9 - 38.7)

Nationality

(Belgian)

69 (95.8%) 69 (100%) 21 (95.5%) 36 (100%)

Education

Primary

Secondary

Higher

2 (2.8%)

35 (48.6%)

35 (48.6%)

0 (0%)

38 (52.8%)

34 (47.2%)

0 (0%)

9 (40.9%)

13 (59.1%)

1 (2.8%)

19 (52.8%)

16 (44.4%)

Profession

Employed

Retired/disabled

Housewife

Unemployed

Student

51 (70.8%)

4 (5.6%)

1 (1.4%)

3 (4.2%)

13 (18.1%)

44 (61.1%)

2 (2.8%)

3 (4.2%)

7 (9.7%)

16 (22.2%)

12 (54.5%)

2 (9.1%)

1 (4.5%)

0 (0%)

7 (31.8%)

24 (66.7%)

0 (0%)

1 (2.8%)

4 (11.1%)

7 (19.4%)

Table 1: Summary statistics in allocated and attended groups. Medians (Q1-Q3) or frequencies are reported.

56

Experimental group (n=72)

Active control group (n=72)

Analysed in experimental group (n=22)

Analysed in active control group (n=36)

Relationship status (no partner)

38 (52.8%) 33 (45.8%) 12 (54.5%) 20 (55.6%)

Red Cross volunteer (no)

66 (91.7%) 63 (87.5%) 18 (81.8%) 34 (94.4%)

Previous first aid training (no)

49 (68.1%) 44 (61.1%) 13 (59.1%) 24 (66.7%)

Experienced a life-threatening emergency (no)

56 (77.8%) 49 (68.1%) 18 (81.8%) 27 (75.0%)

Multiple choice test score (max. possible score=18)

9 (7 – 10) 8 (7 – 10) 10 (7 – 12) 8 (7 – 11)

Table 1: Continued.

We found no statistically or clinically significant differences between the

experimental and control group for any of the measures. Table 2 shows the

results for the time-related outcomes per analysed group. The ratio of the time

until seeking help in the control group versus the experimental group was 1.02

(95% CI 0.71 to 1.35).

Experimental group (n=22)

Active control group (n=36)

Time between start of simulation and seeking help

55.5 (42.9 – 72.0) 56.5 (43.0-74.3)

Detection delay 15.0 (10.2-22.3) 18.3 (12.1-27.8)

Response delay 4.0 (2.2 – 7.3) 4.8 (2.6 – 9.1)

Help-seeking delay 37.5 (27.7-50.8) 31.7 (23.0 – 43.7)

Table 2: Geometrical means and 95% confidence intervals for time-related

57

variables (seconds).

All participants showed some kind of helping reaction. Nearly all participants

asked the victim what was wrong and took measures to obtain help. About 57%

(n=33) asked a bystander to seek help, 40% (n=23) left the victim to seek help

themselves, and 3% (n=2) did not seek any help within the allocated 3 minutes.

Table 3 reports the results per analysed group.

Experimental group

(n=22)

Active control group (n=36)

Any helping reaction (yes) 22 (100%) 36 (100%)

Asking victim what is wrong (yes) 21 (95.5%) 34 (94.4%)

Seeking help

By study participant

By bystander (at request of study

participant)

By nobody

9 (40.9%)

12 (54.5%)

1 (4.5%)

14 (38.9%)

21 (58.3%)

1 (2.8%)

Asking about medication use (yes) 1 (4.5%) 2 (5.6%)

Attention to body position of victim (yes)

10 (45.5%) 12 (33.3%)

Telling the victim to stay calm (yes) 8 (36.4%) 10 (27.8%)

Table 3: Frequencies of types of helping reactions

Most participants found the deception test rather impactful with an overall

median (IQR) score of 4 (3 to 5). We found substantially higher median (IQR)

scores for the positive mood affect, 18.5 (15 to 20), than for the negative mood

affect, 8 (6 to 10) (possible range= 5 to 25). The positive and negative mood

items with the highest score were feeling proud with median (IQR) score of 4 (3

to 5), and feeling nervous, 2 (2 to 3). Five participants indicated being either

very nervous (n=3), confused (n=2), ashamed (n=1), anxious (n=1), or angry

(n=1). One person indicated the maximum score on every negative mood

58

question.

Participants indicated a mean (95% CI) self-efficacy score of 25.2 (23.9 to 26.6)

in the experimental group and 24.4 (23.0 to 25.8) in the control group (Possible

range= 6 to 30; Cronbach’s alpha = 0.68). The self-efficacy score did not

correlate with the time-related outcomes. The experimental training group

scored a median (IQR) of 21.5 (12 to 24) on the satisfaction scale (Possible

range= 7 to 28 ; Cronbach’s alpha = 0.94) versus a median (IQR) of 18.5 (12 to

26) in the control group.

Discussion

The experimental training on dealing with barriers to helping did not alter the

time or rate of helping. The good news is that all the participants demonstrated

some type of helping reaction and nearly all the participants sought help within

three minutes after the start of the simulation. Ten percent remained passive

for more than one minute, which was an awfully long time in the context of this

study. Although the first aid training curriculum teaches participants to stay

with the victim if bystanders are available to seek help, almost 40% left the

victim to seek help themselves. This might be a flight reaction in response to the

acutely stressful situation.

While our results regarding the time to helping response were similar to the

findings of Hawks et al,3 we made some divergent observations regarding the

rate of helping behaviour. It is remarkable that we found a 100% helping rate in

our study versus 16% and 45% in the trials by Hawks.3;4 However, the trials

differed in several ways. Participants in our community-based study were older

and included more women than the student-based studies by Hawks. The

studies by Hawks took place in the United States, while ours was conducted in

Europe. The diffusion of responsibility to help might have played a greater role

in the studies by Hawks, with four to five passive bystanders versus two in our

59

study. The emergency might have been more ambiguous in the Hawks studies,

where the victim periodically grabbed for his heart and tried to catch his breath.

In our study, the victim simulated the same signs but on a continuous basis,

which might have made the emergency more explicit. In the studies by Hawks,

participants had two minutes to respond to the emergency, versus three

minutes in our trial. Even after two minutes we found a 93% helping rate.

Almost half of the participants in Hawks 1992 were moderately to extremely

suspicious about the deception test.3 This proportion was considerably higher

than in our study (13%). Moreover, Hawks did not exclude these participants

from the analysis. The study by Hawks 1998 did not measure credibility but

used the same scenario for the deception test.4 In our study most participants

were assessed within two weeks after the intervention versus within one4 or

two months3. The level of prior first aid training might also have differed, but

this was not clear from the manuscripts.

The first aid self-efficacy beliefs were on average high, but did not predict the

performance during the deception test. This corresponds with other studies

which found that self-assessment of performance is often substantively

flawed.15

The satisfactory positive and negative mood scores, collected after the

participants were told about the deception, provide support for their use in new

trials on the helping behaviour of first aid trainees.

Strengths and limitations of the study

To get the required sample size, we had to oversample substantially. Forty

percent of the enrolled participants dropped out before taking part in the

experimental or control training. This high number is consistent with the drop-

out rates in general for this training. Considering the community-based setting,

the non-obligatory character of the training and the option to follow only part

of it, the resulting adequately powered study can be seen as a strength.

60

Although we found no difference in baseline data between those analysed and

those who dropped out (results not reported), it is possible that unmeasured

factors such as personality traits might have been important. Those participants

for whom the experimental training may have been most beneficial, might have

dropped out. We lost more participants in the experimental group than the

control group. This difference can be explained by the sign-up procedure for the

deception experiment. In the first year of the trial we asked the participants to

sign up at the end of the control or experimental training. Since the active

control training always preceded the experimental training, the control

participants were able to select the most convenient timeslots on the timetable.

In the last part of the trial, we presented the timetable before the participants

attended the experimental or control training. After this correction the loss to

follow-up became similar in both groups. Despite the high number of drop-outs

the comparability of the two groups remained intact. The experimental training

may have been weakened by the high drop-out rates, since it relied on the

contribution of participants in group discussions and role plays. It was not

always possible to give this training according to the didactical plan because of

the very small training groups. Another element which might have diluted the

effect of the intervention was that trainers were not restricted to talking about

helping behaviour during the preceding 24 hours of first aid training. Although

the didactical plan for this course did not fully address helping behaviour,

trainers may have incorporated it. Contamination between the study groups

may also have diluted any effect.

A strength of this study is the evaluation of the effects of the deception test on

the participants. Although deception is common in social-psychological

research, this aspect is not typically evaluated.13

Meaning of the study

This trial found no difference in time or rate of helping between conventional

61

first aid training and conventional training plus a supplementary training to

reduce barriers to helping. The high loss to follow-up was an important

limitation of this study making it difficult to derive conclusions. Despite the very

high rates of seeking help or providing help in general, there is still a need to

increase the timeliness and appropriateness of the aid provided. Help-seeking

represented both actions to obtain professional medical care or help from the

test supervisor. From the findings it is not clear how many participants would

actually have called for professional medical help. Since the participants were

focusing on the driving test, the detection delay might have been longer than in

more normal conditions. With regard to first aid self-efficacy beliefs, we

conclude that these were not useful to predict performance during an

emergency.

Deception in future research

The deception test did not have a negative impact on the study participants and

can be used in new trials on emergency helping behaviour of first aid trainees.

In this trial we used deception as a tool to evaluate the effectiveness of a

training intervention. Some study participants informed us that the deception

test was a learning experience for them. An RCT with medical students found

that feedback from unannounced simulation patients was a highly effective

educational method in itself.16 When conducting other trials about first aid

training, it might also be interesting to evaluate the potential of the deception

test as a teaching tool. The main first aid training course in the RCT offered

formal assessment leading to a certificate of first aid competence. To our

knowledge, the predictive validity of such a formal assessment for actual

helping behaviour still needs to be assessed. A deception test could be used as a

reference standard for this purpose.

62

What is already known on this topic

A systematic review tentatively concluded that conventional first aid training

improved competences but not performance. Supplementary training on

dealing with barriers to helping might increase helping rates.

The available evidence is of low quality and limited to university student

populations in the U.S.

What this study adds

This community-based trial found that supplementary training on dealing with

barriers to helping did not alter the time or rate of helping in an acute

myocardial infarction emergency.

Despite the very high helping rates, there is still a need to increase the

timeliness and appropriateness of the aid provided.

First aid self-efficacy beliefs were not useful to predict performance.

Competing interest: All authors have completed the Unified Competing Interest

form at www.icmje.org/coi_disclosure.pdf (available on request from the

corresponding author) and declare that (1) PV, SVDV, KVP are employed and KV

volunteers in the Belgian Red Cross-Flanders which provides training in first aid

and which received funding for this study from the Laerdal Foundation for Acute

Medicine; (2) AH, AR, BA, DR, LN, and PD have no relationships with companies

that might have an interest in the submitted work in the previous 3 years; (3)

their spouses, partners, or children have no financial relationships that may be

relevant to the submitted work; and (4) AH, AR, BA, DR, LN, PD have no non-

financial interests that may be relevant to the submitted work.

Contributions: SVDV, BA, and DR conceived and designed the study. SVDV

wrote the protocol. BA and DR gave methodological advice. AR provided a

medical education perspective. KV provided an experimental clinical and health

63

psychology perspective. LN provided a social psychology perspective. KVP

provided a psycho-social support perspective. PV, PD, AH provided general

advice on the study. BA was the guarantor of the study.

Ethical approval: Ethics committee approval for this study was obtained from

the University Hospitals Leuven Medical Ethics Committee. Participants

provided informed consent before and after the study.

Funding: This study was co-funded by the Belgian Red Cross-Flanders and the

Laerdal Foundation for Acute Medicine. The Laerdal Foundation was not

involved in any part of the study.

Trial registration: We registered this trial at ClinicalTrials.gov as NCT00954161.

References

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(2) Shotland RL, Heinold WD. Bystander response to arterial bleeding:

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helping response. J Pers Soc Psychol 1985; 49(2):347-356.

(3) Hawks SR, Peck SL, Vail-Smith K. An educational test of health behavior

models in relation to emergency helping. Health Psychol 1992;

11(6):396-402.

(4) Hawks SR, Egan M. The impact of three different first aid curricula on

emergency helping among college students. J Health Educ 1998;

29(5):289-293.

64

(5) Darley JM, Latane B. Bystander intervention in emergencies: diffusion

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(6) Latane B, Rodin J. A Lady in Distress - Inhibiting Effects of Friends and

Strangers on Bystander Intervention. J Exp Soc Psychol 1969; 5(2):189-

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(7) Penner LA, Dovidio JF, Piliavin JA, Schroeder DA. Prosocial behavior:

multilevel perspectives. Annu Rev Psychol 2005; 56:365-392.

(8) Rowe BH, Shuster M, Zambon S, Wilson E, Stewart D, Nolan RP et al.

Preparation, attitudes and behaviour in nonhospital cardiac

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(9) Mogielnicki RP, Stevenson KA, Willemain TR. Patient and bystander

response to medical emergencies. Med Care 1975; 13(9):753-762.

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act in out of hospital cardiac emergencies? Emerg Med J 2003;

20(1):85-87.

(11) van der Bijl JJ, Shortridge-Baggett LM. The theory and measurement of

the self-efficacy construct. Sch Inq Nurs Pract 2001; 15(3):189-207.

(12) Luszczynska A, Gutiérrez-Dona B, Schwarzer R. General self-efficacy in

various domains of human functioning: Evidence from five countries.

Int J Psychol 2005; 40(2):80-89.

(13) Pittenger DJ. Deception in research: Distinctions and solutions from the

perspective of utilitarianism. Ethics Behav 2002; 12(2):117-142.

65

(14) Watson D, Clark LA, Tellegen A. Development and validation of brief

measures of positive and negative affect: the PANAS scales. J Pers Soc

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(15) Dunning D, Heath C, Suls JM. Flawed self-assessment: Implications for

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(16) Elman D, Hooks R, Tabak D, Regehr G, Freeman R. The effectiveness of

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66

CHAPTER 5

Rapid reviews

De Buck E, Van de Velde S. Towards evidence based emergency medicine: best

BETs from the Manchester Royal Infirmary. BET 1. Optimal body position in oral

poisoning cases. Emerg Med J. 2010; 27(12):952-3.

De Buck E, Van de Velde S. Towards evidence based emergency medicine: best

BETs from the Manchester Royal Infirmary. BET 2: potato peel dressings for

burn wounds. Emerg Med J. 2010;27(1):55-56.

Van de Velde S, De Buck E, Dieltjens T, Aertgeerts B. Medicinal use of potato-

derived products: conclusions of a rapid versus full systematic review. Phytother

Res. 2010 (Epublication ahead of print).

67

Systematic reviews are considered to be the most reliable summaries of primary

studies. However, their production is a time-consuming process. Time

constraints have led to the development of rapid reviews in which

methodological shortcuts are applied to accelerate the production process.

Rapid reviews provide concise summaries of the best available evidence for very

specific clinical questions. BestBETs is a database of such rapid reviews relating

to emergency medicine (www.bestbets.org). In this chapter we present two

rapid reviews that were published as Best Evidence Topic reports

Although the number of published rapid reviews is rising, limited research has

been done to evaluate its validity. Therefore this chapter also compares the

results of one of these rapid reviews with a systematic review focusing on the

same topic.

5.1. BestBET 1: optimal body position in oral poisoning cases

Three-part question

In [orally poisoned patients] does [a specific body position] result in [a better

outcome for the patient]?

Clinical scenario

A 30-year-old woman had swallowed an overdose of pills. Her husband asks you

what he could have done to help his wife while waiting for the emergency

medical services te arrive. You wonder whether he could have laid her in a

particular position to ensure that the poisoning would have less detrimental

effects.

68

Search strategy

Ovid MEDLINE(R) 1950 to August Week 3 2010: Exp poisoning/0R exp

Acetaminophen/po (Poisoning) AND exp posture/. 144 records.

