Towards anundergraduateresuscitation curriculum:the competenciesrequired of graduatingdoctorsPeter Barton and John McGowan, University of Glasgow, Southern General Hospital,Govan, UK

Acute care is not taught wellto undergraduates acrossthe UK,1 and national

standards of acute care have beenshown to be deficient.2 In 2005,following an internal review ofacute care skills provision for itsfinal-year students, the MedicalSchool of the University ofGlasgow decided that all students

graduating should possess aResuscitation Council ImmediateLife Support (ILS) certificate. Thiscompetence exceeds that cur-rently required by the GeneralMedical Council (GMC),3 whoexpect it to be attained byFoundation Year One doctorsduring their first postgraduateyear.

While the competencies of ILShave been defined clearly by theResuscitation Council,4 to ourknowledge there has not previ-ously been within the UK anyclear guidance about teachingthis topic. Our aim in producingthis draft curriculum is to stimu-late debate – in particular, butnot exclusively, within under-

Nationalstandards of

acute care havebeen shown to

be deficient

Practicalteaching

36 � Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 36–39

graduate medical education in theUK, and to promote the develop-ment of a national curriculum.

BACKGROUND

Teaching in resuscitation in par-ticular5,6 has traditionally beengiven little curricular space. Gra-ham and Scollon recognised in2002 that the Glasgow curriculumhad shown a sustained improve-ment in CPR training over theprevious 10 years,7 but it wasequally clear that this had not ledto improved overall confidence inusing these skills on qualification.Our internal review revealed avariety of resuscitation activitiesbut, consistent with a previousEuropean survey in 1999 by Gar-cia-Barbero and Caturla-Such,8

no coherent developmental plan.Published general descriptions ofcurricula9,10 do exist, but they donot contain detailed plans of thetopics to be covered. In theUnited States, the voluntaryAccreditation Council for Gradu-ate Medical Education (ACGME)programme has published theprinciples of general competen-cies required for residents, buthas not defined a specific corecurriculum.11

Resuscitation itself is nolonger merely about cardiopul-monary resuscitation (CPR).12

Recognition of serious illnessand injury related to trauma orsurgery are among the topicsembraced by resuscitation.A reasonable definition mightbe ‘dealing with the patient onthe edge of death’. The topicstaught in this 5-year programmeof resuscitation complement therecommendations from theACUTE initiative.13

Resuscitation training formspart of the curricular outcomes forboth the Scottish Doctor (2002)14

and Tomorrow’s Doctors (2003):‘Graduates must … Demonstratecompetence in cardiopulmonaryresuscitation and advanced life-support skills’.15

DEVELOPMENT

Our resuscitation curriculum wasguided by two key considerations:

1. In Glasgow’s spiral andexperiential problem-basedcurriculum (see Box 1), eachyear reinforces or buildson topics learnt in previousyears.

2. Assessment drives learningand so a demonstration ofcompetence at each stageshould be linked to studentprogress. Students in Years 1and 4 are assessed forma-tively, while students in Years

2, 3 and their final year areassessed summatively.

TEACHING METHODOLOGY

A four-stage approach to teachingpsychomotor skills is employed ateach teaching session.16 There isa brief introduction, includinghow the skill is to be taught,followed by:

Stage 1The skill is performed in realtime, with no commentarybeing made on it. This allowsstudents to see how the skillwould be performed by an‘expert’.

Stage 2The skill is performed moreslowly, and a commentary isadded, explaining what isbeing done; after this, ques-tions are allowed, as theindividual actions might nothave been clear to some stu-dents.

Stage 3Stage 2 is repeated, this timewith one of the students add-ing the commentary. However,the demonstration shouldshow how the skill should beperformed, regardless of thestudent’s comments.

Stage 4A student performs the skill,with a commentary added byhim/her or a fellow student.Expect the skill to be per-formed slowly, because, formany, this will be the firsttime they have done this.Once all the students havepractised, allow questions,give a brief summary, andclose.

This approach combines itera-tive, visual and narrative teachingstyles and is a remarkably effec-tive way of increasing psychomo-tor skills. By developing the skillstaught each year, it is hoped thatthe deficit between a student’sperception of his or her abilitiesand the actual abilities can bereduced.17

Resuscitationitself is nolonger merelyabout cardio-pulmonaryresuscitation

� Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 36–39 37

Thedemonstration

should showhow the skill

should beperformed

Box 1. Glasgow’s resuscitation curriculum

Curricular phase Learning outcomes

Year 11. Emergency life supportCurrent assessment:Formative Objective StructuredClinical Examination (OSCE)

