PURPOSE: To identify factors associated with candidate outcome in the European Resuscitation Council (ERC) advanced life support (ALS) provider courses.

METHODS: Medical doctors participating as candidates to consecutive ALS courses organised by an ERC training centre in Italy were enrolled in this prospective cohort study. The association between the ALS course outcome and candidate demographics, professional background and pre-course knowledge measured by using the pre-course multiple choice quiz (MCQ) was investigated by using logistic regression.

RESULTS: A total of 283 candidates, median age 31 years, were evaluated. Among them, 269 (95.1%) passed the final evaluation and 14 (4.9%) failed. Candidates who passed were younger (median age 31 vs. 37.5 years; p = 0.006) and attained a higher pre-course MCQ score (median 84 vs. 72.5%; p < 0.0001). On multivariate analysis, a higher pre-course MCQ score (OR 1.18 [95%CI 1.09-1.28]) and a basic life support (BLS) certification (OR 5.00 [95%CI 1.12-22.42]) were independent predictors of candidate success, while older age was associated with a significantly higher risk of failing (OR 0.90 [95%CI 0.83-0.97]). Female candidates had higher pass rates (97.2 vs. 91.2%; p = 0.048); however, after correction for confounders gender was not significantly associated with candidate outcome. Neither candidate specialty nor site of work was a predictor of candidate success.

CONCLUSIONS: On ALS courses, younger age and a higher level of specific pre-course knowledge, as measured by both the pre-course MCQ and the presence of BLS certification, are the most important predictors of success. Candidate gender and professional background did not show a significant correlation with course outcom