Embase 1947 to 1 February 2010 via the http://www.Embase.com interface:

‘intoxication'/exp OR poison* AND 'body posture'/exp AND (english)/Iim. 118

records.

The Cochrane Library August 2010: (MeSH descriptor Poisoning explode all trees

OR MeSH descriptor Acetaminophen explode all trees) AND MeSH descriptor

Posture explode all trees. 9 records 0 relevant.

Search outcome

Two hundred and fifty nine papers were found of which 257 were irrelevant or

of insufficient quality. The remaining two papers are shown in the table 1.

Comments

Thc evidence suggests that drug absorption is lowest in patients Iying on their

left side. However, the left side position is relatively poor at reducing the risk of

aspiration pneumonia in patients with a reduced level of consciousness.

International basic lifc support guidelines for laypersons reccommend that

patients who are unconscious but breathing should be placed in the recovery

position.

69

Table 1 Optimal body position in oral poisoning cases

Author, date and country

Patient group Study type Outcomes Key results

Study weaknesses

Vance et al, 1992, USA

12 healthy volunteers that ingested an overdose of acetaminophen (80 mg/kg) following an 8 h fasting period. Placed in left side, right side, supine, prone and sitting positions.

Experimental Group mean drug absorption

Differences between different body positions could be exaggerated because volunteers fasted for 8 h. Small sample size. Co-ingestants such as ethanol were absent and this may affect the findings.

(AUC 0-2 h, mg/l/min)

6.0

Left side 9.0 Right side 6.7 Supine 7.4 Prone 8.6

(p <0.05)

Adnet et al, 1999, France

205 acutely poisoned comatose patients < 65 years with a Glasgow Coma Scale less than or equal to 12. Placed in left side, right side, supine, prone, or semi-recumbent position.

Observational study

Frequency of suspected aspiration pneumonia

There are baseline differences between comparison groups. Blinded outcome measurement was not reported. Risk of contamination bias.

Left side 36.7%

Right side 45%

Supine 39.3%

Prone 8%

Semi-recumbent

11.1% (p=0.006)

AUC. area under the curve.

Clinical bottom line

Placing awake patients who have ingested oral poisons on to their left side may

reduce absorption of the poison. If the patient has reduced conscious level,

then the risk of aspiration pneumonia must be considered and the prone or

semi-recumbent positions are safer.

70

Contributions EDB and SVDV conceived the review question and search

strategy. They independently screened the literature to identify and select

retrieved studies against inclusion criteria. ED extracted the data and SVDV

checked if the synthesis was accurate. ED submitted the report to BestBETs.

References

Vance MV, Selden BS, Clark RF. Optimal patient position for transport and initial

management of toxic ingestions. Ann Emerg Med 1992; 21: 243-6.

Adnet F, Borron SW, Finot MA, et al. Relation of body position at the time of

discovery with suspected aspiration pneumonia in poisoned comatose patients.

Crit Care Med 1999; 27:745-8.

71

5.2. BET 2: Potato peel dressings for burn wounds

A short-cut review was carried out to establish whether potato peel dressings

are better than gauze alone in the acute management of burns. Nineteen

papers were found using the reported searches, of which three presented the

best evidence to answer the clinical question. The author, date and country of

publication, patient group studied, study type, relevant outcomes, results and

study weaknesses of these best papers are shown in table 1. It is concluded that

there is no evidence to show that potato peel is of benefit in the acute phase,

but that sterile potato peel dressings are better than gauze alone in the healing

phase.

Three-part question

In [patients with acute burns] is [potato peel dressing better than gauze or cloth

alone] at [promoting healing and preventing infection]?

Clinical scenario

During a camp trip in a remote area, a 32-year-old man has burned his hand and

arm in the camp fire. As he had neither a first aid kit nor bandages or dressings

to cover the wounds, he used cooked potato peels for this purpose. When you

see him some time later in the emergency department you are very impressed

by his innovative use of vegetables, though somewhat less sure of their efficacy

and safety in burns. Before you dismiss the idea completely, however, you

wonder if there is any published evidence.

Search strategy

Medline 1966–2008/09 using the Pubmed interface: (‘‘Burns’’ [Mesh] OR

Burn*[TW]) AND (‘‘Bandages’’ [Mesh] OR ‘‘dressing’’ [TW]) AND ‘‘potato’’ [TW]

72

LIMITS to English. Ovid MEDLINE(R) 1950 to September week 4 2009: Exp

Burns/AND exp Solanum tuberosum/OR potato.mp.

Embase via the NLH interface 1980–30 September 2009: exp BURN/OR exp

potato/OR potato.mp.

The Cochrane Library, Issue 3, 2009: MeSH descriptor Burns explode all trees

AND MeSH descriptor Solanum tuberosum explode all trees OR potato, ti, ab,

kw.

Search outcome

Nineteen papers were found of which 16 were irrelevant or of insufficient

quality. Details of the three remaining papers are shown in table 2.

Comments

The evidence presented is all from burns units in areas of the world where skin

homographs and xenographs are rarely available and is therefore not directly

applicable to settings in which such grafts are common. Furthermore, all the

studies use sterile potato peel dressings, not rough cut potato peel as set out in

the clinical scenario. The value of potato peel seems to be in reducing

desiccation and thereby promoting healing during the burns unit phase; there is

little evidence of independent antibacterial effect.

Clinical bottom line

There is no evidence to suggest that potato peel is effective as a burns dressing

in the acute phase. Sterile potato peel dressings are better than gauze alone

during the healing phase.

73

Table 2 Potato peel dressings for burn wounds

Author, date and country

Patient group Study type Outcomes Key results Study weaknesses

Keswani et al, 1990, India

17 hospital patients aged 1.5–45 years with burns between 5% and 42% of body surface area (mean 18.6%). Gauze with potato peel vs gauze alone in similar burns on each patient. All patients had silver sulfadia-zine applied below the dressing.

Clinical trial Bacterial growth

No difference in bacterial growth

Much of the data here is histological; there are no patient outcomes. No statistics performed. Blinding and follow-up are not clear.

Epidermal regeneration

Faster epithelial regeneration in potato peel dressings

Formation of exudates

Prevention of dessication in potato peel dressings

Survival of superficial skin cells

Increased survival of superficial skin cells in potato peel dressings

Subrah-manyam, 1996, India

100 patients with partial thickness burns over ,40% of body surface area treated within 6 h. Potato peel vs honey.

Randomised controlled trial

Days for complete healing

16.2 vs 10.2 days (p<0.001)

Randomisa-tion not clear; blinding not reported. Persistent

infection at day 7

10% vs 100% (p<0.001)

Adverse effects There were no adverse effects in either of the groups

Subjective relief of pain

No significant difference

Gore and Akolekar, 2003, India

30 patients aged 40 years with a burn size 50% of body surface area. Gauze with potato peel vs gauze with banana leaf. Potato peel applied to the left side and banana leaf dressing to the right.

Clinical trial Days until complete epithelialisation.

No clinical difference No statistics performed; blinding is not clear; no control group (crossover trial)

Eschar formation

No clinical difference

Number of areas requiring skin grafting

No clinical difference

Pain No clinical difference

Patient comfort

No clinical difference

Dressing handling

No clinical difference

74

Contributions EDB and SVDV conceived the review question and search

strategy. They independently screened the literature to identify and select

retrieved studies against inclusion criteria. ED extracted the data and SVDV

checked if the synthesis was accurate. ED submitted the report to BestBETs.

References

Keswani MH, Vartak AM, Patil A, et al. Histological and bacteriological studies of

burn wounds treated with boiled potato peel dressings. Burns 1990;16: 137–43.

Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment

of burns: a prospective randomized study. Burns 1996;22:491–3.

Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness

burn wounds. Burns 2003;29:487–92.

75

5.3. Medicinal use of potato-derived products: conclusions of a rapid versus full systematic review

Abstract

Vlachojannis et al reported a systematic review on the medicinal use of potato-

derived products. The authors identified five trials for inclusion in the review,

including one study on the treatment of burns.Based on this RCT the review

authors concluded that potato peel is not recommended for burns.

As the authors of a rapid review on the use of potato peels for burns, we read

this systematic review with great interest. Although the concept of rapid review

is rising, accelerating the review process might introduce bias and its

conclusions may be subject to change once a systematic review is available.

Since this rapid and systematic review were done at similar times, we explored

if the results were consistent.

We identified three trials on the use of potato peels. Two of these trials were

not mentioned in the systematic review. The evidence indicates that sterile

potato peel dressings are better than gauze alone during the healing

phase.While there is no evidence of an antibacterial effect, we concluded that

potato peels promote healing.

Potato peel dressings might be the best available dressing in resource poor

countries. Because systematic reviews have a major impact it is crucial that

systematic reviews meet specified quality criteria. Therefore we draw attention

to adherance to the PRISMA statement.

76

Letter to the editor

Vlachojannis et al. reported the results of a systematic review on the medicinal

use of potato-derived products (Vlachojannis et al., 2010). Searching MEDLINE

and CENTRAL (based on the terms potato or Solanum tuberosum) plus hand

searching yielded 132 potentially relevant citations. From these, the authors

identified five clinical trials for inclusion in the review, including one study on

the treatment of burn wounds (Subrahmanyam, 1996).This RCT demonstrated

that burns covered with honey dressings healed better than burns covered with

potato peels. Based on this unique RCT the authors of the systematic review

concluded that topical potato peel is not recommended for the treatment of

burns.

As the authors of a rapid review on the efficacy and safety of potato peel

dressings for burns, we read this systematic review with great interest (De Buck

and Van de Velde, 2010). Rapid review means that we accelerated the

systematic research process by restricting the number of electronic databases

searched, building a specific search strategy, not searching for grey literature,

using focused selection criteria, and not performing a meta-analysis. These

shortcuts are a compromise between scientific rigour, transparency and

timeliness. Our rapid review was not meant to be a full systematic review and

this is also mentioned in the publication.

The need to provide quick but accurate evidence-based information is

increasing in the healthcare sector and the concept of rapid reviews is rising

(Watt et al., 2008). However, accelerating the review process might introduce

bias and therefore it may be subject to change once a systematic review is

available (Ganann et al., 2010). Since these rapid and regular systematic reviews

were done at similar times, we considered it an opportunity to explore if the

findings and conclusions were consistent.

77

Our rapid review was produced in approximately 1 month. We searched

MEDLINE, EMBASE and CENTRAL using strategies based on the terms potato,

Solanum tuberosum, burns, bandages. From 19 references screened, we

identified three trials on the use of potato peel dressings (Subrahmanyam,

1996; Gore and Akolekar, 2003; Keswani et al., 1990). To our surprise, two of

these clinical trials were not mentioned in the full systematic review (Gore and

Akolekar, 2003; Keswani et al., 1990). These studies compared potato peel

dressings with either gauze alone, or banana leaf dressing. The evidence

indicates that sterile potato peel dressings are better than gauze alone during

the healing phase. While there is no evidence of an independent antibacterial

effect, we concluded that potato peels promote healing, which could be

possibly due to a reduction in desiccation.

It is important that our conclusion was different from that of Vlachojannis.

Systematic reviews tend to be the most read and cited type of article and have a

major impact (Dijkers, 2009).While potato peel dressings are not directly

applicable to Western settings, it might be the best available dressing in

resource poor countries. This is illustrated by the fact that all the trials included

in our rapid review were all conducted in burn centres in India where they had

an acute need for cheap and easily available dressings (Gore and Akolekar,

2003). One explanation for the evidence gap in the review of Vlachojannis and

ours might be the lack of awareness of relevant evidence: the study by Gore

might have been missed during the screening of citation titles, because the title

only mentions banana leaf dressings and not potato peels.Another explanation

might be exclusion of evidence that did not match the eligibility criteria: in the

study by Keswani the data are histological and there are no patient outcomes

which could have been a reason to exclude the study. However, based on the

manuscript it is not possible to evaluate this.

78

The difference in conclusions between these two reviews shows the

implications this can have for practice. Therefore it is crucial that systematic

reviews meet specified quality criteria. In order to be able to evaluate the

strengths and weaknesses of systematic reviews,we draw attention to

adherence to the Preferred Reporting Items for Systematic Reviews and Meta-

Analyses, i.e. the PRISMA statement (Liberati et al., 2009). Amongst other items,

the PRISMA statement asks authors of systematic reviews to describe eligibility

criteria and the results of the study selection process.

Contributions: SVDV wrote the letter to the editor. EDB, TD, and BA provided

feedback on the letter.

Conflicts of Interest SVDV and EDB are authors of the rapid review on potato

peel dressings for burn wounds. TD and BA have no conflicts of interests.

Ethical approval Not applicable

References

De Buck E, Van de Velde S. 2010. Towards evidence based emergency medicine:

best BETs from the Manchester Royal Infirmary. BET 2: potato peel dressings for

burn wounds. Emerg Med J 27: 55–56.

Dijkers MP. 2009. The value of traditional reviews in the era of systematic

reviewing. Am J Phys Med Rehabil 88: 423–430.

Ganann R, Ciliska D, Thomas H. 2010. Expediting systematic reviews: methods

and implications of rapid reviews. Implement Sci 5: 56.

Gore MA, Akolekar D. 2003. Evaluation of banana leaf dressing for partial

thickness burn wounds. Burns 29: 487–492.

79

Keswani MH, Vartak AM, Patil A, Davies JW. 1990. Histological and

bacteriological studies of burn wounds treated with boiled potato peel

dressings. Burns 16: 137–143.

Liberati A, Altman DG, Tetzlaff J et al. 2009. The PRISMA statement for reporting

systematic reviews and meta-analyses of studies that evaluate healthcare

interventions: explanation and elaboration. Br Med J 339: b2700.

Subrahmanyam M. 1996. Honey dressing versus boiled potato peel in the

treatment of burns: a prospective randomized study. Burns 22: 491–493.

Vlachojannis JE, Cameron M, Chrubasik S. 2010. Medicinal use of potato-derived

products: a systematic review. Phytother Res 24: 159–162.

Watt A, Cameron A, Sturm L et al. 2008. Rapid reviews versus full systematic

reviews: an inventory of current methods and practice in health technology

assessment. Int J Technol Assess Health Care 24: 133–139

80

Rigour of development does not AGREE with

recommendations in practice guidelines on the use of

ice for acute ankle sprains

CHAPTER 6

Van de Velde S, Heselmans A, Donceel P, Vandekerckhove P, Ramaekers D,

Aertgeerts B. Rigour of development does not AGREE with recommendations in

practice guidelines on the use of ice for acute ankle sprains. BMJ Qual Saf. 2011

(Epublication ahead of print).

81

Rigour of development does notAGREE with recommendations inpractice guidelines on the use of ice foracute ankle sprains

S Van de Velde,1,2 A Heselmans,2 P Donceel,3 P Vandekerckhove,1

D Ramaekers,2 B Aertgeerts2

ABSTRACTObjective: This study evaluated whether the Appraisal

of Guidelines Research and Evaluation (AGREE) rigour

of development score of practice guidelines on ice for

acute ankle sprains is related to the convergence

between recommendations.

Design: The authors systematically reviewed guidelines

on ice for acute ankle sprains. Four appraisers

independently used the AGREE instrument to evaluate

the rigour of development of selected guidelines. For

each guideline, one reviewer listed the cited evidence on

ice and calculated a cited evidence score. The authors

plotted the recommended durations and numbers of ice

applications over the standardised rigour of

development score to explore the relationships.

Data sources: Three reviewers searched for

guidelines in Medline, Embase, Sportdiscus, PEDro,

G-I-N Guideline Library, Trip Database, SumSearch,

National Guideline Clearinghouse and the Health

Technology Assessment database, and conducted

a web-based search for guideline development

organisations.

Eligibility criteria: Eligible guidelines had

a development methodology that included a process to

search or use results from scientific studies and the

participation of an expert group to formulate

recommendations.

Results: The authors identified 21 guidelines,

containing clinically significant variations in

recommended durations and numbers of ice

applications. The median standardised rigour of

development score was 57% (IQR 18 to 77). Variations

occurred evenly among guidelines with low moderate

or high rigour scores. The median evidence citation

score in the guidelines was 7% (IQR 0 to 61).

