ANZCOR Guideline 10.2 outlines the design and delivery of advanced life support (ALS) education for healthcare providers in all settings. This guideline should be read alongside the age-specific life support recommendations (Refer to ANZCOR Guidelines 11 to 13).

ALS training builds on the continuum of care initiated by bystander and basic life support (BLS) (Refer to ANZCOR Guideline 10.1) by integrating advanced skills and resources to optimise resuscitation outcomes. A robust foundation in BLS is a prerequisite for ALS. Accordingly, this guideline focuses on the acquisition and ongoing maintenance of the enhanced knowledge, technical proficiency and non-technical behaviours required for effective performance as part of a resuscitation team.¹

To whom does this guideline apply?

This guideline applies to healthcare professionals who may either have a role as an initial responder or as part of a responding team involved in the resuscitation of newborns, children, or adults.

Who is the audience for this guideline?

This guideline is intended for ALS education curriculum developers and providers of ALS training.

Conflict of interest statement

The New Zealand Resuscitation Council and the Australian Resuscitation Council credential resuscitation training curricula. Some member organisations are providers of life support training and generate income from these activities.

Recommendations

Who should training be available to?

• ANZCOR recommends the provision of accredited ALS training for health care providers who provide ALS for adults [CoSTR 2022, strong recommendation, very low certainty of evidence].
• ANZCOR recommends the provision of accredited courses in Paediatric ALS (PALS) Training for health care providers who provide ALS for infants and children [CoSTR 2022, strong recommendation, very low certainty of evidence].
• ANZCOR recommends the provision of accredited courses in Neonatal Resuscitation Training (NRT) and Helping Babies Breathe (HBB) for health care providers who provide ALS care for newborns and babies [CoSTR 2022, strong recommendation, very low certainty of evidence].

What should training include?

• ANZCOR recommends that pre-course preparation is provided [CoSTR 2022, strong recommendation, very low to low certainty of evidence].
• ANZCOR suggests that delivery of the required knowledge that underpins ALS should be flexible and consider prior knowledge of experienced practitioners [Good Practice Statement].
• ANZCOR suggests that team and leadership training should be included as part of ALS training [CoSTR 2022, weak recommendation, very low-certainty evidence].

How should training be delivered?

• ANZCOR recommends the option of blended learning (combination of online and face-to-face) where resources and accessibility permit its implementation [CoSTR 2022, strong recommendation, very low-to-low certainty evidence].
• ANZCOR suggests the use of cognitive aids in ALS training [CoSTR 2023, weak recommendation, very low certainty of evidence]. It is preferable that these cognitive aids should be the same or similar, where practical, to those available to participants in clinical practice [Good Practice Statement].
• ANZCOR suggests the use of feedback devices that provide directive feedback on the quality of cardiopulmonary resuscitation (CPR) during training [CoSTR 2024, weak recommendation, low-certainty evidence]. If feedback devices are not available, we suggest the use of tonal guidance (examples include music or a metronome) during training to improve compression rate only [CoSTR 2024, weak recommendation, low-certainty evidence]. ANZCOR suggests data-driven, performance-focused feedback and debriefing of rescuers during training [Good Practice Statement].
• ANZCOR suggests the use of high-fidelity manikins when training centres/organisations have the infrastructure, trained personnel, and resources to maintain the program [CoSTR 2024, weak recommendation, very-low-certainty evidence].
• ANZCOR suggests the use of low-fidelity manikins if high-fidelity manikins are not available [CoSTR 2024, weak recommendation, low-certainty evidence].
• ANZCOR suggests that technology needs to be appropriate in order to generate skills; therefore, at a minimum, there should be learner access to a basic manikin with an airway and the ability to simulate the display of cardiac rhythm [Good Practice Statement].
• ANZCOR suggests that high fidelity scenarios (those that integrate psychomotor skills, non-technical skills, and clinical decision making) are more important than the fidelity of the manikin [Good Practice Statement].
• ANZCOR suggests that either the use of augmented reality or traditional methods be used for basic life support (BLS) training of lay people and healthcare providers [CoSTR 2023, weak recommendation, very-low certainty of evidence].
• ANZCOR suggests that resuscitation education be configured to account for local resource availability in terms of both appropriateness of learning objectives and selection of equipment and adjuncts with which to conduct ALS training [Good Practice Statement].