Chiara de Waure

CL Grady

Claudio Sandroni

F Napier

F Semeraro

Fabio Cavallaro

GD Perkins

Gian Luigi Gonnella

Giuseppe La Torre

J Nolan

M Knowles

Massimo Antonelli

S Jones

The CoBaTriCE Collaboration

English

PubMed

Springer - Publisher Connector

Claudio Sandroni
Gian Luigi Gonnella
Chiara de Waure
Fabio Cavallaro
Giuseppe La Torre
Massimo Antonelli
Which factors predict candidate outcome
in advanced life support courses?
A preliminary observational study
Received: 21 October 2009
Accepted: 30 March 2010
Published online: 18 June 2010
 The Author(s) 2010. This article is
published with open access at
Springerlink.com
The study was performed at the Catholic
University School of Medicine, Rome, Italy.
C. Sandroni ())  G. L. Gonnella 
F. Cavallaro  M. Antonelli
Department of Anaesthesiology
and Intensive Care, Catholic University
School of Medicine, Largo A. Gemelli 8,
00168 Rome, Italy
e-mail: sandroni@rm.unicatt.it
Tel.: ?39-06-30154490
Fax: ?39-06-3013450
C. de Waure
Institute of Hygiene, Catholic University
School of Medicine, Largo F. Vito 1,
00168 Rome, Italy
G. L. Torre
Clinical Medicine and Public Health Unit,
Sapienza University of Rome,
Viale Regina Elena 324,
00161 Rome, Italy
Abstract Purpose: To identify
factors associated with candidate
outcome in the European Resuscita-
tion Council (ERC) advanced life
support (ALS) provider courses.
Methods: Medical doctors partici-
pating as candidates to consecutive
ALS courses organised by an ERC
training centre in Italy were enrolled
in this prospective cohort study. The
association between the ALS course
outcome and candidate demograph-
ics, professional background and pre-
course knowledge measured by using
the pre-course multiple choice quiz
(MCQ) was investigated by using
logistic regression. Results: A total
of 283 candidates, median age
31 years, were evaluated. Among
them, 269 (95.1%) passed the final
evaluation and 14 (4.9%) failed.
Candidates who passed were younger
(median age 31 vs. 37.5 years;
p = 0.006) and attained a higher pre-
course MCQ score (median 84 vs.
72.5%; p \ 0.0001). On multivariate
analysis, a higher pre-course MCQ
score (OR 1.18 [95%CI 1.09–1.28])
and a basic life support (BLS)
certification (OR 5.00 [95%CI 1.12–
22.42]) were independent predictors
of candidate success, while older age
was associated with a significantly
higher risk of failing (OR 0.90
[95%CI 0.83–0.97]). Female candi-
dates had higher pass rates (97.2 vs.
91.2%; p = 0.048); however, after
correction for confounders gender
was not significantly associated with
candidate outcome. Neither candidate
specialty nor site of work was a pre-
dictor of candidate success.
Conclusions: On ALS courses,
younger age and a higher level of
specific pre-course knowledge, as
measured by both the pre-course
MCQ and the presence of BLS certi-
fication, are the most important
predictors of success. Candidate
gender and professional background
did not show a significant correlation
with course outcome.
Keywords Advanced life support
(ALS)  Assessment 
Cardiopulmonary resuscitation 
Education  Training  Outcome
Introduction
In most European countries, the European Resuscitation
Council (ERC) advanced life support (ALS) provider
course is recognised as the gold standard to prepare
members of multidisciplinary teams to manage both car-
diac arrest and peri-arrest situations [1, 2]. Resuscitation
and initial management of the acutely ill patient are
among the twelve domains of the core competencies
required of a specialist in intensive care medicine [3].
Unfortunately, some ALS candidates fail to achieve
their ALS certification. Failure rates in the cardiac arrest
scenario test (CASTest) at the end of the ALS course may
be as high as 60% [4]. Until now, no specific investigation
Intensive Care Med (2010) 36:1521–1525
DOI 10.1007/s00134-010-1926-1 ORIGINAL
has been conducted to identify factors associated with
ALS course outcome. Knowing in advance those factors
would be useful for two reasons:
1. At the beginning of an ALS course, it would allow the
course faculty to identify early on those candidates
who are at risk of failure and who need additional
support;
2. As a general policy, it would help in targeting the ALS
course to the most appropriate candidates, i.e. those
professional figures who are most likely to benefit
from ALS training.
The aim of this study was to investigate whether
pre-course factors, such as candidate age and gender,
professional background and pre-course knowledge, can
predict the outcome of the ALS course.
Materials and methods
This was a prospective, single-centre cohort study.
Candidates and data collection
All medical doctors participating in the ALS provider
courses organised by the Catholic University School of
Medicine (UCSC) Training Centre in Rome between 1
November 2006 and 30 June 2009 who did not have a
previous ALS certification were included in the study.
The UCSC Training Centre operates within the ALS
national training network of the Italian Resuscitation
Council (IRC), an ERC approved school.
Candidates gave their consent for anonymous use of
both their demographic information and course results for
scientific investigational purposes on applying for the
ALS course via the UCSC course management website
(www.corsi-rianimazione.it). The study was approved by
the ethics committee of the UCSC (protocol number A598).
The ERC ALS provider course
The ALS provider course has been described elsewhere
[1]. It is a residential teaching and training course
designed for healthcare professionals and focused on