Conclusions: There is no relationship between the

rigour of development score and the

recommendations in guidelines on ice for acute ankle

sprains. The guidelines suffered from methodological

problems which were not captured by the AGREE

instrument.

INTRODUCTION

Evidence-based guidelines form a typical

approach to bridging the gap between

evidence and practice.1 Although practice

guidelines aim to reduce inappropriate

treatment variations, guidelines on the same

topic often make conflicting recom-

mendations.2e4 The reasons behind these

conflicting recommendations include insuf-

ficient evidence, lack of awareness of relevant

evidence or ignoring such evidence, failure

to appraise the evidence critically, the

composition and interactions of a guideline

panel, differences in context, values and

preferences, and the applicability of the

evidence.5 6 Only differences in context,

values and preferences can be considered

as valid reasons for disagreement between

recommendations. In other cases, guideline

divergence is the result of suboptimal deci-

sions. This may confuse guideline users and

raises concerns about the use of biased

practice guidelines.7 8

Critical appraisal instruments for practice

guidelines exist to give healthcare providers

an idea of the quality of guidelines before

adopting the recommendations. One limita-

tion of these instruments is that they do not

evaluate the guideline content.9 The

Appraisal of Guidelines Research and Evalu-

ation (AGREE) instrument is a validated

instrument that is widely used to evaluate

guidelines.10 11 Studies that evaluated the

link between the methodological quality of

a guideline and its content found no rela-

tionship.12 13 This is troubling if a high-

quality score does not necessarily imply

clinically appropriate recommendations.12 13

One limitation of the existing studies on

1Belgian Red Cross-Flanders,

Mechelen, Belgium2Belgian Branch of the

Cochrane Collaboration,

Belgian Centre for

Evidence-Based Medicine,

Katholieke Universiteit

Leuven, Leuven, Belgium3School of Public Health,

Katholieke Universiteit

Leuven, Leuven, Belgium

Correspondence to

S Van de Velde, Belgian Red

Cross-Flanders, Motstraat

40, 2800 Mechelen, Belgium;

stijn.vandevelde@rodekruis.

be

Accepted 13 October 2010

Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435 1

82

conflicting recommendations is that variations could be

attributed to reasonable differences in context. This

study evaluates whether the AGREE domain for rigour of

development is related to the convergence between

recommendations for a common disorder and a cheap

and available treatment: acute ankle sprain and ice.

Rest, ice, compression and elevation is the usual

treatment for ankle sprains.14 15 However, textbook

information on the use of ice for acute sprains varies

greatly as regards the time and frequency of its applica-

tion.16 MacAuley propagated evidence-based guidelines

to reach consensus on the appropriate management.

METHODOLOGY

Selection of guidelines

Three authors (BA, DR, SVDV) searched for practice

guidelines in Medline, Embase, Sportdiscus, PEDro, G-I-

N Guideline Library, Trip Database, SumSearch,

National Guideline Clearinghouse and the Health

Technology Assessment database, and conducted a web-

based search for guideline development organisations.

Because soft-tissue injury is a very broad domain, this

study focused on guidelines with recommendations on

ice for ankle sprains and strains. This criterion excluded

guidelines on other joints than ankles. Guidelines

focusing on soft-tissue injuries in general were included

if they encompassed ankle sprains or strains. We

excluded guidelines that focused only on bruises, dislo-

cations, subluxations, fractures or chronic injuries, as

well as those for paediatric patients only.

We used the Institute of Medicine definition of clinical

guidelines, namely systematically developed statements

to assist practitioner and patient decisions about appro-

priate healthcare for specific circumstances. This study

only considered practice guidelines if their development

methodology included a process to search or use results

from scientific studies and the participation of an

expert group to formulate recommendations. Consensus

statements, systematic reviews, narrative reviews, text-

books and patient information leaflets belong to the

exclusion criteria. If two or more guidelines by the same

group were available, we selected only the most recent

one.

Rigour of development

To evaluate the quality of the selected guidelines, we

used the AGREE instrument,10 but limited ourselves to

the domain for rigour of development. Because ice

application is a cheap and available treatment, in our

opinion this domain was the most relevant

AGREE category to explain divergence between practice

guidelines on this topic. Four appraisers (AH, BA, DR,

SVDV) independently used the corresponding domain

questions in the AGREE instrument to evaluate each

selected guideline.10

We calculated the standardised domain score as

instructed in the AGREE checklist (obtained scoree

minimum possible score)/(maximum possible scoree

minimum possible score).

If the guideline did not report certain information, we

either tried to collect information from background

documents on the guideline or contacted the authors. If

the information for a certain item was still unclear, this

item was scored as ‘strongly disagree.’ The intraclass

correlation coefficient two-way mixed model for single

measurements was calculated using an agreement defi-

nition,17 18 to measure the appraiser agreement for the

rigour of development domain.10 During a panel

meeting, the appraisers discussed any deviations in

scores and resolved disagreements.

Data extraction

For each guideline, one reviewer (SVDV) tabulated

those recommendations on the duration per ice appli-

cation, the number of applications per 12 h, and the

number of days of ice applications. If guidelines

recommended a minimum and maximum duration and

frequency, both were extracted. For each guideline, we

calculated the overall ice application duration

(¼minutes per ice application3times per day3number

of days).

For each guideline, one reviewer (SVDV) checked the

references cited in the sections on the application of ice.

From the cited references, he extracted all the inter-

vention studies that tested the effect of cryotherapy. The

group of authors decided to include studies of patients

with sprains or strains to the ankle, which compared

any type of cryotherapy with a control condition,

another type of cryotherapy or another type of treatment

for any type of outcome. We also included intervention

studies cited in secondary sources, if these sources

provided sufficient details about the characteristics and

results of the presented intervention study. Next, we

calculated the cited evidence score as follows: (number

of cited intervention studies in a single guideline)/

(maximum possible number of unique intervention

studies cited according to the publication date of the

guideline). In this study we did not perform an inde-

pendent systematic review on the role of ice for ankle

sprains. So, the maximum possible number of unique

intervention studies is the sum of studies retrieved by

screening the selected guidelines, existing systematic

reviews19 20 and the ‘Related citations’ in Pubmed.

Data synthesis

One reviewer (SVDV) tabulated the rigour of develop-

ment score, cited evidence score and overall ice

2 Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435

Original research

group.bmj.com on February 25, 2011 - Published by qualitysafety.bmj.comDownloaded from

83

application duration to explore the relationships. To

visualise this, we made highelow plots. Since the

number of guidelines was too few to perform statistical

tests, we conducted a descriptive analysis of the

quantitative data.

RESULTS

Identification of guidelines

Figure 1 provides a flow chart of the identification and

selection of practice guidelines. We screened 56 publi-

cations and included 21 guidelines for the analysis.

Target users of the selected guidelines included general

practitioners, specialists, physiotherapists, nurses and

first-aiders.

Table 1 describes the key data of the selected practice

guidelines.

Description of recommendations

While 19 guidelines recommended the use of ice, two

guidelines found that the benefit was too uncertain to

give any recommendation for or against.26 30 The

guidelines recommended durations of each ice applica-

tion ranging from 12 to 30 min, with 20 min recom-

mended most frequently. The recommended frequency

of ice applications varied from one to eight times a day,

with six times a day recommended most frequently. The

recommended number of days of ice application varied

from 1 to 7 days. Data from two guidelines mentioning

that ice applications might be prolonged in the reha-

bilitation phase were not included in the analysis. The

maximum recommended overall duration of ice appli-

cation was 14 h,27 while the minimum recommended

overall duration was 45 min.21 Five guidelines recom-

mended ice,29 31 35 38 39 without any further details about

the time or frequency.

Rigour of development

The median standardised rigour of development score

was 57% (IQR: 18e77). For guidelines published within

the last 5 years (n¼15) this was 54% (IQR: 19e77) versus

59% (IQR: 56e77) for older guidelines (n¼6). The

initial intraclass correlation coefficient was 73%, and

after discussion of deviations among the panel members

the score evolved to 93%.

Comparison of cited intervention studies

From the selected guidelines and its secondary sources,

we identified a total of seven relevant intervention

studies.42e48 None of the recent guidelines captured the

study published by Bleakley in 2006.49 While it was not

the intent of this study to do a systematic review on the

role of ice for ankle sprains, we provide an informative

summary with the relevant evidence in table 2.

A guideline published in 2009 which captured six

relevant intervention studies obtained the highest

evidence citation score (six cited intervention studies/

eight unique intervention studies available by

2009¼75%).23 Nine guidelines did not refer to any

intervention study on cryotherapy.25 27 31 33 35 36 38 39 41

In three guidelines, we could not assess the number of

cited intervention studies because there were no in-text

citations, or because the secondary sources could not be

obtained.34 37 40 The median evidence citation score in

the guidelines was 7% (IQR 0 to 61). The guidelines

cited positive or negative results equally (RR 0.8; 95% CI

0.5 to 1.2).

Relationship between rigour of development and guideline

recommendations

Figures 2e5 plot the guideline recommendations over

the standardised rigour of development score. Clinically

significant variations in recommended durations,

frequencies and number of days occur evenly among

guidelines with low, moderate or high rigour scores.

DISCUSSION

The AGREE rigour of development score of practice

guidelines on ice for acute ankle sprains is not related to

the convergence between recommendations. The diver-

sity of the recommended durations and frequencies of

ice application is remarkable and comparable with the

reported variety in textbooks.16 The evidence-based

guidelines did not lead to a consensus on the use of ice

Figure 1 Flow chart of identification and selection of

guidelines. G-I-N, G-I-N Guideline Library; NGC, National

Guideline Clearinghouse.

Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435 3

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Table

1Descriptionofselectedguidelines

Guideline,yearandcountrycode

Standardised

rigour

score

(%)

Cited

evidence

score

(%)

Duration(m

in)

perice

application

Noof

times

perday

Noof

days

Overall

duration(h)

oficeapplication

RoyalDutchSociety

forPhysicalTherapyd2006dNL21

87

57

15e20

1e3

30.75e3

AssociationofCharteredPhysiotherapists

inSports

Medicined1998dUK22

85

71

20e30

63

6e9

Work

LossData

Instituted2009dUS23

83

75

uu

1e2

u

BelgianRedCrossd2007dBE24

80

57

20

uu

u

AmericanCollegeofOccupationalandEnvironmental

Medicined2008dUS25

77

0u

u1.5e2

u

DutchInstitute

forHealthcare

Improvementd

1998dNL26

77

57

uu

uu

Institute

forClinicalSystemsIm

provementd

2006dUS27

75

015e20

4e6

77e14

NationalFirstAid

ScienceAdvisory

Boardd2005dUS28

68

29

20

uu

u

FrenchNationalAgencyforAccreditationandEvaluation

InHealthd2000dFR29

60

71

uu

uu

DutchCollegeofGeneralPractitionersd2000dNL30

58

71

uu

uu

Duodecim

d2009dFI31

57

0u

uu

u

FlemishCollegeofGeneralPractitionersd2001dBE32

56

14

15e25

4e8

33e10

SowerbyCentreforHealthInform

aticsatNewcastled2008dUK33

54

015e20

4e6

2e3

2e6

MexicanInstitute

ofSocialSecurityd2004dMX34

29

u12e20

2e3

3e7

1.2e7

BrazilianSociety

ofOrthopaedicsandTraumatologyd2008dBR35

20

0u

uu

u

Emedecined2008dUS36

20

015e20

31e3

0.75e3

MadiganArm

yMedicalCentere

2007dUS37

19

u20

63eu

6eu

ColoradoDivisionofLabourandEmploymentd

2009dUS38

14

0u

uu

u

GovernmentofWestern

Australia,Carepointd

2009dAU39

70

uu

uu

Junta

DeExtremadurad2004dSP40

5u

20

62e3

4e6

HealthCanadad2000dCA41

50

12e14

62eu

2.4eu

u,unclear.

4 Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435

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Table

2Summary

ofrelevantevidencerelatingto

iceforankle

sprains

Study

Injury

Treatm

entgroups

Recovery

period

Function

Pain

Swelling

ROM

PEDro

score

Nilsson

198342

Ankle

sprains

(gradeunclear)

within

last6h

A(n¼59):459cold

ononeoccasion

withrubberpadandphysiotherapy

B(n¼60):459cold

ononeoccasion

withrubberpad,steroid

injectionand

physiotherapy

C(n¼59):nocold

Allgroupsreceivedabandageand

adviceregardingelevation

Significant

difference

infavourof

AandB

Significant

difference

infavourofB

Significant

difference

infavourof

AandB

Significant

differencein

favourofA

Significant

differencein

favourof

AandB

5

Laba

198943

GradeIII/IV

ankle

sprainswithin

last

2days

A(n¼14):20min

cold

onone

occasion

B(n¼16):nocold

Both

groupsreceivedcompression+

ultrasound+exercises

Nosignificant

difference

eNosignificant

difference

Nosignificant

difference

e3to

4

Sloan

198948

143patients

with

ankle

sprains

(gradeunclear)

within

last24h

A(n¼u):30min

cold

ononeoccasion

andelevation

B(n¼u):30min

placebowithout

elevation

Both

groupsreceivedwrittenadvice

regardingcompression,elevation,

medicationwhile

athome

Nosignificant

difference

Nosignificant

difference

Nosignificant

difference

Nosignificant

difference

Nosignificant

difference

3

Wilkerson

199344

GradeIIankle

sprainswithin

last24h

A(n¼10):20e30min

cold,repeated

every

4hduringacute

phaseandstrap

B(n¼12):20e30min

cold,atleast

onceperdayduringacute

phaseand

strap

C(n¼12):20e30min

cold,atleast

onceperdayduringacute

phasewith

elastictape

Allgroupsreceivedabrace

ee

Nosignificant

difference

ee

3

Cote

198847

GradeI/IIankle

sprains(tim

e

sinceinjury

is

unclear)

A(n¼10):20min

cold,once

daily

during3days

B(n¼10):20min

heat,oncedaily

during3days

C(n¼10):20min

contrastbath,once

daily

during3days

ee

eSignificant

differencein

favourofA

e4to

5

Hocutt

198246

GradeIII/IV

ankle

sprains(tim

e

sinceinjury

is

unclear)

A(n¼30):12e20min

cold,1e3times

perdayforminim

um

3days

B(n¼7):15min

heat,1e3timesper

dayforminim

um

3days

Both

groupsreceivedabandage

Significant

difference

infavourofA

ee

ee

2

Continued

Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435 5

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for ankle injuries. Since it was not the objective of this

study to evaluate the validity of the recommendations,

we take no position on which recommendations on ice

are most appropriate.

This study identified a number of methodological

problems of guidelines and shortcomings in the AGREE

instrument to capture these. Only six guidelines

discussed half or more of the available evidence on ice

for ankle sprains. One potential explanation is that

guideline developers compromised on the literature

review to save time or resources. Making use of existing

systematic reviews19 20 or adaptation of other guidelines

with a well-conducted systematic review may substantially

reduce the time and resources required.50 51 As the

PEDro quality score was low for most of the trials, it is

Table

2Continued

Study

Injury

Treatm

entgroups

Recovery

period

Function

Pain

Swelling

ROM

PEDro

score

Basur

197645

Ankle

sprains

(gradeunclear,

timesinceinjury

isunclear)

A(n¼30):cold

every

4hduring

2daysandbandage

B(n¼30):bandageonly

Significant

difference

infavourofA

ee

ee

3

Bleakley

200649

GradeI/IIankle

sprainswithin

last48h

A(n¼46):20min

cold,every

2h

until72hpostinjury

B(n¼43):10min

coldd10min

restd

10min

cold,every

2huntil

72hpostinjury

Both

groupsreceivedhome

exercises

eNosignificant

difference

Nosignificant

differencefor

pain

atrest

Significant

differencewithin

firstweekforpain

duringactivityin

favourofB

Nosignificant

differencewithin

weeks2to

6for

pain

duringactivity

Nosignificant

difference

e7

Significantdifferencerefers

tostatisticaltests

ofsignificanceandnotto

clinicalsignificance.Data

onthePhysiotherapyEvidenceDatabase(PEDro)ScoringScale

were

collectedfrom

two

systematicreviews1920andthePEDro

databaseitself(http://www.pedro.org.au/).

