Non-technical skills in out-of-hospital cardiac arrest management: A scoping review


non-technical skills
out-of-hospital cardiac arrest
ad-hoc teams

How to Cite

Cormack S, Scott S, Stedmon A. Non-technical skills in out-of-hospital cardiac arrest management: A scoping review. Australasian Journal of Paramedicine [Internet]. 2020May13 [cited 2020Aug.8];17. Available from:



Current United Kingdom resuscitation guidance advocates the use of non-technical skills (NTS) such as teamwork, decision-making and communication for ad-hoc teams managing an out-of-hospital cardiac arrest (OHCA). It is unknown which NTS are advantageous or commonly used, or if there is supporting literature. This scoping review sought to establish a literature base and identify key NTS relevant to ad-hoc teams managing an OHCA.


Arksey and O’Malley’s five-stage framework was used to perform a scoping review to identify relevant literature from the medical domain. Thematic analyses were used to identify relevant NTS in relation to OHCA management.


A total of 12 articles were identified and selected for detailed analysis. The articles represented a range of study designs, with most commenting on observed simulated practice from in-hospital practice. There was a paucity of literature for NTS associated with ad-hoc OHCA teams. Three common NTS were identified: leadership, teamwork and communication, with improved team performance associated with a hands-off team leader. Barriers were also identified and included low confidence in communicating and hierarchical difficulties in resuscitation teams.


We believe this scoping review provides the first comprehensive review of its kind and identifies important knowledge gaps, NTS themes and recommendations for paramedic-led OHCA teams. Three NTS from in-hospital cardiac arrest management can be related to OHCA management, but further research is needed to identify specific NTS for ad-hoc teams managing an OHCA.


Perkins GD, Brace-McDonnell SJ, on behalf of the OHCAO Project Group. The UK Out of Hospital Cardiac Arrest Outcome (OHCAO) project. BMJ Open 2015;5:e008736.

Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the chain of survival concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee. Circulation 1991;83:1832-7.

de Visser M, Bosch J, Bootsma M, et al. An observational study on survival rates of patients with out-of-hospital cardiac arrest in the Netherlands after improving the ‘chain of survival’. BMJ Open 2019;9:e029254.

Rajagopal S, Booth SJ, Brown TP on behalf of OHCAO collaborators, et al. Data quality and 30-day survival for out-of-hospital cardiac arrest in the UK out-of-hospital cardiac arrest registry: a data linkage study. ibid. 2017;7:e017784.

Larribau R, Deham H, Niquille M, Sarasin FP. Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines. PLoS One 2018;13:e0204169.

Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation 2010;3:63-81.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-15.

Perkins GD, Lockey AS, de Belder MA, et al, on behalf of the Community Resuscitation Group. National initiatives to improve outcomes from out-of-hospital cardiac arrest in England. Emerg Med J 2016;33:448-51.

Nas J, Thannhauser J, Heramann JJ, et al. Changes in automated external defibrillator use and survival after out-of-hospital cardiac arrest in the Nijmegen area. Neth Heart J 2018;28:600-05.

Tiah L, Kajino K, Alsakaf O, et al. Does pre-hospital endotracheal intubation improve survival in adults with non-traumatic out-of-hospital cardiac arrest? A systematic review. West J Emerg Med 2014;15:749-7.

Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. Resuscitation 2011;82:1138-3.

Stiell IG, Wells GA, Field B, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-6.

Cournoyer A, Notebaert E, Iseppon M, et al. Prehospital advanced cardiac life support for out-of-hospital cardiac arrest: a cohort study. Acad Emerg Med 2017;24:1100-9.

Weiss N, Ross E, Cooley C, et al. Does experience matter? Paramedic cardiac resuscitation experience effect on out-of-hospital cardiac arrest outcomes. Prehosp Emerg Care 2018;22:332-37.

Salas E, Sims DE, Burke CS. Is there a "big five" in teamwork? Small Group Res 2005;36:555-99.

McClellend G, Younger P, Haworth D, Gospel A, Aitken-Fell P. A service evaluation of a dedicated pre-hospital cardiac arrest response unit in the North East of England. British Paramedic Journal 2016;1:35-41.

Hinski S, Cooke NJ, McNeese A, Sen A, Patel B. A human factors approach to building high-performance multi-professional cardiac arrest teams: developing a code blue team performance metric. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care. 2017;5:68-71. Available at:

Panesar SS, Ignatowicz AM, Donaldson LJ. Errors in the management of cardiac arrests: An observational study of patient safety incidents in England. Resuscitation 2014;85:1759-63.

Brandling J, Kirby K, Black S, Voss S, Benger J. Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study. BMC Emerg Med 2017;17:1-8.

Smith MW, Bentley MA, Fernandez AR, et al. Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study. Ann Emerg Med 2013;62:367-79.

Dyson K, Bray JE, Smith K, et al. Paramedic exposure to out-of-hospital cardiac arrest resuscitation is associated with patient survival. Circ Cardiovasc Qual Outcomes 2016;9:154-60.

Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills. Br J Anaesth 2010;105:38-44.

Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open 2016;7:1-10.

Nallamothu BK, Guetterman TC, Harrod M, et al. How do resuscitation teams at top performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation 2018;138:154-63.

Norris EM, Lockey AS. Human factors in resuscitation teaching. Resuscitation 2012;83:423-7.