prevention of cardiac arrest, management of cardiac arrest
and peri-arrest situations and stabilisation of the resusci-
tated patient until transfer to a critical care area.
Before the ALS course, a 120-item multiple choice
quiz (MCQ) is usually sent to the candidates along
with the manual to allow self-assessment of candidates’
pre-course knowledge. For the purpose of this study—in
order both to standardise testing and to avoid reference
to the manual—the pre-course MCQ was given on
candidates’ arrival at the training centre and invigilated.
A maximum of 60 min was allowed to complete the test.
During the first day of the course, candidates are
assessed on airway management and initial assessment
and resuscitation (IAR) and must demonstrate compe-
tence on both these skills before the final assessment in
order to achieve their ALS certification.
Final assessment of the ERC ALS course includes
both a 120-item final MCQ and a cardiac arrest simulation
test (CASTest). The final MCQ must be completed in
60 min and it has a pass mark of 75%. During CASTest,
candidates are assessed on their ability to manage a
simulated cardiac arrest scenario as team leaders. Can-
didates who fail either the final MCQ or the CASTest are
entitled to a second attempt (retest) and, if still unsuc-
cessful, are failed. Those who are successful in both the
final MCQ and the CASTest (either at first or at second
attempt) are certified as ALS providers.
Statistical analysis
The following variables were considered as possible
predictors of the course outcome: age; gender; specialty;
site of work; previous certification in basic life support
(BLS) courses for healthcare providers; and pre-course
MCQ score. Univariate analysis was carried out to
investigate predictors of course outcomes. Medical spe-
cialties that were more pertinent to the subject of the ALS
course, such as anaesthesiology, cardiology and emer-
gency medicine, were compared with all the other ones.
Chi square or Fisher’s exact test and Mann–Whitney tests
were applied for categorical and continuous data,
respectively. Statistical significance was set at p \ 0.05.
Stepwise multivariate logistic regression was per-
formed by entering into the model all the variables whose
p value was less than 0.25 in the univariate analysis. The
model goodness of fit was assessed with the Hosmer–
Lemeshow test. Statistical analysis was carried out using
SPSS, release 12.0 for Windows.
Results
A total of 290 medical doctors participating in 13 con-
secutive ALS courses were considered for inclusion in the
study. Four of them were excluded due to a previous ALS
certification. Three candidates dropped out of the ALS
course before completion for personal reasons and were
also excluded.
The remaining 283 candidates (median age 31 years;
64.0% females) were included in the study. All candidates
in our population demonstrated sufficient competence on
both airway management and IAR by the end of the first
1522
day. As regards final evaluation, 269 (95.1%) candidates
passed and 14 (4.9%) failed. Ten of these 14 candidates
attained a sufficient score on the final MCQ but failed the
CASTest, while four failed both the CASTest and the MCQ.
Candidates’ characteristics are summarised in Table 1.
In comparison with those who failed, candidates who
passed were significantly younger (31 vs. 37.5 years;
p = 0.006; Table 2), and attained a significantly higher
median score at the pre-course MCQ (84 vs. 72.5%;
p \ 0.0001). On multivariate analysis (Table 3), a higher
pre-course MCQ score and a BLS certification were
associated with significantly higher probabilities of
passing the final test (OR 1.18 [95%CI 1.09–1.28] and OR
5.00 [95%CI 1.12–22.42] respectively), while older can-
didates had significantly lower probabilities of passing
(OR 0.90 [95%CI 0.83–0.97]). Women had a significantly
higher pass rate (97.2 vs. 91.2%; p = 0.048) but on
multivariate analysis gender was not an independent
predictor of outcome.
Discussion
Candidate age, BLS certification and pre-course knowl-
edge, as measured by the pre-course MCQ, were the most
important predictors of ALS course outcome in our
population.
Increasing age was associated with a lower proba-
bility of passing the final evaluation. Probably, in older
candidates a higher decay of their knowledge about
emergency medicine may have occurred, due to the
longer time passed between their degree and the ALS
course. Another cause could have been an age-related
decay in learning capability. It has been estimated that
learning capability declines by a 1% per year in adults
from 22 to 50 years of age [5]. Age-related losses are
substantial in ‘working memory’ tasks, which usually
require the maintenance of some information while
dealing concurrently with further incoming stimuli—as
occurs during an ALS scenario [6, 7]. Furthermore, it is
also possible that older candidates may have not been
familiar or comfortable with the scenario-based/
role play-type teaching as it is a relatively new
methodology.
High scores on the pre-course MCQ and a BLS cer-
tification were independent predictors of course pass in
our study. We think that previous BLS training may have
Table 1 Characteristics of the study subjects
Number of subjects 283
Median age, years (range) 31 (25–57)
Females 181 (64.0)
Specialist 173 (61.2)
Resident 110 (38.8)
Specialty
Anaesthesiology 77 (27.2)
Internal medicine 41 (14.5)
Cardiology 32 (11.3)
Infectious diseases 20 (7.1)
Surgery 12 (4.2)
Respiratory medicine 12 (4.2)
Emergency medicine 10 (3.5)
Geriatric medicine 9 (3.2)
Other 70 (24.7)
BLS certification
BLS provider 134 (47.9)