How often should training take place?

• ANZCOR suggests frequent manikin-based ALS refresher training to maintain competence compared with standard retraining intervals of 12 to 24 months [CoSTR 2020, weak recommendation, very-low-certainty evidence].
• ANZCOR suggests that all ALS courses should have a robust process for continuous evaluation and quality improvement [Good Practice Statement].

Who should deliver ALS training?

• ANZCOR suggests trainers/facilitators (for courses for laypersons or healthcare professionals) must have received appropriate instruction qualifications in facilitation of learning and must receive facilitation updates on a regular basis [Good Practice Statement].
• ANZCOR suggests that educators who use high-fidelity manikins and simulators must have adequate knowledge and familiarity with the capabilities of their training devices [Good Practice Statement].

How long should training be?

• ANZCOR suggests that ALS training programs include 6 to 8 hours of instructor-led training time [Good Practice Statement].
• ANZCOR suggests ALS training can be delivered by either a spaced learning approach (training/retraining distributed over time) or a 1 to 2 day block ALS course [CoSTR 2020, weak recommendation, very low certainty of evidence].

• For the purposes of this guideline, the terms Basic Life Support (BLS), Advanced Life Support (ALS) and Health Care Professional are defined in the Australian and New Zealand Resuscitation Councils glossary (https://resus.org.au/glossary/ )
• Blended learning: is an educational approach that combines face-to-face and online approaches.¹
• Deliberate practice: Activities that have been specifically designed to improve the current level of performance, in which weaknesses are systematically identified and addressed to move on to the next level.²
• Fidelity: Fidelity in simulation training refers to the degree to which a simulation replicates real‐life clinical scenarios. This includes both the technical or “hardware” fidelity (e.g., high‐fidelity manikins that provide realistic physiological responses) and the scenario fidelity, that is, how well the simulated environment incorporates realistic clinical cues, patient responses, and the integration of psychomotor skills, non‐technical skills, and clinical decision‐making.³
• Insitu training: in situ training, workplace-based simulation-based resuscitation training.⁴
• Instructor-led training: as education or training (e.g., lecture, simulation, skills demonstration, skills feedback) that occurs in the presence of a BLS instructor.⁵
• Mastery: The term mastery implies that the learner can consistently demonstrate a predefined level of competence for a specific skill or task.²
• Self-directed, digitally based BLS training is defined as any form of digital (e.g, video, phone application [app] based, internet based, game based, virtual reality, augmented reality) education or training for BLS that can be completed without an instructor, except for mass media campaigns (e.g., television, social media education).⁵

Advanced Life Support (ALS) training enhances the ability of health professionals to manage life-threatening emergencies effectively. ALS training equips healthcare providers with structured, evidence-based protocols for cardiac arrest, acute coronary syndromes, stroke, and other critical conditions, improving patient survival and outcomes.⁶

Acquisition of ALS knowledge, skills, attitudes and behaviours have a positive impact on quality of resuscitation and patient outcomes (return of spontaneous circulation and survival).^6-10

ANZCOR recommends the following [CoSTR 2022, strong recommendation, very low certainty of evidence]:

• Provision of accredited ALS training for health care providers who provide ALS care for adults.
• Provision of accredited courses in paediatric resuscitation training for health care providers who provide ALS for infants and children.
• Provision of accredited courses in newborn resuscitation training and Helping Babies Breathe or equivalent for health care providers who provide ALS care for newborns and babies.

Section 1 covers the content for initial ALS training and Section 2 covers refresher training. 