Figure 2 Highelow plot of maximum and minimum duration

per individual ice application expressed in minutes over the

standardised rigour of development score.

Figure 3 Highelow plot of maximum and minimum number of

applications per 12 h over the standardised rigour of

development score.

6 Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435

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possible that guideline authors decided to exclude

studies with a risk of bias. This might also explain the low

evidence citation score.

A number of guidelines succeed in getting good or

high AGREE rigour of development scores, while their

cited evidence score is suboptimal.21 24e28 These find-

ings illustrate that an evaluation of the validity of the

literature search is an important component of guide-

line appraisal. This problem was previously described as

an important limitation of AGREE,9 and is unfortunately

not solved with the publication of AGREE II. We fully

support the plan of the AGREE Trust to address the

clinical validity or appropriateness in the AGREE A3

initiative.52

Guideline grading systems are proposed to help users

in the interpretation of guidelines. GRADE is such

a system and asks those making the recommendations to

categorise recommendations as strong or weak.53 The

strength of recommendations is determined in GRADE

by the balance between benefits and harms, quality of

evidence, values and preferences, and costs. Guideline

authors are instructed to be transparant on their

judgements. Only half of the guidelines used a grading

system to indicate the degree of confidence one can

have in the evidence or recommendations. Given the

elusive evidence, incorporating a grading system could

better indicate the current uncertainty associated with

ice applications. The new item in AGREE II that requires

a clear description of the strengths and limitations of the

body of evidence is pertinent in this regard.54

Only occasionally did guidelines describe how consid-

erations about the uncertain benefit of prolonged/

minimal/no ice application versus the discomfort/risks

for the patient influenced the final recommendation.

Information about the role of opinion versus the

evidence is only mentioned as an additional consider-

ation in item 12 of AGREE II. This is an improvement

compared with the original AGREE instrument, but we

believe that this item should explicitly request trans-

parency on the influence of opinion per final decision.

This study has several limitations. Because identifying

guidelines requires a laborious search of multiple data-

bases, we might have missed relevant guidelines.55 The

National Guideline Clearinghouse (http://www.guide-

line.gov/) contained only two of the selected guidelines

in our study. The G-I-N Guideline Library (http://www.

g-i-n.net/) was the most comprehensive guideline data-

base, containing half of the selected guidelines.

While we evaluated the rigour of development for the

guideline document as a whole, we further focused on

the individual recommendations on ice for ankle

sprains. Because the quality of the evidence review may

vary per recommendation in a guideline, the conclu-

sions on the gathering of evidence may not be applicable

for the whole guideline.

Another limitation of this study is that guidelines

authors poorly reported their methodology. We emailed

the authors of 18 included guidelines with a request for

more information. Only five replied with more details.

This might under- or overvalue the actual rigour of

development score. Many guidelines referred to

a general manual endorsed by their organisation

describing the various steps that should be followed.

Because ‘should’ does not always mean that it has been

done, the rigour score might be overvalued for certain

guidelines. Poor reporting is a common problem with

guidelines and has been identified in previous studies.56

In contrast with publication guidelines such as Quorum

Figure 4 Highelow plot of maximum and minimum number of

days of ice application over the standardised rigour of

development score.

Figure 5 Highelow plot of maximum and minimum overall ice

application duration expressed in hours over the standardised

rigour of development score.

Van de Velde S, Heselmans A, Donceel P, et al. BMJ Qual Saf (2011). doi:10.1136/bmjqs.2010.045435 7

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for the reporting of systematic reviews, there are no

recommendations for the transparent reporting of

guidelines.57 Because many guidelines are not published

in scientific journals, it might be more challenging to

enforce such criteria. A related problem was that we

could not identify the last date of the literature search.

To calculate the evidence citation score, we therefore

used the publication date of the guideline as denomi-

nator rather than the last date of the literature search.

Given the time between initiation and publication of

guidelines, the evidence score might be underestimated.

However, we do not think that this influenced the

conclusions for the following reasons. The two oldest

guidelines published in 1998, mentioned that they

searched until 199822 or cited studies published in 1998

for related topics.26 This shows that they were in the

ability of retrieving the seven trials published before

1994. For the guidelines published between 2007 and

2009, it is possible that the trial49 published in August

2006 fell outside the literature search date range.

However, eight of these guidelines did not refer to any

intervention study. The other guideline cited studies

published in 2009 for related topics, which indicates

that they were in the ability of retrieving this trial

from 2006.

The evidence citation score is an indicator of the

quality of the literature review, but it does not address

correspondence between the evidence description and

the recommendations. Therefore, we cannot judge if the

lack of agreement between guidelines is explained by

differences in evidence. Additionally, the total body of

evidence is wider than the best available evidence which

we screened. Some guidelines also referred to indirect

evidence from surgery patients or healthy subjects, case

studies and animal studies, which may explain the

differences in recommendations.

A final limitation is the difficulty of scoring items with

AGREE that only partially fulfil the criteria. While it is

clear when to use a score of ‘strongly agree’ or ‘strongly

disagree,’ it is less obvious for an ‘agree’ or ‘disagree’

score. The more explicit scoring system of AGREE II

might improve this.54 58

In conclusion, we identified 21 guidelines on ankle

sprains and ice. The recommended durations and

number of ice applications varied significantly. The role

of evidence versus expert opinion was obscure in many

guidelines. As the differences occurred evenly among

guidelines with low, moderate or high rigour scores, we

conclude that the guidelines suffered from methodo-

logical shortcomings which the AGREE instrument did

not capture. We believe that a verification of the validity

of the literature search and an item assessing the

description of the role of expert opinion should be

added to the AGREE instrument.

Funding This study was funded by the Belgian Red CrossdFlanders.

Competing interests PVDK and SVDV are employed in the Belgian Red

Cross-Flanders from which a guideline was included; BA, DR and SVDV

regularly review practice guidelines for the Flemish College of General

Practitioners from which a guideline was included. AH, PD and PVDK have no

relationships with companies that might have an interest in the submitted work

in the previous 3 years; AH, BA, DR, PD, PVDK and SVDV, their spouses,

partners and children have no financial relationships that may be relevant to

the submitted work; BA and SVDV are authors of a guideline which is included

in the analysis and have non-financial interests that may be relevant to the

submitted work.

Contributors SVDV, BA and DR conceived and designed the study. SVDV, BA

and DR searched for eligible guidelines. SVDV, AH, BA and DR evaluated the

retrieved guidelines on rigour of development. PVDK and PD provided general

advice on the study. SVDV wrote the research paper. BA was the guarantor of

the study.

Provenance and peer review Not commissioned; externally peer reviewed.

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DISCUSSION

CHAPTER 7

91

7.1 Contributions of this thesis

The main achievement of this thesis is that we introduced evidence-based

practice to the practice-oriented domain of first aid training and to the Belgian

Red Cross-Flanders. Following the European first aid guidelines project,

evidence-based practice became an integral part of the Belgian Red Cross-

Flanders. The Expertise Centre was founded in 2009 to review evidence in all

the areas where the organisation is active: from blood supply to international

humanitarian aid and social care. In the strategic plan “Pledge 2015” of the

Belgian Red Cross-Flanders, the evidence-based principle is the central thread.

After a project to help develop evidence-based first aid guidelines and materials

specifically directed at the African context, we have now taken the initiative to

introduce evidence-based practice within the network of 186 National Red

Cross and Red Crescent societies.

Although the development of evidence-based guidelines (chapter 2) was new

for the Belgian Red Cross-Flanders, we were able to complete this task within a

strict two-year timeline through an intense collaboration. This was a particular

challenge because the formal development of evidence-based guidelines is

cumbersome and often takes two years or more.31;32 To implement the

guidelines efficiently and effectively, we developed the European First Aid

Manual (EFAM). EFAM combines the guidelines for first aid and guidelines for

resuscitation from the European Resuscitation Council in a format ready for

training the lay public. Authors of first aid manuals can use the EFAM digital

texts and photos to develop or update their first aid courses along the current

European guidelines. By 2011, 32 organisations were already making use of

EFAM for their first aid programmes. An updated version of EFAM is now being

developed taking into account the recommendations of the more recent 2010

guidelines.33-35

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In a systematic review on the effectiveness of first aid training (chapter 3), we

identified 15 relevant studies. It was regrettable that 10 studies were excluded

because of probable bias. Another study was excluded because of poor

reporting. This finding was an illustration of the amount of waste in research.

However, this review did find two studies that measured the change in practice

with unannounced simulations. From this review we tentatively concluded that

conventional first aid training improved competences but not performance.

Supplementary training on dealing with barriers to helping might increase

helping rates. A limitation of our process for assessing the risk of bias is that we

did not take into account the potential impact of the different quality criteria on

the results of the selected studies. While allocation concealment is one of the

most important quality criteria for RCTs it received equal weight as the other

quality criteria.

The systematic review was paramount to the choice of research question for

the RCT (chapter 4) in this thesis. Designing the RCT with reference to this

systematic review was important because it not only identified, but also

justified the research question and informed us when deciding on the study

design.36;37

In the community-based RCT we found that supplementary training on dealing

with barriers to helping did not alter the time or rate of helping in an acute

myocardial infarction emergency. This finding is different from previous trials

which did find an increase. The good news was that all the participants

demonstrated some type of helping reaction and nearly all the participants

sought help. Despite the very high helping rates, there is still a need to increase

the timeliness and appropriateness of the aid provided. First aid self-efficacy

beliefs were not useful to predict performance.

Since the development of a systematic review is time-consuming and typically

takes 6 to 12 months,38 the Expertise Centre of the Belgian Red Cross-Flanders

93

also uses rapid reviews to realise its goals within the given time and resource

constraints. Two examples of such a rapid review are given in chapter 5.

Although the rapid review on pototo peel dressings for burns presents three

studies, it should be mentioned that only one study provided direct evidence to

the specific question asked. The other two studies provided indirect evidence as

a summary of the best available evidence.

Because evidence regarding the implications of rapid reviews is limited, we

compared the results of this rapid review with a systematic review on the same

topic. We found differences in the selected evidence and conclusions.

Unfortunately the manuscript of the systematic review did not contain the

information required to evaluate why these differences occurred. This

observation illustrated the importance of the Preferred Reporting Items for

Systematic Reviews and Meta-Analyses, i.e. the PRISMA statement.39 It is a

limitation of this thesis that we were not able to compare a broader sample of

rapid and systematic reviews.

An evaluation of guidelines on ice for ankle sprains (chapter 6) illustrated

methodological problems among the included guidelines and shortcomings of

the AGREE instrument to identify them. Later in this chapter we make the link

between the methods used for the European first aid guidelines, the

conclusions from this methodological research, and conclusions from key

commentaries.

7.2 Current methodological perspectives on evidence-based

guidelines in general and on the European first aid guidelines in

particular

Evidence-based guidelines are promoted as an important tool to bridge the gap

between evidence and practice. To be a reliable source of information, it is

94

widely accepted that guideline development methods need to be rigorous and

transparent. Such formal methods must prevent invalid guidelines from

replacing normal clinician variation with consistently inappropriate practice.40

However, a systematic review of guideline appraisal studies, including a total of

627 guidelines published since 1980, demonstrated that many guidelines are of

low quality. Only half of the guidelines (55%, 168 on a subsample of 270

guidelines) could be recommended or recommended with provisos after an

evaluation with the AGREE instrument. The most worrying was the low mean

score for the AGREE rigour of development domain (43%; 95% CI 41.0 to 45.2),

since this domain is considered as the most important indicator of guideline

quality.41

In our methodological research on the rigour of development of practice

guidelines on ice for acute ankle sprains, we illustrated a recurrent problem

associated with evidence-based guidelines: different panels coming to different

conclusions based on a review for the same topic.42 The reasons for this are

many and vary between valid and invalid. From key commentaries on the

quality of guidelines in general we identified five main problems in the

development of evidence-based guidelines relating to: 1) incomplete

identification of evidence, 2) composition of guideline panels, 3) conflicts of

interest, 4) consensus development methods, 5) independent review before

dissemination.32;42;43

Below we discuss the strengths and weaknesses of the European first aid

guideline from this perspective. We also incorporate relevant conclusions from

our methodological research on ice for ankle sprains, since the European first

aid guidelines were among the 21 guidelines analysed.

95

Incomplete identification of evidence

On the one hand, most guidelines cannot be based on evidence alone because

of inevitable gaps in the research for many questions.32;42 On the other hand

they often rely too much on expert opinion because the authors do not cite the

available evidence.43 Reasons for this can be lack of awareness of relevant

evidence or ignoring such evidence.44 Giannakakis et al found that among 40

guidelines published in 1999 in six influential medical journals, only 12.5% did a

systematic review and pertinent RCTs were often not included.45 Now a decade

later, our study on ankle sprain guidelines provides another illustration of this

problem.

Despite the fact that the development process for the European first aid

guidelines included a systematic literature review, we relied heavily on existing

guidelines as a source of information. Although we appraised these guidelines

with the AGREE instrument, our methodological research shows that this was

not a guarantee for identifying the relevant evidence. The ADAPTE procedure

provides a framework on how to use existing guidelines as a source of

information.46

Composition of guideline panels

Studies have shown that the characteristics of experts in panels might influence

the recommendations.47 Sniderman defines this problem as follows: “ what is to

be decided is often already decided with the selection of the deciders”.42 For

example, there is evidence that current performers of a specific procedure

judge it as more appropriate versus non-performing clinicians.47 The

composition of an expert panel is therefore a vital step and advice is given on

this matter in all guideline development handbooks.48 To compose the expert

panel for the European first aid guidelines, we focussed on obtaining a

multidisciplinary panel as it was described in the SIGN guideline developers’

handbook. We selected panellists from a variety of backgrounds with either

96

clinical, training or evidence-based expertise. Taking into account the

importance of this step, we believe that it would be useful if the SIGN handbook

could provide more rigorous procedures for the selection of experts.

Conflict of interest

In guideline panels, a conflict of interest is a situation in which an expert’s

judgement of a recommendation is improperly influenced by financial,

professional, or other personal interest. A typical example is involvement with

drug companies. Such conflicts can make guidelines marketing tools for the

industry.42 Since layperson first aid assumes that minimal or no equipment is

required, the potential for commercial conflicts is limited. More relevant are

intellectual conflicts, which may arise when an expert holds personal strong

views on a guideline topic. In the European first aid guidelines panel members

were asked to declare any possible conflict of interest with respect to the topics

being included. Although the input of experts in the formulation of the

recommendations was important, it was a strength that unconflicted

methodological experts had the main responsibility for the guidelines.

Consensus development methods

The assumed principle behind consensus is that a group has a more valid and

reliable view than an individual.32 However, the presence and actions of a panel

member also affects the actions of others.47;49 To safeguard the validity of

consensus-based recommendations, rigorous procedures on how the experts

interact when formulating recommendations have been recommended.32

Formal consensus methods explicitly define the procedures and output in the

guideline development plan.49 Typical formal approaches include the Delphi

method, the Nominal group technique and the RAND method. While the Delphi

method assembles the viewpoints with mailed questionnaires, the Nominal

Group Technique involves a face-to-face meeting. The RAND method combines

both approaches, by first using mailed questionnaires and then following up

97

with a face-to-face meeting. All approaches include the recording of personal

views, formal group feedback on these views using a structured interaction, and

explicit methods to aggregate the personal views.49

In the European first aid guidelines, the role of expert opinion was significant

since the body of evidence with relevance to layperson first aid is incomplete.

At the start of the meeting we explained the consensus procedures. According

to the SIGN methods we used the considered judgement procedure to move

from the evidence synthesis to formulating recommendations. This considered

judgement took the following factors into account: quantity and quality of the

evidence, the clinical impact and the implementability. During the meeting, the

panel members first considered the available evidence and then discussed the

recommendations until a consensus was reached. While we made extensive use

of consensus to agree on the recommendations, it is a weakness that we did not

use a more formal consensus method. This would have allowed us to structure

the interaction between panel members and to represent the extent of

agreement in the panel per recommendation.