BLS instructor 13 (4.6)
Site of work
Ward 128 (45.2)
Operating room 58 (20.2)
ICU 29 (10.6)
Clinic 38 (13.4)
ED 21 (7.4)
Ambulance 9 (3.2)
Course outcome
Passed 269 (95.1)
Failed 14 (4.9)
Values are numbers (percentages) unless otherwise stated
ICU intensive care unit, ED emergency department
Table 2 Results of univariate analysis comparing passed and failed
candidates
Passed
(n = 269)
Failed
(n = 14)
p Value
Median age, year (range) 31 (25–57) 37.5 (27–54) 0.006
Gender
Male 93 (91.2) 9 (8.8) 0.048
Female 176 (97.2) 5 (2.8)
Medical specialties
Anaesthesiology, cardiology
or emergency medicine
114 (95.8) 5 (4.2) 0.78
All other specialties 155 (94.5) 9 (5.5)
Site of work
Ward/clinic 155 (93.4) 11 (6.6) 0.27
Operating room 57 (98.3) 1 (1.7)
ICU/ED/ambulance 57 (96.6) 2 (3.4)
BLS certification
Yes 147 (97.4) 4 (2.6) 0.1
No 122 (92.4) 10 (7.6)
Median score at the
pre-course MCQ, % (range)
84 (54–100) 72.5 (37–89) \0.0001
Values are numbers (percentages) unless otherwise stated
Table 3 Predictors of course pass according to multivariate
logistic regression
Variable Odds ratio (95% CI) p Value
Pre-course MCQ score (%) 1.18 (1.09–1.28) 0.0001
BLS certification 5.00 (1.12–22.42) 0.03
Age (years) 0.90 (0.83–0.97) 0.008
Hosmer–Lemeshow goodness-of-fit = 0.456
1523
influenced the ALS course outcome in two ways: first by
teaching candidates a correct approach to cardiovascular
emergencies; secondly because it may have increased
candidates’ confidence with scenario teaching and
assessment. Although BLS certification is currently not
required for access to ERC ALS courses, results of our
study suggest that proficiency in BLS should be recom-
mended to ALS course participants.
We administered the pre-course MCQ on arrival in
standardised and invigilated conditions, which is not rou-
tine practice of the ALS course. This, however, was
necessary to ensure that pre-course MCQ results would
reliably reflect the candidates’ pre-course knowledge.
Results of our study, if confirmed, would suggest that the
pre-course MCQ may be used at the beginning of the
course to identify early on those candidates at risk of fail-
ure who may benefit from additional support during the
course.
Pre-course knowledge about cardiac arrest may also be
a result of candidate professional background. One can
expect higher ALS course pass rates in those professional
groups more likely to be involved in management of
cardiac arrests, such as anaesthesiologists, cardiologists,
emergency physicians and those working in ICUs. How-
ever, neither candidate specialty nor site of work showed
a significant association with candidate success or failure
in our population, which suggests that professional
background is less important for ALS course success than
specific pre-course preparation as measured by the pre-
course MCQ. Our results are in accordance with those of
Napier et al. [8] who documented no differences in
CASTest pass rates between professions in UK ALS
course candidates.
The final pass rate in our study (95.1%) is similar to
the national average (97%) reported for ALS courses in
Italy [9]. We are not aware of national reports on ALS
outcome in other countries. In a large group of UK course
centres, Perkins et al. [4] reported a pass rate ranging
from 40 to 93%. However, these data refer only to the
outcome of the CASTest pass at first attempt, therefore
not including retests. The international course manage-
ment system (http://courses.erc.edu/) recently introduced
by the ERC will certainly represent an important research
tool to monitor and compare the outcome of ALS courses
internationally.
Study limitations
Our study has a series of limitations. Firstly, its single-
centre nature may limit its generalizability. We cannot
exclude that results of this study may have been affected
by the specific features of our group of candidates and
instructors. A recent study [4] documented how the out-
come of ALS courses can vary—at least in terms of pass
rates—among training centres. Larger, multicentre studies
are needed to confirm our findings.
Secondly, this study was not blinded. In fact, all the
predictive factors we analysed, including the results of the
pre-course MCQ, were known by the course faculty and
this may in theory have biased the course results. How-
ever, concealing candidate data from the faculty would
have been impractical, since those data are needed by the
ALS course faculty in order to provide feedback and
support to candidates during the course. To overcome this
limitation, future studies should allocate the CASTest
evaluation to independent assessors.
Thirdly, our study was limited only to medical can-
didates, therefore excluding nurses. This is because in
Italy very few nurses apply to ALS provider courses.
Future multicentre studies should address whether spe-
cific predictive factors exist for the nurse population.
Conclusions
Results of our study showed that younger age, a previous
BLS certification and a higher pre-course knowledge, as
measured by the pre-course MCQ administered on arrival,
were independent predictors of success for medical doctors
participating in ALS courses. Candidate professional
background did not show a significant association with
ALS course outcome. Larger, multicentre studies are nee-
ded to confirm the results of this preliminary investigation.
Conflict of interest statement None to declare.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and reproduction in
any medium, provided the original author(s) and source are
credited.
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1525