Resuscitation Council (UK). Prehospital resuscitation. London, UK; 2015. Available at:

Shields A, Flin R. Paramedics’ non-technical skills: a literature review. Emerg Med J 2013;30:350-4.

von Wyl T, Zuercher M, Amsler F, Walter B, Ummenhoffer W. Technical and non-technical skills can be reliably assessed during paramedic simulation training. Acta Anaesthesiol Scand 2009;53:121-7.

Clarke S, Lyon RM, Short S, Crookston C, Clegg GR. A specialist, second-tier response to out-of-hospital cardiac arrest: setting up TOPCAT2. Emerg Med J 2014;31:405-7.

Pham MT, Rajić A, Greig JD, et al. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods 2014;5:371-5.

Anderson N, Slark J, Gott M. How are ambulance personnel prepared and supported to withhold or terminate resuscitation and manage patient death in the field? A scoping review. Australasian Journal of Paramedicine 2019;16. doi:

Munn Z, Peters MDJ, Stern C, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18:2-7.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19-32.

MeSH on Demand. USA: U.S. National Library of Medicine. 2017. Available at:

Marsch SC, Muller C, Marquard K, et al. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51-6.

Tschan F, Semmer NK, Gautschi D, et al. Leading to recovery: group performance and coordinative activities in medical emergency driven. Hum Perform 2006;19:277-4.

Andersen PO, Jensen MK, Lippert A, Østergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010;81:695-2.

Hunziker S, Tschan F, Semmer N, Howell MD, Marsch S. Human factors in resuscitation: lessons learned from simulator studies. J Emerg Trauma Shock 2010;3:389-4.

Hunziker S, Johansson AC, Tschan F, et al. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol 2011;57:2381-8.

Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. Br J Anaesth 2012;109:723-8.

Castelao EF, Russo SG, Riethmuller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. J Crit Care 2013;28:504-21.

Castelao EF, Boos M, Ringer C, Eich C, Russo SG. Effect of CRM team leader training on team performance and leadership behaviour in simulated cardiac arrest scenarios: a prospective, randomized, controlled study. BMC Med Educ 2015;15:116.

Miller J. Better together? Ambulance staff views of human factors in resuscitation. Emerg Med J 2015;32:P006.

Lowe DJ, Dewar A, Lloyd A, Edgar S, Clegg GR. Optimising clinical performance during resuscitation using video evaluation. Postgrad Med J 2016;93:449-3.

Arriage AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013;368:246-53.

Burgess MR, Crewdson K, Lockey DJ, Perkins ZB. Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists. Emerg Med J 2018;35:532-7.

Thomassen Ø, Espeland A, Søfteland E, et al. Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc 2011;19:53.

Webster CS. Checklist, cognitive aids, and the future of patient safety. Br J Anaesth 2017;119:178-81.

Catchpole K, Russ S. The problems with checklists. BMJ Qual Saf 2015;24:545-9.

Ong ME, Perkins GD, Cariou A. Out-of-hospital cardiac arrest: prehospital management. Lancet 2018;391:980-8.

Anderson NE, Gott M, Slark J. Grey areas: New Zealand ambulance personnel’s experiences of challenging resuscitation decision-making. Int Emerg Nurs 2018;39:62-7.

Krage R, Zwaan L, Tjon Soei Len L, et al. Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence. Emerg Med J 2017;34:728-3.

Ågård A, Herlitz J, Casten N, Jonsson L, Sandman L. Guidance for ambulance personnel in decisions and situations related to out-of-hospital CPR. Resuscitation 2012;83:27-1.

Reeve S, Kitto S, Masiello I. Crew resource management: how well does it translate to an interprofessional healthcare context? J Interprof Care 2013;27:207-9.

Langdalen H, Abrahamsen EB, Sollid SJM, Sorskar LIK, Abrahamsen HB. A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services. BMC Health Serv Res 2018;18:509-22.

Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth 2010;105:3-6.

Myers JA, Powell DM, Psirides A, et al. Non-technical skills evaluation in the critical care air ambulance environment: introduction of an adapted rating instrument—an observational study. Scand J Trauma Resusc Emerg Med 2016;(24):24.

Gaudry PL, Ryan JM, Aders HP. Protecting privacy during video recording resuscitations. Emerg Med 1996;8:141-5.

Gelbart B, Barfield C, Watkins A. Ethical and legal considerations in video recording neonatal resuscitations. J Med Ethics 2009;35:120-4.

Bracco F, de Tonetti G, Masini M, et al. Crisis resource management in the delivery room: development of behavioural markers for team performance in emergency simulation. Int Environ Res Public Health 2018;15:439-49.

Sui J, Maran N, Paterson-Brown S. Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. Surgeon 2016;14:119-28.

Fletcher G, Flin R, McGeorge P, et al. Anaesthetists’ non-technical skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003;90:580-8.

Holly D, Swanson V, Cachia P, Beasant B, Laird C. Development of a behaviour rating system for rural/remote pre-hospital settings. Appl Ergon 2017;58:405-13.

Young MS, Lenné MG and Stedmon AW. Prologue. In: MS Young and MG Lenné (editors). Simulators for transportation human factors: research and practice. Florida: CRC Press, 2017, pp.3-18.

Smith JH. Elton Mayo and the hidden Hawthorne. Work Employ Soc 1987;1107-20.

Dyson K, Bray JE, Smith K, et al. Paramedic resuscitation competency: a survey of Australian and New Zealand emergency medical services. Emerg Med Australas 2017;29:217-2.

Steen E, Naess AC, Steen PA. Paramedics organizational culture and their care for relative of cardiac arrest victims. Resuscitation 1997;34:57-3.