Independent review before dissemination

Many guidelines are not published in scientific journals and the decision to

undertake an external review often depends on the authors. Even if guidelines

are published in a scientific journal, they often bypass the peer-review system.42

As a consequence, many guidelines are disseminated without independent

review or external validation. Among the 21 guidelines on ice for ankle sprains,

only half included an external review before its publication. It was definitely a

strength that the European first aid guidelines were formally validated before

dissemination. This means that an independent committee of three experts

appraised the guidelines using the AGREE instrument.

98

7.3 Potential solutions for drawing the line between evidence-

based and ‘evidence-biased’50 guidelines

The last word on the development of guidelines has clearly not been said. Below

we propose various solutions to improve the quality of guidelines.

Balanced guideline development panels

The selection of panel members usually takes the form of purposive sampling by

the guideline organising committee. This type of sampling opens the door to

bias since the panel is selected subjectively. Formalising the identification and

selection process through public vacancies and criteria listed in expert profile

descriptions might already be an improvement. Below we present two

approaches which are not mentioned in general guideline development

handbooks48 but which might be useful when composing guideline panels.

Maximum heterogeneity sampling, also called maximum variation sampling,

could reduce the risk of selecting a sample with little variation in viewpoints

when a wide variation or controversy is present among experts.51 This selection

procedure involves the identification of extremes in the relevant area of

expertise.

Nominations by practitioners in the field is another approach which might

increase the perceived credibility of the panel among stakeholders and the

chances of implementation.52

Addressing conflict of interest

While evidence-based guidelines usually report on any financial conflicts, this is

much less the case for intellectual conflicts. Disclosure of both financial and

intellectual conflicts would be an improvement. However, disclosing conflicts of

interest is not enough to prevent biased recommendations. If conflicts occur,

these also have to be managed. Several approaches have been suggested.

99

One approach is to ensure that in guideline panels conflicted experts are

balanced by unconflicted ones.43 A more stringent approach is to allow

conflicted experts to provide input in a panel, but to exclude them from

decision-making for the related recommendations.53 One step further is to

exclude conflicted experts from participation in guideline panels.42 Since

participation in a guideline panels is also a type of intellectual conflict, it has

been suggested that the members of the guideline panel are changed each time

a new edition of a guideline is being developed.42;54

Validation framework for guidelines

Reforming the guideline development process is difficult because guideline

development is not centralised and because many guidelines are not published

in peer-reviewed journals.43 In Belgium, the Belgian Centre for Evidence-Based

Medicine (CEBAM) validates guidelines with the AGREE instrument in

combination with a limited analysis of the content. The validation procedure

results in a decision to recommend or not to recommend use of the guideline by

the targeted caregivers. This validation procedure is quite unique. Embedding

such a procedure in other countries or at international level might improve the

quality of guidelines and support the users of guidelines. Further research

comparing the quality of validated with non-validated guidelines is warranted.

7.4 Suggestions for future research

Keeping up-to-date

The number of new trials being published per day is impressive and still

growing. Keeping up-to-date with current evidence is therefore a major

challenge.20 Systematic reviews have an important role to play in keeping track.

Taking into account the findings of our RCT, an update of our systematic review

is recommended.

100

This will also allow the inclusion of an additional study that we missed, and the

identification of any new relevant studies published since the completion of our

search in May 2007.

Can rapid reviews be quick without being dirty 19?

The success of evidence-based practice has led to a rise in review studies.20

Grant and Booth identified 14 commonly published types of reviews, including

rapid reviews. For the reader of such reviews, the value of the different types of

reviews is not always clear. Therefore, it is recommended to explicitly report the

methods and its limitations.19 This is particularly important for rapid reviews,

because of the methodological shortcuts which increase the risk of bias.

Our rapid review was published as a BestBet. In the general introduction of the

BestBet journal section the reader is informed about the standard methods

used and it is reported that BestBets are not meant to be full systematic

reviews. The first sentence of our specific BestBet even mentions that it is a

“short-cut review”.

Informing the reader about the likely effect of this approach would have been

of added value. However, from current research it is not possible to evaluate

how robust they are in comparison to systematic reviews. We believe this forms

an opportunity for further research and we suggest the following plan. When

planning a new systematic review, a preliminary assessment of the available

evidence is also required. If rapid review procedures are consistently used

during this scoping phase, it would be possible to compare the results of the

rapid and fully systematic process afterwards.

Further primary research in non-resuscitative first aid

All the research that we have done illustrates the lack of evidence in the field of

non-resuscitative first aid. The considerable burden of injuries highlights the

need for further primary research. Unfortunately there is a poor correlation

101

between the burden of disease or injury and funding for health and research.55

This is illustrated by the budget allocation of the WHO. In 2006 the WHO

allocated less than 1% of its total budget to injuries, although injuries account

for one tenth of the global burden of disease and injury.1;56

We give as an example ankle sprains, for which the incidence has been

estimated at 1/10000 people per day.57 Common sense and practical experience

have led to the widespread use of bandages as first aid management for

sprained ankle. If you need 1 meter of bandage per ankle sprain, this amounts

to 32,000 km (by way of reference, the length of the equator is about 40,000

km) of bandage per year in Europe alone.28 However, there is weak evidence

that in the case of mild or moderate ankle sprains, elastic bandages do not have

significantly better outcomes than no bandages, and might even lead to worse

outcomes.58-61 New robust evidence would be relevant to reassure users about

which procedures are most appropriate.

Evidence-based practice for laypeople

Typically, the evidence-based discourse is held among professionals. However,

the concept of evidence-based practice is diffusing gradually towards the

general lay public. The layperson can come into contact with evidence-based

practice through shared decision-making during medical visits, information on

the internet or in the general media. In the setting of first aid training, lay first

aid trainers and those attending the training are the end users of the guidelines.

Every five years, these stakeholders are expected to learn the procedures from

the newly published guidelines for basic life-support and now also the

guidelines for non-resuscitative first aid. Encouraging them to do so is especially

difficult when the guidelines contain procedures that conflict with customary

practice or with information in previous versions. This has led to situations in

which laypeople are frustrated with evidence-based practice.

102

A main problem is that many laypeople are unfamiliar with terms related to

medical evidence and may misunderstand the concept of evidence-based

practice.62 While training in evidence-based medicine is now well established

for professional care providers, it is hard to find such training for non-medical

laypeople.63 Effective communication about evidence-based practice is essential

to engage the lay public in evidence-based practice. Since the research on such

training for laypeople is still in its infancy, we believe the first aid setting

provides an opportunity to contribute to this research.

7.5 Conclusions

The number of recommendations in the European first aid guidelines for which

no strong evidence was available, the amount of relevant but biased studies in

the systematic review, and the findings from the methodological research on

guidelines for ice and ankle sprains illustrated that the evidence in first aid was

sometimes disastrous. However, when available we turned evidence into

practice.

Although an editorial about the European first aid guidelines reported that the

European first aid guidelines were “highly appropriate” and an “excellent

start”,64 we are also aware of its shortcomings. A particular strength of the

guidelines was the positive evaluation by a formal external validation

committee. Since the use of external validation procedures for guidelines is

quite unique, this approach might be an important strategy for improving the

quality of guidelines.

Despite the general belief in the potential of first aid training, our systematic

review on the effectiveness of non-resuscitative first aid training showed that it

does not always translate into helping behaviour. The use of deception tests

was identified as a way of measuring emergency helping behaviour.

103

In our community-based trial on conventional first aid training only versus

conventional first aid training with a supplementary intervention to decrease

barriers, we made diverging observations regarding the rate of helping

behaviour versus previous trials. We found that supplementary training did not

alter the helping behaviour. The high loss to follow-up was an important

limitation of this study, making it difficult to derive conclusions. Further

research is necessary to gather information on the helping behaviour of

laypeople trained in first aid.

Unfortunately we were not able to address the question about the validity of

rapid reviews. We believe this provides an opportunity for further research and

have proposed a plan by which it might be evaluated.

The low quality of clinical practice guidelines in general is an important

problem.41 Our methodological study on the quality of guidelines showed that

there is only a thin line between evidence-based practice for accidents and

accidents in evidence-based practice. The AGREE instrument did not highlight

essential methodological shortcomings. We suggest an additional analysis of the

content of the recommendations to evaluate the validity of guidelines. As the

rigour of development and overall quality of many guidelines is low,41 we

recommend caution in viewing guidelines themselves as a form of evidence.

The different studies included in this thesis illustrate that first aid is not merely a

medical topic; it also touches the fields of social psychology, and education.

Using the evidence-based methodology in collaboration with experts in the

range of included topics, we made considered judgements on these matters.

We believe that this thesis made a significant contribution to the field of

evidence-based first aid and has created the enthusiasm to start new evidence-

based projects in first aid and beyond in the area of humanitarian aid.

104

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105

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consumer representatives in the basic competencies of evidence-based

medicine: a feasibility study. BMC Med Educ. 2010;10:16.

64 Handley AJ. European first aid guidelines. Resuscitation.

2007;72(2):178-179.

111

112

Summary

113

Introduction

In order to improve the quality of care, evidence-based practice seeks to bridge

the gap between evidence and practice.While cardiopulmonary resuscitation by

laypeople was extensively studied and evidence-based guidelines were

published, the field of non-resuscitative first aid lagged behind in applying

evidence-based practice. Taking into account the considerable burden of injury,

the life-saving potential of first aid, the potential benefits of evidence-based

practice, areas of controversy in first aid, and the gaps in systematic analysis of

first aid evidence, it was the purpose of this thesis to introduce evidence-based

practice in the first aid training activities of the Belgian Red Cross-Flanders and

to add new empirical data to the research base.

Methods

To realise this objective we first produced an evidence-based guideline to

determine the most effective, safe, and feasible first aid techniques and

procedures, and to formulate recommendations for training.

Next we performed a systematic review to evaluate the effectiveness of first aid

training. This systematic review also led us to the design of a randomised

controlled trial (RCT) to evaluate if training on barriers to helping facilitates

emergency helping behaviour among laypersons trained in first aid. We

evaluated this by means of a deception test in which the participants were

unaware that an emergency was simulated and did not know that their helping

behaviour was being evaluated. Having the confidence to provide first aid may

influence helping barriers. Therefore this RCT also measured the participants’

self-efficacy beliefs and related these to the performance demonstrated in the

deception.

114

The pressing need for information, especially in emergency care settings, has

given rise to the methodology of rapid reviews in which methods for the search,

appraisal, synthesis and analysis are determined by time constraints. We

conducted two such rapid reviews for very specific clinical questions. Because

there is limited evidence regarding the validity of rapid reviews, we compared

the results of one of our rapid reviews with a systematic review on the same

topic. Finally, we tried to add to the research in the quality of evidence-based

guidelines by evaluating the content and rigour of development of

recommendations on the use of ice in guidelines for acute ankle sprains.

Results

With a multidisciplinary panel of European experts that considered the findings

from the available evidence, we produced European guidelines on safety

measures, emergency removal of victims, psychosocial first aid and first aid for

trauma and oral poisoning. Our systematic review found two studies that

succeeded in measuring the change in helping behaviour after first aid training.

Based on these studies we tentatively concluded that conventional first aid

training improved competences but not performance. Supplementary training

on dealing with barriers to helping might increase helping rates. In our RCT we

found that such supplementary training did not alter the time or rate of helping

in an acute myocardial infarction emergency. The good news was that all the

participants demonstrated some type of helping reaction and nearly all the

participants sought help. Despite the very high helping rates, there is still a need

to increase the timeliness and appropriateness of the aid provided. First aid self-

efficacy beliefs were not correlated with performance.

The comparison between a rapid review and a systematic review on the same

topic demonstrated differences in the selected evidence and conclusions. From

the manuscript of the systematic review it was not possible to evaluate the

reasons for these differences. In a published letter to the editor we drew

attention to adherence to the Preferred Reporting Items for Systematic Reviews

and Meta-Analyses, i.e. the PRISMA statement.

115

The evaluation of guidelines on ice for ankle sprains found methodological

problems among the included guidelines and shortcomings of the AGREE

instrument to identify them. The 21 guidelines included in the analysis,

contained clinically significant variations in their recommendations. The

variation was not related to the quality of the guideline.

Discussion

The main achievement of this thesis is that we introduced evidence-based

practice to the practice-oriented domain of first aid training and to the Belgian

Red Cross-Flanders. In 2009, the Belgian Red Cross-Flanders founded the

Expertise Centre which reviews evidence in all the areas where the organisation

is active. Furthermore, the evidence-based principle became the central

principle in the strategic plan “Pledge 2015” of the Belgian Red Cross-Flanders.

The number of recommendations in the European first aid guidelines for which

no strong evidence was available, the amount of relevant but biased studies in

the systematic review, and the findings from the methodological research on

guidelines for ice and ankle sprains illustrated that the evidence in first aid was

sometimes disastrous. However, when available we turned evidence into

practice.

In our community-based trial we made diverging observations versus previous

trials regarding the effect of supplementary training on dealing with barriers to

helping and regarding the rate of helping behaviour. The high loss to follow-up

was an important limitation of this study, making it difficult to derive

conclusions. First aid self-efficacy beliefs did not appear to be a good predictor

of performance. Deception tests showed to be a useful way to gather

information on the helping behaviour of laypeople trained in first aid.

Our comparison of guidelines on ankle sprains illustrated that many guidelines

suffer from methodological shortcomings. To evaluate the validity of guidelines,

we suggest an analysis of the content of the recommendations in addition to an

116

AGREE evaluation. We recommend caution in viewing guidelines themselves as

a form of evidence and we made suggestions to improve the quality of

evidence-based guidelines. Further research is needed to address the question

about the validity of rapid reviews and a concept to evaluate this has been

presented.

We believe that this thesis made a significant contribution to the field of

evidence-based first aid and has created the enthusiasm to start new evidence-

based projects in first aid and beyond in the area of humanitarian aid.

117

118

Samenvatting

119

Inleiding

Evidence-based practice tracht de kwaliteit van zorg te verhogen door de kloof

tussen onderzoek en praktijk te overbruggen. Er is uitgebreid onderzoek gedaan

naar cardiopulmonaire reanimatie door leken en de bevindingen werden

vertaald naar evidence-based richtlijnen. Op het vlak van eerste hulp naast

reanimatie stond evidence-based practice nog in de kinderschoenen.

Rekening houdend met de aanzienlijke impact van traumatische letsels, het

levensreddende potentieel van eerste hulp, de potentiële voordelen van

evidence-based practice, gebieden van tegenstrijdigheid in eerste hulp, en de

nood aan een systematische analyse van evidence aangaande eerste hulp, was

het doel van deze thesis om evidence-based practice te introduceren in het

eerstehulponderwijs van Rode Kruis-Vlaanderen en om nieuwe empirische

gegevens te verzamelen.

Methodes

Om deze doelstelling te realiseren, ontwikkelden we eerst een evidence-based

richtlijn. Deze richtlijn bepaalde de meest effectieve, veilige en toepasbare

eerstehulptechnieken en formuleerde aanbevelingen voor training.

Vervolgens voerden we een systematische review uit om de effectiviteit van

eerstehulponderwijs te evalueren. Deze review bepaalde ook het

onderzoeksplan voor een randomised controlled trial (RCT). Deze RCT

onderzocht of training aangaande drempels tot het bieden van hulp een

positieve invloed heeft op het helpend gedrag in noodsituaties van leken

getraind in eerste hulp. We maakten gebruik van een misleidingstest om het

helpend gedrag te evalueren. In deze misleidingstest wisten de deelnemers niet

dat een noodsituatie gesimuleerd werd, noch dat hun helpend gedrag

geobserveerd werd. Vertrouwen hebben in het bieden van eerste hulp, zou de

drempels tot het bieden van hulp kunnen beïnvloeden. Daarom hebben we in

120

deze RCT ook gekeken of er een verband was tussen de

zelfeffectiviteitsverwachting van de deelnemers en hun helpend gedrag tijdens

de misleidingstest.