Which factors predict candidate outcome in advanced life support courses? A preliminary observational study

PURPOSE: To identify factors associated with candidate outcome in the European Resuscitation Council (ERC) advanced life support (ALS) provider courses.

METHODS: Medical doctors participating as candidates to consecutive ALS courses organised by an ERC training centre in Italy were enrolled in this prospective cohort study. The association between the ALS course outcome and candidate demographics, professional background and pre-course knowledge measured by using the pre-course multiple choice quiz (MCQ) was investigated by using logistic regression.

RESULTS: A total of 283 candidates, median age 31 years, were evaluated. Among them, 269 (95.1%) passed the final evaluation and 14 (4.9%) failed. Candidates who passed were younger (median age 31 vs. 37.5 years; p = 0.006) and attained a higher pre-course MCQ score (median 84 vs. 72.5%; p < 0.0001). On multivariate analysis, a higher pre-course MCQ score (OR 1.18 [95%CI 1.09-1.28]) and a basic life support (BLS) certification (OR 5.00 [95%CI 1.12-22.42]) were independent predictors of candidate success, while older age was associated with a significantly higher risk of failing (OR 0.90 [95%CI 0.83-0.97]). Female candidates had higher pass rates (97.2 vs. 91.2%; p = 0.048); however, after correction for confounders gender was not significantly associated with candidate outcome. Neither candidate specialty nor site of work was a predictor of candidate success.

CONCLUSIONS: On ALS courses, younger age and a higher level of specific pre-course knowledge, as measured by both the pre-course MCQ and the presence of BLS certification, are the most important predictors of success. Candidate gender and professional background did not show a significant correlation with course outcom

Sandroni, Claudio (ORCID:0000-0002-8878-2611)

Gonnella, Gian Luigi

De Waure, Chiara (ORCID:0000-0002-4346-1494)

Cavallaro, Fabio

Antonelli, Massimo (ORCID:0000-0003-3007-1670)