Demonstrate a safe approach and a check of the casualty’s responsivenessDemonstrate head tilt, chin lift, mouth inspection and finger sweepsDemonstrate and describe assessment of breathing and signs of lifeDescribe activation of the emergency servicesDemonstrate initiating and continuing 30 chest compressions followed by2 breathsDemonstrate placing a colleague in a recovery positionDescribe methods of haemorrhage controlDemonstrate management of foreign-body airway obstruction in thenon-collapsed casualtyDescribe the management in the collapsed casualty

Year 21. Emergency life support2. Introduction to in-hospitalresuscitationCurrent assessment:Station in summative OSCE

Repeat Year 1 activitiesBe able to state the hospital’s emergency telephone numberDemonstrate the location of the carotid pulseDemonstrate simultaneous airway opening, breathing and pulse checkDemonstrate the assembly and use of a pocket mask on a manikinDemonstrate two-rescuer cardiopulmonary resuscitation

Year 31. Basic airway management2. Cardiac arrest3. Rhythm recognition4. DefibrillationCurrent assessment:Station in summative OSCE.Course regulations requirethis to be passed beforeprogressing to Year 4

Describe the signs of airway obstructionDemonstrate on a manikin head tilt, chin lift and jaw thrustDemonstrate on a manikin the use of suction and the application of a trauma maskState the indications for and contraindications of using nasal and oral pharyngealairwaysDemonstrate, on a manikin, the sizing and insertion of nasal and oral pharyngealairwaysDemonstrate, on a manikin, ventilation with a bag-valve-mask resuscitator, using atwo-person techniqueDescribe a sinus rhythm on a monitor using a five-point systemIdentify, on a monitor, ventricular fibrillation, ventricular tachycardia and asystoleDescribe the clinical features of pulseless electrical activityState that CPR should continue while they prepare to defibrillateDemonstrate switching on the defibrillator and attaching correctly appliedpatchesIdentify ventricular fibrillation on the monitor, state that this is a shockablerhythmGive a verbal warning, visually ensure that the area around the manikin is safe, anddeliver a shock of the correct energy to the manikinState that CPR should commence immediately for 2 minutes, indicate how theywould time this and demonstrate reassessment of the manikin after 2 minutes,or earlier if signs of life are seen

Year 4Initial assessment andresuscitationCurrent assessment:Formative resuscitation

On a manikin, the student should:Demonstrate the rapid assessment of a patient using the ABCDE systemDescribe the signs of airway obstruction and demonstrate how to clear thisDemonstrate palpation, percussion and auscultation, and state the importance ofrespiratory rate and use of pulse oximetryDemonstrate assessment of peripheral perfusion, pulse and capillary refill timeDemonstrate the application of blood pressure cuff and ECG monitoring electrodesDemonstrate a mini neurological assessment using AVPU scale, limb movement,pupil size and reaction to lightDemonstrate exposure of the manikin for examination, maintaining dignity andpreventing heat loss

Year 5Immediate life supportCurrent assessment:ILS certification is astand-alone

competence and must beachieved prior to graduation

To train health care personnel in the causes and prevention of cardiopulmonaryarrest, the ABCDE approach, initial resuscitation and defibrillation (manual and/orautomated external defibrillator (AED)) and simple airway managementTo train health care personnel to manage patients in cardiopulmonary arrest untilarrival of the resuscitation teamTo train health care personnel to participate as members of the resuscitation team

This approachcombines

iterative, visualand narrative

teaching styles

38 � Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 36–39

IMPLEMENTATION

This model of resuscitationtraining takes place in all years.Heart Start Initiative medicalstudents (from Years 4 and 5)teach Year 1, and the other yearsare taught by staff members. InYear 2, we use vocational studiestutors, and in Years 3, 4 and 5,resuscitation officers (ROs) andmedical staff from local NHShospitals.

CONCLUSION

Very few careers place such highexpectations on new graduates asdoes medicine. In the first fewweeks of their first job, manynewly-qualified doctors will initi-ate resuscitation of seriously ill orarrested patients. Patients andtheir families trust that these newdoctors will be able to providethese life-saving treatmentscompetently.

In completing this curriculum,these new doctors will have beencarrying out CPR for five years,using emergency airway manage-ment and defibrillators for threeyears, and using a structuredassessment and treatment ofseriously ill patients for two years.We believe that these skills should

better equip them for the chal-lenges they will face.

We have presented our work-ing resuscitation curriculum andreadily acknowledge that it is a‘work in progress’. The Resuscita-tion Council (UK) guidelines willbe revised in 2010, and thiscurriculum will be reviewed atthat time. We would welcomeconstructive comments at anytime from others engaged in thisfield regarding the design of ourcourse and the desirability of amore explicit standard of resusci-tation competence to be achievedby medical students beforeentering the workplace.

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