De nood aan snel beschikbare informatie, in het bijzonder in de context van

spoedeisende hulp, heeft geleid tot de methodologie van rapid reviews. In deze

rapid reviews worden de methodes voor het zoeken, beoordelen en

samenvatten van evidence bepaald door de tijdsbeperkingen. Wij hebben rapid

reviews uitgevoerd voor twee specifieke praktijkvragen. Omdat het onderzoek

naar de validiteit van rapid reviews erg beperkt is, hebben we de conclusies van

een van onze rapid reviews vergeleken met die van een systematische review

over hetzelfde onderwerp. Tenslotte, probeerden we een bijdrage te leveren

aan het onderzoek naar de kwaliteit van evidence-based richtlijnen door de

inhoud en methodologische kwaliteit van richtlijnen over het gebruik van ijs

voor acute enkelverstuikingen te vergelijken.

Resultaten

Een multidisciplinair panel van Europese experten nam de beschikbare evidence

in overweging en produceerde aanbevelingen aangaande

veiligheidsmaatregelen, noodevacuatie van slachtoffers, psychosociale eerste

hulp en eerste hulp voor trauma en orale vergiftiging.

De systematische review vond twee studies die erin geslaagd waren om het

effect van eerstehulptraining op het helpend gedrag te meten. Gebaseerd op

deze studies concludeerden we, onder voorbehoud van verdere studies, dat

conventioneel eerstehulponderwijs wel de competenties verhoogde maar geen

invloed had op het helpend gedrag. Bijkomende training aangaande drempels

tot het bieden van hulp zou het aantal mensen die hulp bieden in noodsituaties

kunnen verhogen.

In onze RCT vonden we dat deze bijkomende training geen invloed had op het

121

helpend gedrag voor een acute hartaanval. Het goede nieuws was dat bijna alle

deelnemers enige vorm van hulp boden. Desondanks bleek er ook een nood om

de snelheid en juistheid van de geboden hulp te verbeteren. De

zelfeffectiviteitsverwachting was niet gecorreleerd met het helpend gedrag.

De vergelijking tussen een rapid review en een systematische review over

hetzelfde onderwerp stelde verschillen vast met betrekking tot de

geselecteerde evidence en de conclusies. Het manuscript van deze

systematische review stond niet toe om de redenen voor deze verschillen te

achterhalen. In een gepubliceerde brief aan de redactie beklemtoonden we het

belang van een goede rapportering van het systematische review proces aan de

hand van de Preferred Reporting Items for Systematic Reviews and Meta-

Analyses, met name de PRISMA statements.

De evaluatie van aanbevelingen over ijs voor enkelverstuikingen vond

methodologische problemen in de richtlijnen die het AGREE instrument niet kon

identificeren. De 21 geïdentificeerde richtlijnen waren beduidend verschillend

in hun aanbevelingen. Deze variatie was niet gerelateerd aan de kwaliteit van

de richtlijn.

Discussie

De belangrijkste verwezenlijking van deze thesis is dat we evidence-based

practice hebben geïntroduceerd in het praktijkgerichte eerstehulponderwijs en

in de werking van Rode Kruis-Vlaanderen in het algemeen. In 2009 richtte Rode

Kruis-Vlaanderen het Expertisecentrum op dat evidence samenvat voor alle

activiteiten van de organisatie. Bovendien werd de evidence-based aanpak de

rode draad in het strategische plan, “Afspraak 2015”, van Rode Kruis-

Vlaanderen.

Het aantal aanbevelingen in de Europese eerstehulprichtlijnen waarvoor geen

sterke evidence beschikbaar was, het aantal relevante maar gebiaste studies in

122

de systematische review, en de bevindingen van het methodologisch onderzoek

over richtlijnen voor ijs bij enkelverstuikingen illustreerden dat de evidence over

eerste hulp soms rampzalig was. Wanneer er echter evidence beschikbaar was,

hebben we deze wetenschappelijke resultaten kunnen vertalen naar de praktijk.

In onze RCT maakten we, in vergelijking met vorige studies, afwijkende

vaststellingen aangaande het effect van bijkomende training over drempels tot

het bieden van hulp en aangaande het helpend gedrag in het algemeen. Het

hoge aantal uitvallers in de studie was een belangrijke beperking die het

moeilijk maakte om besluiten te trekken. De zelfeffectiviteitsverwachting

aangaande eerste hulp bleek geen goede predictor te zijn van het helpend

gedrag. Misleidingstesten bleken een nuttige manier om informatie te

verzamelen over het helpend gedrag van leken getraind in eerste hulp.

Onze vergelijking van richtlijnen over enkelverstuikingen illustreerde dat vele

richtlijnen methodologische problemen hebben. Om de geldigheid van

richtlijnen te evalueren, stellen we aanvullend bij de AGREE evaluatie ook een

analyse van de inhoud van de aanbevelingen voor. We manen aan tot

voorzichtigheid wanneer richtlijnen als een vorm van evidence worden gezien

en maakten suggesties om de kwaliteit van evidence-based guidelines te

verhogen. Verder onderzoek is nodig om de vraag over de validiteit van rapid

reviews te beantwoorden. Een concept om dit te evalueren werd voorgesteld in

de thesis.

We denken dat deze thesis een belangrijke bijdrage heeft geleverd in het

domein van evidence-based eerste hulp. Tevens hebben we het nodige

enthousiasme gecreëerd om nieuwe evidence-based projecten te starten in het

domein van eerste hulp en ook ruimer in het gebied van humanitaire hulp.

123

124

Professional career

125

In 2000, Stijn Van de Velde completed his Licence in Physical Therapy at the

University of Ghent. He commenced his career as a physical therapist working

with children suffering from asthma, mucoviscidosis or obesity and served the

Belgian national rowing teams in training camps and international competitions.

As a result of his strong interest in humanitarian aid, Stijn studied in a

Postgraduate program on Development Cooperation.

After that, he joined the Belgian Red Cross-Flanders in 2002 as project manager

on sports injury prevention. During his work at the Belgian Red Cross, he started

a part-time Masters degree in Public Health Methodology and graduated with

great distinction in 2005. In this study he was intrigued by the evidence-based

methodology and, as project manager of the European first aid guidelines and

manual project, Stijn took up the challenge to implement this within the Red

Cross.

Evidence-based practice has since become an integral part of the Belgian Red

Cross-Flanders. To implement evidence-based practice in the Belgian Red Cross-

Flanders, Stijn was closely involved in the establishment of the Expertise Centre.

This centre systematically revises all the programmes that are run so that they

can carry the label ‘evidence-based’. Following the European first aid project, he

also used the evidence-based methodology to create African first aid guidelines

and training material.

Within the international Red Cross movement, Stijn has been elected by the

First Aid Education European Network as member of the steering committee.

This network brings together those responsible for first aid from Red Cross

National Societies in the Pan-European region. He also co-authored the

International first aid guidelines published in 2010 by the International

Federation of the Red Cross and Red Crescent.

126

In parallel with his work at the Red Cross, Stijn started working for the Belgian

Centre for Evidence-based Medicine (CEBAM) in 2007. In this Centre he gives

methodological advice to guideline authors, participates in the validation of

Belgian clinical practice guidelines, and gives training on evidence-based

medicine.

Stijn Van de Velde (32 years) is married to Kriki and they have 3 daughters.

127

128

List of publications

129

International peer reviewed journals

Van de Velde S, Heselmans A, Donceel P, Vandekerckhove P, Ramaekers D,

Aertgeerts B. Rigour of development does not AGREE with recommendations in

practice guidelines on the use of ice for acute ankle sprains. BMJ Qual Saf. 2011

(Epublication ahead of print).

Van de Velde S, De Buck E, Dieltjens T, Aertgeerts B. Medicinal use of potato-

derived products: conclusions of a rapid versus full systematic review. Phytother

Res. 2010 (Epublication ahead of print).

De Buck E, Van de Velde S. Towards evidence based emergency medicine: best

BETs from the Manchester Royal Infirmary. BET 1. Optimal body position in oral

poisoning cases. Emerg Med J. 2010; 27(12):952-3.

De Buck E, Van de Velde S. Towards evidence based emergency medicine: best

BETs from the Manchester Royal Infirmary. BET 2: potato peel dressings for

burn wounds. Emerg Med J. 2010;27(1):55-56.

Heselmans A, Donceel P, Aertgeerts B, Van de Velde S, Ramaekers D. The

attitude of Flemish occupational health physicians toward evidence-based

occupational health and clinical practice guidelines. Int Arch Occup Environ

Health . 2010;83(2):201-208.

Van de Velde S, Heselmans A, Roex A, Vandekerckhove P, Ramaekers D,

Aertgeerts B. Effectiveness of nonresuscitative first aid training in laypersons: a

systematic review. Ann Emerg Med. 2009;54(3):447-457.

Heselmans A, Van de Velde S, Donceel P, Aertgeerts B, Ramaekers D.

Effectiveness of electronic guideline-based implementation systems in

ambulatory care settings - a systematic review. Implement Sci. 2009;4:82.

130

Heselmans A, Donceel P, Aertgeerts B, Van de Velde S, Ramaekers D. The

attitude of Belgian social insurance physicians towards evidence-based practice

and clinical practice guidelines. BMC Fam Pract. 2009;10:64.

Van de Velde S, Broos P, Van Bouwelen M, De Win R, Sermon A, Verduyckt J,

Van Tichelen A, Lauwaert D, Vantroyen B, Tobback C, Van den Steene P, Villere

S, Mieres CU, Gobl G, Schunder S, Monsieurs K, Bierens J, Cassan P, Davoli E,

Sabbe M, Lo G, De Vries M, Aertgeerts B. European first aid guidelines.

Resuscitation. 2007;72(2):240-251.

Other journals

Van de Velde S, Broos P, Van Bouwelen M, De Win R, Sermon A, Verduyckt J,

Van Tichelen A, Lauwaert D, Vantroyen B, Tobback C, Van den Steene P, Villere

S, Mieres CU, Göbl G, Schunder S, Monsieurs K, Bierens J, Cassan P, Davoli E,

Sabbe M, Lo G, De Vries M, Aertgeerts B; Europese richtlijnen voor eerste hulp.

Huisarts Nu. 2009;38(4):159-166.

Training manuals

AFAM project Group. African first aid materials. Published by the Belgian Red

Cross-Flanders, 2010.

EFAM project Group. European First Aid Manual. Published by the Belgian Red

Cross-Flanders, 2007.

131

Translations

Van de Velde S, Verbeke H, Rosenbrand K, Burgers J. (2010). Translation from

English to Dutch of the Appraisal of Guidelines for Research and Evaluation

(AGREE) II Instrument. Available at www.agreetrust.org.

Presentations on symposia

Van de Velde S, Heselmans A, Roex A, Vandekerckhove P, Ramaekers D,

Aertgeerts B. (2008). How effective is first aid training? Association for Medical

Education in Europe (AMEE) Conference, Prague, Czech Republic.

Van de Velde S. (2007).First aid guidelines and evidence-based medicine.

European first aid guidelines. European congress on CPR, Prehospital Care and

Prevention, Ostend, Belgium.

Van de Velde S. (2007). Evidence based practice in first aid. Expert meeting

Science and Practice in Disaster Management, Arnhem, Netherlands.

Van de Velde S. (2007). Evidence based practice in first aid. First aid symposium,

Tampere, Finland.

132

Acknowledgements

133

Now that my PhD project is coming to an end, I want to express my sincere

gratitude to many people for their support, interest and enthusiasm.

First of all I would like to thank my promoters Bert Aertgeerts, Dirk Ramaekers

and Philippe Vandekerckhove. It was a great honour to learn from you and I

hope that my respect came across. Thanks to you, I have reached a professional

milestone in my career. Bert, you wisely guided me along the way and patiently

answered my many questions. Your ‘people first’ approach made the work a

pleasure and strongly encouraged me to continue when the going got tough.

Dirk, your commitment to excellence always challenged and motivated me.

Many thanks for being such a valuable sparring partner. Philippe, thank you for

the opportunities to achieve this goal and for your enthusiasm in setting up the

Expertise Centre.

My sincere thanks also goes to the members of the jury for their efforts in

evaluating my work. I also want to thank the co-authors in my research and the

Medical Commission of the Belgian Red Cross-Flanders for the productive

collaboration.

To the members of the RESCUI research group. Apart from the advice and

guidance that you offered, I very much enjoyed all the good laughs during our

monthly meetings. Annemie, my fellow PhD student, thank you for your help

with the research. You definitely have my respect for your achievements, keep

going. Olivier, good luck with your project.

I am grateful to my colleagues and volunteers from the Red Cross for helping

me to implement the research. I was lucky to work with you. To my manager

Katja, thank you for the confidence and I especially remember the great times

we had during the Nairobi and Cape Town meetings. Special thanks to Emmy,

Tessa and Nele for being such a motivated colleagues. It’s a pleasure to walk

the evidence-based path with you (and I am not referring to the memorable

134

walks after the colloquia in Colorado and London). For those that were involved

in the deception tests, I hope it has been memorable for you as well. A special

word of thanks to Firmin, Frans and Jacques for simulating the many heart

attacks and to Bea for giving the training sessions for the RCT.

To my colleagues from CEBAM, I admire you for your talent to explain

something difficult in an easy way and thanks for the friendly and supportive

work environment.

Marina and Katrien, I very much appreciated your practical assistance during

and at the end of my thesis.

On a personal level I also want to thank my friends for the nice moments

throughout these years which have helped me think of something other than

evidence.

Maarten, many thanks for the good times that we always have together and for

being my brother and dearest friend.

Of course I cannot thank my parents enough for all they have given me. Thank

you for being such a great example and for your support in making my dreams

come true. I recall some time ago how you always wanted me to get a bit more

organised. You would be surprised to see how I have my ‘stuff’ managed now.

However, evidence-based searches still can’t solve the problem of where I left

my keys this time.

Finally, my gratitude goes to my dear Kriki. Thank you for helping me see things

in perspective and for reminding me of what is important in life. I’m fortunate

that you are my personal coach.

Eleni, Stiene en Nienke, ook jullie hebben een hele bijdrage geleverd (ondanks

dat ik even werkonbekwaam was toen Stiene vakkundig de toetsen van mijn

135

klavier had gepeuterd). Met jullie zelf bereide ‘goestingsiroop’ zijn jullie mijn

drie kleine feeën.

136

Appendix

European first aid guidelines: search strategy

137

Key question

1."What is the efficacy and feasibility of ensuring accident site safety by a lay person after a road accident ?"

Search strategy

N° Type Limits Databases Search terms Date of search

1. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

road accident, traffic accident, site protection, accident spot

july 2005

Individual studies

No limits

Pubmed "Accidents, Traffic"[MeSH] AND ("First Aid" OR "Rescue work" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") AND ("site protection" OR "Accident Prevention"[MeSH] OR "Safety")

sep/05

Embase 'traffic accident'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND ('accident prevention'/exp OR 'site protection' OR 'safety'/exp) AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(road accident OR traffic accident ) AND TS=(first aid OR rescue* OR prehospital OR out of hospital) AND TS=(scene protect* OR site protect* OR scene assess* OR site assess* OR safety)

138

Key question

2. "What is the efficacy and feasibility of ensuring accident site safety by a lay person in case of fire ?"

Search strategy

N° Type Limits Databases Search terms Date of search

2. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

fire july 2005

Individual studies

No limits

Pubmed “Fires”[MeSH] AND ("First Aid" OR "Rescue work" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") AND ("site protection" OR "Accident Prevention"[MeSH] OR "Safety")

sep/05

Embase 'fire'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND ('accident prevention'/exp OR 'site protection' OR 'safety'/exp) AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=fire AND TS=(first aid OR rescue* OR prehospital OR out of hospital) AND TS=(scene protect* OR site protect* OR scene assess* OR site assess* OR safety)

139

Key question

3. "What is the efficacy and feasibility of ensuring accident site safety by a lay person after an electrical accident ?”