PubliCatt

Claudio SandroniGian Luigi GonnellaChiara de WaureFabio CavallaroGiuseppe La TorreMassimo AntonelliWhich factors predict candidate outcomein advanced life support courses?A preliminary observational studyReceived: 21 October 2009Accepted: 30 March 2010Published online: 18 June 2010 The Author(s) 2010. This article ispublished with open access atSpringerlink.comThe study was performed at the CatholicUniversity School of Medicine, Rome, Italy.C. Sandroni ())  G. L. Gonnella F. Cavallaro  M. AntonelliDepartment of Anaesthesiologyand Intensive Care, Catholic UniversitySchool of Medicine, Largo A. Gemelli 8,00168 Rome, Italye-mail: sandroni@rm.unicatt.itTel.: ?39-06-30154490Fax: ?39-06-3013450C. de WaureInstitute of Hygiene, Catholic UniversitySchool of Medicine, Largo F. Vito 1,00168 Rome, ItalyG. L. TorreClinical Medicine and Public Health Unit,Sapienza University of Rome,Viale Regina Elena 324,00161 Rome, ItalyAbstract Purpose: To identifyfactors associated with candidateoutcome in the European Resuscita-tion Council (ERC) advanced lifesupport (ALS) provider courses.Methods: Medical doctors partici-pating as candidates to consecutiveALS courses organised by an ERCtraining centre in Italy were enrolledin this prospective cohort study. Theassociation between the ALS courseoutcome and candidate demograph-ics, professional background and pre-course knowledge measured by usingthe pre-course multiple choice quiz(MCQ) was investigated by usinglogistic regression. Results: A totalof 283 candidates, median age31 years, were evaluated. Amongthem, 269 (95.1%) passed the finalevaluation and 14 (4.9%) failed.Candidates who passed were younger(median age 31 vs. 37.5 years;p = 0.006) and attained a higher pre-course MCQ score (median 84 vs.72.5%; p \ 0.0001). On multivariateanalysis, a higher pre-course MCQscore (OR 1.18 [95%CI 1.09–1.28])and a basic life support (BLS)certification (OR 5.00 [95%CI 1.12–22.42]) were independent predictorsof candidate success, while older agewas associated with a significantlyhigher risk of failing (OR 0.90[95%CI 0.83–0.97]). Female candi-dates had higher pass rates (97.2 vs.91.2%; p = 0.048); however, aftercorrection for confounders genderwas not significantly associated withcandidate outcome. Neither candidatespecialty nor site of work was a pre-dictor of candidate success.Conclusions: On ALS courses,younger age and a higher level ofspecific pre-course knowledge, asmeasured by both the pre-courseMCQ and the presence of BLS certi-fication, are the most importantpredictors of success. Candidategender and professional backgrounddid not show a significant correlationwith course outcome.Keywords Advanced life support(ALS)  Assessment Cardiopulmonary resuscitation Education  Training  OutcomeIntroductionIn most European countries, the European ResuscitationCouncil (ERC) advanced life support (ALS) providercourse is recognised as the gold standard to preparemembers of multidisciplinary teams to manage both car-diac arrest and peri-arrest situations [1, 2]. Resuscitationand initial management of the acutely ill patient areamong the twelve domains of the core competenciesrequired of a specialist in intensive care medicine [3].Unfortunately, some ALS candidates fail to achievetheir ALS certification. Failure rates in the cardiac arrestscenario test (CASTest) at the end of the ALS course maybe as high as 60% [4]. Until now, no specific investigationIntensive Care Med (2010) 36:1521–1525DOI 10.1007/s00134-010-1926-1 ORIGINALhas been conducted to identify factors associated withALS course outcome. Knowing in advance those factorswould be useful for two reasons:1. At the beginning of an ALS course, it would allow thecourse faculty to identify early on those candidateswho are at risk of failure and who need additionalsupport;2. As a general policy, it would help in targeting the ALScourse to the most appropriate candidates, i.e. thoseprofessional figures who are most likely to benefitfrom ALS training.The aim of this study was to investigate whetherpre-course factors, such as candidate age and gender,professional background and pre-course knowledge, canpredict the outcome of the ALS course.Materials and methodsThis was a prospective, single-centre cohort study.Candidates and data collectionAll medical doctors participating in the ALS providercourses organised by the Catholic University School ofMedicine (UCSC) Training Centre in Rome between 1November 2006 and 30 June 2009 who did not have aprevious ALS certification were included in the study.The UCSC Training Centre operates within the ALSnational training network of the Italian ResuscitationCouncil (IRC), an ERC approved school.Candidates gave their consent for anonymous use ofboth their demographic information and course results forscientific investigational purposes on applying for theALS course via the UCSC course management website(www.corsi-rianimazione.it). The study was approved bythe ethics committee of the UCSC (protocol number A598).The ERC ALS provider courseThe ALS provider course has been described elsewhere[1]. It is a residential teaching and training coursedesigned for healthcare professionals and focused onprevention of cardiac arrest, management of cardiac arrestand peri-arrest situations and stabilisation of the resusci-tated patient until transfer to a critical care area.Before the ALS course, a 120-item multiple choicequiz (MCQ) is usually sent to the candidates alongwith the manual to allow self-assessment of candidates’pre-course knowledge. For the purpose of this study—inorder both to standardise testing and to avoid referenceto the manual—the pre-course MCQ was given oncandidates’ arrival at the training centre and invigilated.A maximum of 60 min was allowed to complete the test.During the first day of the course, candidates areassessed on airway management and initial assessmentand resuscitation (IAR) and must demonstrate compe-tence on both these skills before the final assessment inorder to achieve their ALS certification.Final assessment of the ERC ALS course includesboth a 120-item final MCQ and a cardiac arrest simulationtest (CASTest). The final MCQ must be completed in60 min and it has a pass mark of 75%. During CASTest,candidates are assessed on their ability to manage asimulated cardiac arrest scenario as team leaders. Can-didates who fail either the final MCQ or the CASTest areentitled to a second attempt (retest) and, if still unsuc-cessful, are failed. Those who are successful in both thefinal MCQ and the CASTest (either at first or at secondattempt) are certified as ALS providers.Statistical analysisThe following variables were considered as possiblepredictors of the course outcome: age; gender; specialty;site of work; previous certification in basic life support(BLS) courses for healthcare providers; and pre-courseMCQ score. Univariate analysis was carried out toinvestigate predictors of course outcomes. Medical spe-cialties that were more pertinent to the subject of the ALScourse, such as anaesthesiology, cardiology and emer-gency medicine, were compared with all the other ones.Chi square or Fisher’s exact test and Mann–Whitney testswere applied for categorical and continuous data,respectively. Statistical significance was set at p \ 0.05.Stepwise multivariate logistic regression was per-formed by entering into the model all the variables whosep value was less than 0.25 in the univariate analysis. Themodel goodness of fit was assessed with the Hosmer–Lemeshow test. Statistical analysis was carried out usingSPSS, release 12.0 for Windows.ResultsA total of 290 medical doctors participating in 13 con-secutive ALS courses were considered for inclusion in thestudy. Four of them were excluded due to a previous ALScertification. Three candidates dropped out of the ALScourse before completion for personal reasons and werealso excluded.The remaining 283 candidates (median age 31 years;64.0% females) were included in the study. All candidatesin our population demonstrated sufficient competence onboth airway management and IAR by the end of the first1522day. As regards final evaluation, 269 (95.1%) candidatespassed and 14 (4.9%) failed. Ten of these 14 candidatesattained a sufficient score on the final MCQ but failed theCASTest, while four failed both the CASTest and the MCQ.Candidates’ characteristics are summarised in Table 1.In comparison with those who failed, candidates whopassed were significantly younger (31 vs. 37.5 years;p = 0.006; Table 2), and attained a significantly highermedian score at the pre-course MCQ (84 vs. 72.5%;p \ 0.0001). On multivariate analysis (Table 3), a higherpre-course MCQ score and a BLS certification wereassociated with significantly higher probabilities ofpassing the final test (OR 1.18 [95%CI 1.09–1.28] and OR5.00 [95%CI 1.12–22.42] respectively), while older can-didates had significantly lower probabilities of passing(OR 0.90 [95%CI 0.83–0.97]). Women had a significantlyhigher pass rate (97.2 vs. 91.2%; p = 0.048) but onmultivariate analysis gender was not an independentpredictor of outcome.DiscussionCandidate age, BLS certification and pre-course knowl-edge, as measured by the pre-course MCQ, were the mostimportant predictors of ALS course outcome in ourpopulation.Increasing age was associated with a lower proba-bility of passing the final evaluation. Probably, in oldercandidates a higher decay of their knowledge aboutemergency medicine may have occurred, due to thelonger time passed between their degree and the ALScourse. Another cause could have been an age-relateddecay in learning capability. It has been estimated thatlearning capability declines by a 1% per year in adultsfrom 22 to 50 years of age [5]. Age-related losses aresubstantial in ‘working memory’ tasks, which usuallyrequire the maintenance of some information whiledealing concurrently with further incoming stimuli—asoccurs during an ALS scenario [6, 7]. Furthermore, it isalso possible that older candidates may have not beenfamiliar or comfortable with the scenario-based/role play-type teaching as it is a relatively newmethodology.High scores on the pre-course MCQ and a BLS cer-tification were independent predictors of course pass inour study. We think that previous BLS training may haveTable 1 Characteristics of the study subjectsNumber of subjects 283Median age, years (range) 31 (25–57)Females 181 (64.0)Specialist 173 (61.2)Resident 110 (38.8)SpecialtyAnaesthesiology 77 (27.2)Internal medicine 41 (14.5)Cardiology 32 (11.3)Infectious diseases 20 (7.1)Surgery 12 (4.2)Respiratory medicine 12 (4.2)Emergency medicine 10 (3.5)Geriatric medicine 9 (3.2)Other 70 (24.7)BLS certificationBLS provider 134 (47.9)BLS instructor 13 (4.6)Site of workWard 128 (45.2)Operating room 58 (20.2)ICU 29 (10.6)Clinic 38 (13.4)ED 21 (7.4)Ambulance 9 (3.2)Course outcomePassed 269 (95.1)Failed 14 (4.9)Values are numbers (percentages) unless otherwise statedICU intensive care unit, ED emergency departmentTable 2 Results of univariate analysis comparing passed and failedcandidatesPassed(n = 269)Failed(n = 14)p ValueMedian age, year (range) 31 (25–57) 37.5 (27–54) 0.006GenderMale 93 (91.2) 9 (8.8) 0.048Female 176 (97.2) 5 (2.8)Medical specialtiesAnaesthesiology, cardiologyor emergency medicine114 (95.8) 5 (4.2) 0.78All other specialties 155 (94.5) 9 (5.5)Site of workWard/clinic 155 (93.4) 11 (6.6) 0.27Operating room 57 (98.3) 1 (1.7)ICU/ED/ambulance 57 (96.6) 2 (3.4)BLS certificationYes 147 (97.4) 4 (2.6) 0.1No 122 (92.4) 10 (7.6)Median score at thepre-course MCQ, % (range)84 (54–100) 72.5 (37–89) \0.0001Values are numbers (percentages) unless otherwise statedTable 3 Predictors of course pass according to multivariatelogistic regressionVariable Odds ratio (95% CI) p ValuePre-course MCQ score (%) 1.18 (1.09–1.28) 0.0001BLS certification 5.00 (1.12–22.42) 