Search strategy

N° Type Limits Databases Search terms Date of search

3. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

electric injury, electrocution, electric accident, electric shock

july 2005

Individual studies

No limits

Pubmed "Electric Injuries"[MeSH] AND ("First Aid" OR "Rescue work" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") AND ("site protection" OR "Accident Prevention"[MeSH] OR "Safety")

sep/05

Embase 'electric accident'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND ('accident prevention'/exp OR 'site protection' OR 'safety'/exp) AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(electrocution* OR electric* accident* OR electric* injur* OR electric* shock*) AND TS=(first aid OR rescue* OR prehospital OR out of hospital) AND TS=(scene protect* OR site protect* OR scene assess* OR site assess* OR safety)

140

Key question

4. “Under what conditions should the lay person remove the casualty from the scene of the accident.”

Search strategy

N° Type Limits Databases Search terms Date of search

4 Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

evacuation, emergency removal, casualty removal, casualty transport, casualty movement

july 2005

Individual studies

No limits

Pubmed ("Accidents"[MeSH] OR "Emergencies"[MeSH]) AND (lifting OR evacuation) AND ("First Aid" OR "Rescue work"[MeSH] OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase ('accident'/exp OR 'emergency'/exp) AND ('lifting'/exp OR 'evacuation') AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(accident* OR emergenc*) AND TS=(lifting OR evacuation OR) AND TS=(first aid OR rescue OR prehospital OR out of hospital)

141

Key question

5. “What is the safety, efficacy and feasibility of emergency removal from the scene of the accident of a casualty by one or two lay persons.”

Search strategy

N° Type Limits Databases Search terms Date of search

5 Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

evacuation, emergency removal, casualty removal, casualty transport, casualty movement

july 2005

Individual studies

No limits

Pubmed ("Accidents"[MeSH] OR "Emergencies"[MeSH]) AND (lifting OR evacuation) AND ("First Aid" OR "Rescue work"[MeSH] OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase ('accident'/exp OR 'emergency'/exp) AND ('lifting'/exp OR 'evacuation') AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(accident* OR emergenc*) AND TS=(lifting OR evacuation OR) AND TS=(first aid OR rescue OR prehospital OR out of hospital)

142

Key question

6. “What is the safety, efficacy and feasibility of using a tourniquet, direct pressure, pressure points and elevation, done in the first aid management by a lay person of a severe external bleeding?”

Search strategy

N° Type Limits Databases Search terms Date of search

6. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

Hemorrhage OR haemorrhage OR bleeding OR hemostasis OR tourniquets

july 2005

Individual studies

No limits

Pubmed ("Hemorrhage"¨[MeSH] OR bleeding*) AND (elevation OR pressure OR "Bandages"[MeSH] OR tourniquet* OR "Hemostasis"[MeSH]) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase 'bleeding'/exp AND ('elevation' OR ' pressure'/exp OR 'bandage'/exp OR tourniquet* OR 'hemostasis'/exp) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(hemorrhage) AND TS=(first aid OR prehospital OR out of hospital) AND TS=(elevation OR pressure OR bandage OR tourniquet OR hemostasis) NOT TS=(surg* OR cerebr* OR stroke OR infarct* OR gastro* OR hepato* OR obstet* OR pulm* OR transfus* OR serum OR fluid* OR neuro*)

143

Key question

7. “Under what conditions should a lay person suspect a spinal injury or head trauma in infants, children and adults?”

Search strategy

N° Type Limits Databases Search terms Date of search

7. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

head injury, cerebral injury, craniocerebral injury, spinal injury

sep/05

7a(infants Individual studies

No limits

Pubmed "Infant"[MeSH] AND ("craniocerebral trauma/diagnosis"[MaJR] OR "spinal injuries/diagnosis*"[MaJR) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT (imaging OR radiography OR "eye"[MeSH] OR dental)

nov/05

Embase infant'/exp AND ('head injury'/exp OR 'spine injury'/exp) AND 'diagnosis'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT ('imaging'/exp OR 'radiography'/exp OR 'eye'/exp OR 'dental') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=infant AND TS=(head injury OR spinal injury) AND TS=(assessment) AND TS=(first aid OR prehospital OR out of hospital) NOT TS=(imag* OR radiograph* OR rehab* OR treatment)

7b(child Individual studies

No limits

Pubmed "Child"[MeSH] AND ("craniocerebral trauma/diagnosis"[MaJR] OR "spinal injuries/diagnosis*"[MaJR) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT (imaging OR radiography OR "eye"[MeSH] OR dental)

nov/05

Embase child'/exp AND ('head injury'/exp OR 'spine injury'/exp) AND 'diagnosis'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT ('imaging'/exp OR 'radiography'/exp OR 'eye'/exp OR 'dental') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=child AND TS=(head injury OR spinal injury) AND TS=(assessment) AND TS=(first aid OR prehospital OR out of hospital) NOT TS=(imag* OR radiograph* OR rehab* OR

144

treatment)

7c(adults Individual studies

No limits

Pubmed "Adult"[MeSH] AND ("craniocerebral trauma/diagnosis"[MaJR] OR "spinal injuries/diagnosis*"[MaJR) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT (imaging OR radiography OR "eye"[MeSH] OR dental)

nov/05

Embase adult'/exp AND ('head injury'/exp OR 'spine injury'/exp) AND 'diagnosis'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT ('imaging'/exp OR 'radiography'/exp OR 'eye'/exp OR 'dental') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=adult AND TS=(head injury OR spinal injury) AND TS=(assessment) AND TS=(first aid OR prehospital OR out of hospital) NOT TS=(imag* OR radiograph* OR rehab* OR treatment)

145

Key question

8. “What is the safety, efficacy and feasibility of immobilization, done by a lay person, in the first aid management of suspected spinal trauma?”

Search strategy

N° Type Limits Databases Search terms Date of search

8. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

spinal injury, immobilization sep/05

Individual studies

No limits

Pubmed “spinal injuries”[MeSH] AND “immobilization”[MeSH] AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase 'spine injury'/exp AND 'immobilization'/exp AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=spinal injury AND TS=immobilization AND TS=(first aid OR prehospital OR out of hospital)

146

Key question

9. “What is the safest, most efficacious and feasible first aid management, done by a lay person, for a traumatised extremity with angulation, without angulation, with an open fracture ?”

Search strategy

N° Type Limits Databases Search terms Date of search

9a. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

limb injur* OR limb trauma OR limb fracture* OR luxat* OR dislocat*

dec/05

Individual studies

No limits

Pubmed (limb OR extremit*) AND (injur* OR trauma*) AND (angula* OR displace* OR "abnormal position" OR dislocat*) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT ("Fractures, Open"[MeSH] OR spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operative OR medication OR drug* OR arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease*)

Embase (limb OR extremit*) AND (injur* OR trauma*) AND (angula* OR displace* OR abnormal position OR dislocat*) AND ('First Aid' OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT ('open fracture'/exp OR spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR 'x ray*' OR operative OR medication OR drug* OR arthroplast* OR osteoporos* OR 'bone density' OR prosthes* OR musculoskeletal disease*) AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(limb OR extremit*) AND TS=(injur* OR trauma*) AND TS=(angula* OR displace* OR abnormal position OR dislocat*) AND TS=(First Aid OR Emergency Medical Services OR prehospital OR out of hospital) NOT TS=(open fractures OR spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operative OR medication OR drug* OR

147

arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease*)

9b. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

limb injur* OR limb trauma OR limb fracture* OR luxat* OR dislocat*

dec/05

Individual studies

No limits

Pubmed (limb OR extremit*) AND (injur* OR trauma*) NOT (angula* OR displace* OR abnormal position OR dislocat* OR "Fractures, Open"[MeSH]) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT (spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operat* OR medication OR drug* OR arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease*)

Embase (limb OR extremit*) AND (injur* OR trauma*) NOT (angula* OR displace* OR abnormal position OR dislocat* OR 'open fracture'/exp) AND ('First Aid' OR 'emergency health service'/exp OR prehospital OR 'out of hospital') NOT (spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR 'x ray*' OR operat* OR medication OR drug* OR arthroplast* OR osteoporos* OR 'bone density' OR prosthes* OR 'musculoskeletal disease*') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(limb OR extremit*) AND TS=(injur* OR trauma*) NOT TS=(angula* OR displace* OR abnormal position OR dislocat* OR open fracture) AND TS=(first aid OR Emergency Medical Services OR prehospital OR out of hospital) NOT TS=(spin* OR crani* OR abdom* OR chest OR lung OR head OR burn* OR amputat* OR penetrat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operat* OR surg* OR medication OR drug* OR arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease* OR brain OR stroke OR hemi* OR economic OR prevent*)

148

9c. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

open fracture* dec/05

Individual studies

No limits

Pubmed (limb OR extremit* ) AND (injur* OR trauma*) AND "Fractures, Open"[MeSH] AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT (spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operative OR medication OR drug* OR arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease*)

Embase (limb OR extremit* ) AND (injur* OR trauma*) AND 'open fracture'/exp AND ('First Aid' OR 'emergency health service'/exp OR prehospital OR 'out of hospital') NOT (spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR bite* OR hypotherm* OR imaging OR 'x ray' OR operative OR medication OR drug* OR arthroplast* OR osteoporos* OR 'bone density' OR prosthes* OR 'musculoskeletal disease*') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(limb OR extremit* ) AND TS=(injur* OR trauma*) AND TS= open fractures AND TS=(First Aid OR Emergency Medical Services OR prehospital OR out of hospital) NOT TS=(spinal OR crani* OR abdom* OR chest OR head OR burn* OR amputat* OR bite* OR hypotherm* OR imaging OR x-ray* OR operative OR medication OR drug* OR arthroplast* OR osteoporos* OR bone density OR prosthes* OR musculoskeletal disease*)

149

Key question

10. “What is the safety, efficacy and feasibility of the ICE-principle, done by a lay person, in the first aid management of an minor injured extremity joint?”

Search strategy

N° Type Limits Databases Search terms Date of search

10. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

sprains, strains, joint injury, athletic injury sep/05

Individual studies

2005 Pubmed ("Sprains and strains"[MeSH] OR "Athletic injuries"[MeSH] OR "Joints/injuries"[MeSH]) AND ("cryotherapy"[MeSH] OR "ice"[MeSH] OR "immobilization"[MeSH] OR compression OR elevation)AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital" OR acute)

sep/05

Embase ('sprain'/exp OR 'sport injury'/exp OR 'joint injury'/exp) AND ('cryotherapy'/exp OR 'ice'/exp OR 'immobilization'/exp OR 'compression'/exp OR elevation) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital' OR 'acute') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(sprain* OR joint injury OR athletic injury) AND TS=(cryotherapy OR ice OR immobilization OR compression OR elevation) AND TS=(first aid OR prehospital OR out of hospital)

150

Key question

11. “What is the safest, most efficacious and feasible first aid management, done by a lay person, for thermal cutaneous burn?”

Search strategy

N° Type Limits Databases Search terms Date of search

11. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

burns july 2005

Individual studies

2004-2005

Pubmed ("Burns/therapy"[MeSH] NOT ("Burns, Inhalation"[MeSH] OR "Burns, Chemical"[MeSH])) AND (cool* OR "Irrigation"[MeSH]) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase ('burn'/exp) NOT ('chemical burn'/exp OR 'lung burn'/exp) AND (cool* OR 'lavage'/exp) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=burns AND TS=(first aid OR prehospital OR out of hospital) AND TS=(cool* OR lavage OR irrigation) NOT TS=(chemical OR inhalation)

151

Key question

12. “What is the safest, most efficacious and feasible first aid, done by a lay person, for the management of a chemical cutaneous burn?”

Search strategy

N° Type Limits Databases Search terms Date of search

12. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

burns july 2005

Individual studies

2004-2005

Pubmed “Burns, Chemical”[MeSH] AND (cool* OR "Irrigation"[MeSH]) AND (“First Aid” OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

sep/05

Embase chemical burn'/exp AND (cool* OR 'lavage'/exp) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=chemical burns AND TS=(first aid OR prehospital OR out of hospital) AND TS=(cool* OR lavage OR irrigation)

152

Key question

13. “What is the safest, most efficacious and feasible first aid, done by a lay person, for the management of non-penetrating wounds?”

Search strategy

N° Type Limits Databases Search terms Date of search

13. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

wounds, skin, irrigation aug/05

Individual studies

2005 Pubmed Wounds and Injuries/therapy[MeSH] AND skin AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR "out of hospital") NOT "Burns"[MeSH]

sep/05

Embase ('laceration'/exp OR 'skin abrasion'/exp OR 'skin bruising'/exp OR 'bite wound'/exp OR 'knife cut'/exp) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT 'burn'/exp AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(wound* OR laceration* OR abrasion* OR cut) AND TS=skin AND TS=(first aid OR prehospital OR out of hospital) NOT TS=(burn* OR fracture* OR surg* OR long term OR chronic* OR ulc* OR necro* OR graft* OR nosocomial)

153

Key question

14. “What is the safest, most efficacious and feasible first aid, done by a lay person, for the management of penetrating wounds?”

Search strategy

N° Type Limits Databases Search terms Date of search

14. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

wounds, stab, penetrating aug/05

Individual studies

No limits

Pubmed Wounds, Stab[MeSH] AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital") NOT "Needlestick Injuries"[MeSH]

sep/05

Embase ('stab wound'/exp OR 'penetrating trauma'/exp) AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') NOT 'needlestick injury'/exp AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(penetrating wound* OR stab wound*) AND TS=(first aid OR prehospital OR out of hospital) NOT TS=(laparoscop* OR incidence OR trend*)

154

Key question

15.“What is the safety, efficacy and feasibility of administration of charcoal, ipecac syrup, water or milk or doing nothing in the first aid managament of oral poisoning by a lay person?”

Search strategy

N° Type Limits Databases Search terms Date of search

15. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

poisoning, charcoal, ipecac, dilution july 2005

Individual studies

2004-2005

Pubmed Poisoning[MeSH] AND ("charcoal"[MeSH] OR "ipecac"[MeSH] OR dilut*) AND ("First Aid" OR "Emergency Medical Services"[MeSH] OR prehospital OR "out of hospital")

Embase 'intoxication'/exp AND ('charcoal'/exp OR 'ipecac'/exp OR 'dilution with water' OR 'dilution with milk') AND ('first aid'/exp OR 'emergency health service'/exp OR 'prehospital' OR 'out of hospital') AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(poisoning OR intoxication) AND TS=(charcoal OR ipecac OR dilution) AND TS=(first aid OR prehospital OR out of hospital)

155

Key question

16. “What is the safety, efficacy and feasibility of psychosocial support in the first aid management in the peritraumatic phase by a lay person for postrauma psychopathology after single individual accidents ?”

Search strategy

N° Type Limits Databases Search terms Date of search

16. Guidelines + SR

1995-2005

Cochrane database, Guidelines International Network database (GIN), Health Evidence Network (WHO), National Guideline Clearinghouse (NGC), National Electronic Library for Health Guidelines finder (NHS), Pubmed, Worksheets of the ILCOR process

psychological first aid, psychosocial first aid, psychological care, debrief, early intervention

july 2005

Specific sources : http://www.nimh.nih.gov/publicat/massviolence.pdf Individual

studies 2005 Pubmed ("Life Change Events"[MeSH] OR "Stress Disorders,

Traumatic"[MeSH] OR "Stress Disorders, Post-Traumatic"[MeSH] OR "Stress Disorders, Traumatic, Acute"[MeSH] OR "Adjustment Disorders"[MeSH]) AND ("First aid"[MeSH] OR "Crisis intervention"[MeSH] OR "psychological first aid" OR "psychosocial first aid" OR "early intervention*" OR debrief*)

july 2005

Embase (('first aid'/exp AND [embase]/lim) OR ('psychosocial care'/exp AND [embase]/lim) OR ('crisis intervention'/exp OR 'early intervention' OR debrief* OR 'psychological first aid' OR 'psychosocial first aid' AND [embase]/lim)) AND (('life event'/exp AND [embase]/lim) OR ('acute stress disorder'/exp AND [embase]/lim) OR ('posttraumatic stress disorder'/exp AND [embase]/lim) OR ('adjustment disorder'/exp AND [embase]/lim)) AND [embase]/lim

Social Science Citation Index, Science Citation Index Expanded

TS=(Life Change Event* OR Stress Disorder* OR Adjustment Disorder* OR critical incident*) AND TS=(First aid OR Crisis intervention OR psychological first aid OR psychosocial first aid OR psychological care OR early intervention* OR debrief*)

156

Appendix

RCT: Questionnaires

157

Vragenlijst naar persoonlijke gegevens

Belangrijke informatie vooraf:Voor de kwaliteit van het onderzoek is het van belang dat je alle vragen beantwoordt.