0.03Age (years) 0.90 (0.83–0.97) 0.008Hosmer–Lemeshow goodness-of-fit = 0.4561523influenced the ALS course outcome in two ways: first byteaching candidates a correct approach to cardiovascularemergencies; secondly because it may have increasedcandidates’ confidence with scenario teaching andassessment. Although BLS certification is currently notrequired for access to ERC ALS courses, results of ourstudy suggest that proficiency in BLS should be recom-mended to ALS course participants.We administered the pre-course MCQ on arrival instandardised and invigilated conditions, which is not rou-tine practice of the ALS course. This, however, wasnecessary to ensure that pre-course MCQ results wouldreliably reflect the candidates’ pre-course knowledge.Results of our study, if confirmed, would suggest that thepre-course MCQ may be used at the beginning of thecourse to identify early on those candidates at risk of fail-ure who may benefit from additional support during thecourse.Pre-course knowledge about cardiac arrest may also bea result of candidate professional background. One canexpect higher ALS course pass rates in those professionalgroups more likely to be involved in management ofcardiac arrests, such as anaesthesiologists, cardiologists,emergency physicians and those working in ICUs. How-ever, neither candidate specialty nor site of work showeda significant association with candidate success or failurein our population, which suggests that professionalbackground is less important for ALS course success thanspecific pre-course preparation as measured by the pre-course MCQ. Our results are in accordance with those ofNapier et al. [8] who documented no differences inCASTest pass rates between professions in UK ALScourse candidates.The final pass rate in our study (95.1%) is similar tothe national average (97%) reported for ALS courses inItaly [9]. We are not aware of national reports on ALSoutcome in other countries. In a large group of UK coursecentres, Perkins et al. [4] reported a pass rate rangingfrom 40 to 93%. However, these data refer only to theoutcome of the CASTest pass at first attempt, thereforenot including retests. The international course manage-ment system (http://courses.erc.edu/) recently introducedby the ERC will certainly represent an important researchtool to monitor and compare the outcome of ALS coursesinternationally.Study limitationsOur study has a series of limitations. Firstly, its single-centre nature may limit its generalizability. We cannotexclude that results of this study may have been affectedby the specific features of our group of candidates andinstructors. A recent study [4] documented how the out-come of ALS courses can vary—at least in terms of passrates—among training centres. Larger, multicentre studiesare needed to confirm our findings.Secondly, this study was not blinded. In fact, all thepredictive factors we analysed, including the results of thepre-course MCQ, were known by the course faculty andthis may in theory have biased the course results. How-ever, concealing candidate data from the faculty wouldhave been impractical, since those data are needed by theALS course faculty in order to provide feedback andsupport to candidates during the course. To overcome thislimitation, future studies should allocate the CASTestevaluation to independent assessors.Thirdly, our study was limited only to medical can-didates, therefore excluding nurses. This is because inItaly very few nurses apply to ALS provider courses.Future multicentre studies should address whether spe-cific predictive factors exist for the nurse population.ConclusionsResults of our study showed that younger age, a previousBLS certification and a higher pre-course knowledge, asmeasured by the pre-course MCQ administered on arrival,were independent predictors of success for medical doctorsparticipating in ALS courses. Candidate professionalbackground did not show a significant association withALS course outcome. Larger, multicentre studies are nee-ded to confirm the results of this preliminary investigation.Conflict of interest statement None to declare.Open Access This article is distributed under the terms of theCreative Commons Attribution Noncommercial License whichpermits any noncommercial use, distribution, and reproduction inany medium, provided the original author(s) and source arecredited.References1. Perkins GD, Lockey A (2002) Theadvanced life support provider course.BMJ 325:S812. Nolan J (2001) Advanced life supporttraining. Resuscitation 50:9–113. The CoBaTriCE Collaboration (2006)Development of core competencies foran international training programme inintensive care medicine. Intensive CareMed 32:1371–13834. Perkins GD, Davies RP, Stallard N,Bullock I, Stevens H, Lockey A (2007)Advanced life support cardiac arrestscenario test evaluation. Resuscitation75:484–49015245. Knowles M (1998) The adult learner:a neglected species. Gulf Publishing,Houston, TX6. Grady CL, Craik FI (2000) Changes inmemory processing with age. Curr OpinNeurobiol 10:224–2317. Jones S, Nyberg L, Sandblom J,Stigsdotter NA, Ingvar M, MagnusPetersson K, Ba¨ckman L (2006)Cognitive and neural plasticity in aging:general and task-specific limitations.Neurosci Biobehav Rev 30:864–8718. Napier F, Davies RP, Baldock C, StevensH, Lockey AS, Bullock I, Perkins GD(2009) Validation for a scoring system ofthe ALS cardiac arrest simulation test(CASTest). Resuscitation 80:1034–10389. Semeraro F, Carloni A, Marchetti L,Sandroni C, Lanfranco G, DiBartolomeoS, Bigi E, Barelli A, Scapigliati A,Boverio R, Gianolio M (2008) Advancedlife support and pre-hospital trauma caredatabase course web-based datamanager. Resuscitation 77S:S371525

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Which factors predict candidate outcome in advanced life support courses? A preliminary observational study

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