Naam: ................................................................................................

Ben je: Man

Vrouw

Wat is je geboortedatum? / /

Welke nationaliteit heb je? Belg

Andere

Wat is je hoogst behaalde diploma of getuigschrift? geen of lager onderwijs

lager secundair onderwijs (minimum 3 jaar)

hoger secundair onderwijs (minimum 6 jaar)

hoger onderwijs korte type (2-3 jaar)

hoger onderwijs lange type of universiteit

Welk beroep heb je? arbeider

bediende

leidinggevende

zelfstandige

vrij beroep (dokter, advocaat, ...)

werkloos

student

arbeidsongeschikt

gepensioneerde

huisvrouw

Wat is je burgerlijke staat? alleenstaand (geen partner)

getrouwd of geregistreerd partnerschap

samenwonend

gescheiden

weduwe

Ben je ooit al rodekruisvrijwilliger geweest? ja

neen

Heb je ooit al ergens eerstehulptraining gevolgd? ja

neen

Heb je ooit al een levensbedreigende situatie meegemaakt? ja

neen

61109

158

159

160

161

Vragenlijst naar zelf-effectiviteitsverwachting

Naam: ................................................................................................

Deze vragenlijst vraagt hoeveel vertrouwen je er in hebt dat je deze acties zal uitvoeren, indien je aanwezig bent in een noodsituatie met eenvoor jou onbekend slachtoffer. Deze vragenlijst vraagt niet of je deze dingen wel of niet gedaan hebt. Om je antwoord aan te geven moet je ééngetal omcirkelen op de schaal bij elke vraag: 1 betekent 'geheel geen vertrouwen en 5 betekent 'volledig vertrouwen'.

1. Ik zal eerste hulp geven zelfs als er andere omstaandersaanwezig zijn die het slachtoffer kunnen helpen.

2. Ik zal eerste hulp geven zelfs als het slachtoffer ernstig bloedt.

1 2 3 4 5

1 2 3 4 5

geheel geenvertrouwen

volledigvertrouwen

3. Ik zal eerste hulp geven zelfs als ik hartmassages moet geven.

4. Ik zal eerste hulp geven zelfs als ik mond-op-mond beademingmoet geven.

5. Ik zal eerste hulp geven zelfs als het slachtoffer mogelijks eenwervelletsel heeft.

6. Ik zal hulp zoeken zelfs als het slachtoffer zegt dat dit niet nodig is.

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

21133

162

Vragenlijst naar tevredenheid over extra les

Naam: ................................................................................................

Deze vragenlijst peilt je tevredenheid over de extra les. Deze vragenlijst vraagt niet wat je vond van de voorgaande lessen eerste hulp

Om je antwoord aan te geven moet je één getal omcirkelen op de schaal bij elke stelling: 1 betekent 'helemaal juist”, 2 betekent ‘juist’, 3 betekent ‘verkeerd’ en 4 betekent 'helemaal verkeerd'. Ook als het moeilijk is om voor één bepaald vakje te kiezen, willen we je toch vragen om je mening te geven.

Helemaal juist Juist Verkeerd Helemaal verkeerd

1. De dingen die in deze les gezien zijn waren nieuw voor mij 1 2 3 4

2. Ik heb goed begrepen wat mij in de les werd aangeleerd 1 2 3 4

3. De les was duidelijke en overzichtelijk opgebouwd 1 2 3 4

4. Wat ik in de les geleerd heb kan ik nu in de praktijk toepassen 1 2 3 4

5. De les werd op een boeiende en levendige manier gegeven 1 2 3 4

6. De sfeer onder de deelnemers was vriendschappelijk 1 2 3 4

7. Voor mij was deze les echt de moeite waard 1 2 3 4

We willen je ook vragen om op de volgende “open vragen” te antwoorden. Met jouw antwoorden zal zeker rekening gehouden worden als deze les een volgende keer georganiseerd wordt.

8.Wat vind je de sterke punten van deze les? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9.Welke punten zijn volgens jou voor verbetering vatbaar ? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

163

164

.~ 24971

Vragenlijst over stemming

Naam: ............... .................................. , .... .......... ... , ..................... .

Deze vragen gaan over hoe u z;,:h voett nadat we je verteld hebben over de misleid ing. Per vraag staal een antwoord dal emoties of gevoelen! i)nchrijtt . lees "Ik" vraag en gebruik bij de beantwoordiJlg volgende schaal'

1 - helemaal niet 2 • e(!n beetje 3· enigszins 4 · nogal 5 m!leel erg

Beantwoord elke vraag door het best pas,,,,,,,,, cijfer 111 omcir1<elen.

helemaal niet

Hoe nerveus voel ja jeze~ op d~ mQlTl.mt? 1

Hoe enthous iast v~ je jezeW op d~ moment? 1

Hoe verward voel Je jezelf op dit moment? 1

Hoe ster\< voel je jezeH op dit moment? 1

Hoe b<:schaamd voel je jezeN op d~ momen1? 1

Hoe vastberaden voetje jezelf op dit rnGlTlen1? 1

Hoe angstig voel je jezelf op dit moment? 1

Hoe trols voel je jezeH op dit moment? 1

Hoe kwud ~ Je jezeH op dit moment? 1

HQe gelnspl ..... rd voel je jezelf op d~ moment? 1

een bee~ .. enigszins nogal heftl erg

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

2 3 , 5

•

• • 165

166

Appendix

RCT: Didactical plan experimental and control

intervention

167

Lesson preparation extra 2 hours Helping Kim Swyngedouw11/03/2009__________________________________________________________________________

Content

In this extra 2 hours you will learn all about what Red Cross calls ‘helping behaviour’. In the first ...

hours of the course you learned all about how to provide first aid and the important steps involved

in first aid provision. In this part we will look more closely at the barriers that might prevent you

from administering aid, despite all the knowledge and skills that you have.

Objectives� To make course participants aware of the importance of administering first aid

� To let course participants know what it’s like to be a casualty

� To make course participants aware of the existence of different barriers

� To make course participants aware of the relativity of these barriers

� To teach course participants how to deal with barriers so as to be able to demonstrate

helping behaviour

Planning and method

Time allocation

10’ Probability of an emergency situation

15’ Positive and negative experiences of helping

35’ How does it feel to be a casualty

15’ My role as a first aider

45’ The various barriers to helping behaviour

168

Lesson preparation

Probability of an emergency situation

A group discussion will reveal whether there are any course participants who have already witnessed

an accident or a situation in which first aid could have been administered. This can be a life-

threatening as well as a non life-threatening situation (child falls off bike in town, grandpa gets pain

in chest, etc.).

In connection with that a number of questions will be asked:

� Did they take action (e.g. call emergency services, help child with bike to get of road, etc.)?

� How did they feel about it

� How long was it before the emergency services arrived (if nobody called emergency services

you can let them make an estimated guess)

Positive and negative experiences of helping

The course participants are given a case study (see below) and are asked what constitutes an

appropriate or less appropriate reason for bystanders and first aid administrators to help or not. The

course participants should also explain their reasoning for this. Then they should think about

opportunities, steps, …needed to remove the reasons they gave for not helping. Examples are:

Helping Not helping

The casualty urgently needs help I don’t want to catch anything

You get a good feeling from helping others There are other people who can help

You feel guilty if you don’t help I don’t know how to give first aid

You might get a reward later What if this is a trap and they attack me

Everyone should help people in need It is late and dark

It is the right thing to do I have an important meeting to get to, so I haven't

got time

If you help that person, someone might help you

when you’re in need

Helping others creates a better society

Out of sympathy with the casualty

… …

Case study

169

There has been a serious car accident on the motorway. Peter lost control of his car because of a

flat tyre and he smashed into another car before coming to a stop against the central barrier.

Peter is completely distressed when he sees the other car lying upside down, but still goes over

to the casualty. Vera was driving in the first lane and saw what happened. Luckily she was able to

stop in time and walked with her colleague to the casualty. Carl, the driver of the smashed car, is

lying on the road. He is conscious but is bleeding seriously from his left wrist. The blood is pouring

out.

How does it feel to be a casualty

The course participants are divided into four groups and each receive the same case study. The idea

is that they look in detail at the case and then play out the next scene. This is first prepared in

writing: what help can be given, how to approach the casualty,…

Then the different groups act out their case study. One person is the casualty, 1 or 2 people play

the role of first aiders.

A group discussion takes place later in which the casualties reveal how they felt in their role. Which

thoughts, emotions, feelings did they experience. If other people in the group report different

feelings or emotions or thoughts, these are recorded too.

Case study

Andrew is going home on the metro after a hard day’s work. There are lots of people crammed into

the carriage and all the seats are taken. After a few minutes standing, Andrew becomes dizzy and

sees spots before his eyes. A few other commuters notice that Andrew is swaying.

My role as a first aider

The group is split into 3. Each group is given a case study. For this case study they have to imagine

that they witness the situation and ask themselves which first aid skills they would use in this

situation. They start out with the most minimal and most appropriate help. Then the different

groups discuss their plans in a meeting.

Case study

Sarah has overslept and is really late for her class. She cycles like a maniac in the pouring rain

through the morning rush hour. Because it is late and she is in a hurry, she’s not paying attention

to the obstacles on the road. Suddenly her back wheel gets stuck in the tram rails. She loses

control and crashes to the ground. She lies there a little stunned and soon notices that there is

blood trickling over the palm of her hand. You are a pedestrian and you saw what happened.

Case study

You are taking your weekly run in the park. On the way you come across a few boys who are

obviously drunk and who are arguing. Unprovoked, one of the boys is hit in the face. The blood

comes gushing out. Some of the boys run off, a few of them stand looking dazed next to the

casualty.

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Case study

You are in a checkout queue in a shop. The man in front of you suddenly starts acting strangely. He

is having difficulty breathing, pulls at his tie, …Suddenly he grabs his chest and collapses.

As a conclusion to this part the instructor explains how important it is that first aid isn’t just talk.

Because offering first aid in an emergency or in a situation where help is needed is not easy, we

have designed a format to help every course participant on their way. The instructor briefly outlines

this objectives page.

Different barriers concerning first aid

The course participants are split up into 4 groups and must first of all think about any possible

barriers to them giving first aid and how they could remove these barriers (e.g. remove fear of

infection by wearing gloves). Then they should choose two barriers to look at in more detail.

They prepare a role play in which they show the other group what their barrier is as well as the

solution they have found for it. This can be fun, serious, etc.

When the different groups have played out their barriers, the instructor uses the cartoons in the

brochure (better if they have not already been given this) to go through which barriers might occur

and how they can be removed (with legal stipulations, measures, education, ...).

Material

Work sheets with assignments and case studies

Projector

Brochures for this lesson

Flipchart/blackboard

Paper and pens

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Lesvoorbereiding extra 2 u Eerste hulp bij alcohol en drugsincidenten (in het kader van veldstudie eerste hulp)Leen Meeremans, Stijn Van de Velde20/10/2009__________________________________________________________________________

Inhoud

In deze extra 2 u leer je wat Rode Kruis-Vlaanderen eerste hulp bij alcohol en drugsincidenten

noemt. In de voorgaande 24u van de cursus leerde je alles over hoe je eerste hulp kan verlenen en

wat belangrijke stappen zijn binnen de eerstehulpverlening.

Ook al ben je in het bezit van een brede eerstehulpkennis, toch zijn er nog een aantal extraaandachtspunten bij de hulpverlening bij alcohol- en drugsincidenten. Bedoeling is om tijdens deze

les dieper in te gaan op deze aandachtspunten en je de eerstehulpverlening te leren in een aantal

specifieke situaties. Hierbij gaan we ook in op theoretische informatie over druggebruik en bij

welke instanties je meer informatie kan krijgen.

Doelstellingen� Cursisten informeren over druggebruik en mogelijke risico’s� Cursisten bewust maken van aandachtspunten bij hulpverlening bij alcohol- en

drugsincidenten

� Cursisten leren eerste hulp verlenen bij een overdosis, oververhitting, bad trip

� Cursisten informeren over instanties waar je extra informatie kan krijgen

Opzet en methodeTijdsindeling

5’ Introductie

10’ Wat zijn drugs en welke risico’s bestaan er ?

10’ Basisprincipes van eerste hulp

15’ Vier stappen in eerste hulp

20’ Overdosis

15’ Oververhitting

20’ Bad Trip

5’ Meer informatie en verdere hulp

20’ Herhalingsoefeningen

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Lesvoorbereiding

Introductie

Korte uitleg omtrent de opzet van deze les (zie ook inhoud).

Wat zijn drugs ?

Vraag- en antwoordgesprek:

- Vraag aan cursisten wat zij verstaan onder drugs en probeer tot een definitie te komen.

- Vraag aan cursisten om de drugs die zij kennen op te sommen en deel deze in categorieën in.

- Vraag aan cursisten welke acute risico’s druggebruik met zich mee kan brengen en lijst deze

op.

Geef op het einde van de bespreking telkens een samenvattend antwoord adhv de ppt-presentatie

Bij stimulerende middelen zoals speed, cocaïne, en XTC krijgt de gebruiker het gevoel eindeloos te

kunnen presteren of uitgaan, zonder te stoppen. Waarschuwingssignalen voor het lichaam zoals

honger en moeheid vallen weg. Daardoor kan totale uitputting ontstaan, een zogenaamde crash.

Toon het filmpje ter illustratie van een crash.

Basisprincipes

De cursisten krijgen opdracht 1 van het oefenboek voorgelegd.

Aansluitend worden de basisprincipes van eerste hulp herhaald. De bijzonderheden van eerste hulp in situaties met alcohol en drugs worden benadrukt.

Vier stappen

De cursisten krijgen opdracht 2 en 6 voorgelegd.

Per opdracht worden de 4 stappen herhaald en duiden ze de bijzonderheden van eerste hulp in

situaties met alcohol en drugs aan.

Vraag cursisten om de nummers op te sommen die belangrijk zijn voor alarmering bij alcohol- en

drugsincidenten.

Wijs cursisten op het belang van lichaamstemperatuur bij alcohol- en drugsincidenten. Vraag aan de

cursisten wat ze kunnen doen met een slachtoffer dat het te koud/warm heeft en vat samen.

Overdosis

De cursisten krijgen opdracht 7 voorgelegd.Overloop met de cursisten hoe ze een overdosis kunnen vaststellen en wat ze kunnen doen.

OververhittingOverloop met de cursisten hoe ze oververhitting kunnen vaststellen en wat ze kunnen doen.

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Toon het filmpje ter illustratie van stuipen.

Bad trip

De cursisten krijgen opdracht 8 voorgelegd.

Overloop met de cursisten hoe ze een bad trip kunnen vaststellen en wat ze kunnen doen.

Meer informatie en verdere hulp

Overloop met de cursisten de instanties waar je meer informatie kan verkrijgen over alcohol- en drugsproblemen.

Herhalingsoefeningen

De cursisten krijgen opdrachten 9,10,11,12 voorgelegd.

Materiaal

Ppt-presentatie

Oplossingen opdrachten

Projector

FilmpjesOefenboek bij deze les

Flip over/krijtbord

Papier en stiften

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