The Australian Resuscitation Council and New Zealand Resuscitation Council (ANZCOR) believe that organisations and individuals experienced in resuscitation training are best positioned to contextualise the above principles into their training programs.

The evidence related to optimal retraining intervals for resuscitation education is limited in both quantity and quality. The optimal interval for retraining, meaning re-completion of a full ALS course, has not been established. However, repeated refresher training is needed for individuals who are not performing resuscitation on a regular basis.²

What is well established is that the frequency of ALS re-training or refresher activities will be influenced by how quickly skills and knowledge gained in training decay over time. CPR skills are known to deteriorate within weeks to months after traditional single-encounter courses and well before traditional retraining intervals of 1 to 2 years.^2,77

Health professionals exposure to cardiac arrest is relatively low. Victorian data shows that paramedics are exposed to an average 1.4 (IQR=0.0- 3.0) out-of-hospital cardiac arrests per year, and it takes, on average, 163 days for paramedics to be exposed to out-of-hospital cardiac arrest.⁷⁶  Annually, there are approximately 10.2 million hospital admissions in Australia⁷⁷ and 1.1 million in New Zealand.⁷⁸ A systematic review of the frequency, characteristics and outcomes of adult in-hospital cardiac arrests in Australia and New Zealand showed that the frequency of in-hospital cardiac arrests ranged from 1.31-6.11 per 1000 admissions in four population studies and 0.58-4.59 per 1000 in 16 cohort studies.⁷⁹ In contrast, newborn resuscitation is more frequent. While one in five newborn infants is reported to receive some form of resuscitation intervention, one in twenty received assisted ventilation (which is often the most important neonatal resuscitation intervention). Nevertheless, only about 3 per 1000 receive chest compressions, suggesting a low frequency of exposure of newborn care providers to the need to provide extensive resuscitation.⁸⁰

Retraining cycles of 12 to 24 months are not adequate to maintain high-quality in resuscitation skills.¹⁰ While the optimal retraining intervals remain uncertain,  more frequent refresher training (brief, focused practice sessions aimed at reinforcing key skills) has been shown to benefit healthcare providers in maintaining ALS proficiency.^10,81-86 Refresher training, in the form of low-dose, high-frequency sessions using manikins, may be a practical, cost-effective solution. Sessions should be brief, typically 5 to 15 minutes in duration, and scheduled frequently, for example, on a weekly, monthly, or quarterly basis, depending on learner needs and operational feasibility.  Note: Throughout this guideline, the term "brief refresher training" refers to short, low-dose practice sessions (5 to 15 minutes in duration), aligned with the principles of low-dose, high-frequency training to support ongoing ALS skill retention. Such sessions can be integrated into daily workflow, reducing the need for full course attendance and allowing for ongoing reinforcement.⁸²  Learning from “frequent, low-dose” compared with “comprehensive, all-at-once” instruction is effective and preferred by learners.⁸³ Instructional methods such as RCDP,^4,84 which involve repeated short simulations with immediate feedback, warrant further consideration. The role of experiential clinical exposure and feedback in retraining requires further study.  

Where possible, more frequent refresher sessions (e.g., monthly) are preferred, but any increase in refresher frequency compared to traditional annual or biennial retraining is likely to improve skill retention and patient outcomes.

In line with the principles outlined for initial ALS education, refresher and retraining programs should incorporate a Minimum Passing Standard where practical. The minimum standard should be made clear to learners at the outset. Educators should define key metrics and assessment tools appropriate to the refresher context, focused on observable performance behaviours. These should aim to reinforce actions that improve patient outcomes and key process measures such as time, accuracy, adherence to best practice, or local protocols.

Figure 2: Examples of refresher training options for ALS skill retention

These examples are flexible and should be adapted to the learner's clinical role, scope of practice, available resources, and operational setting. Emphasis should be placed on critical interventions that are low frequency but high-risk, and on maintaining familiarity with evolving ALS protocols and local guidelines.

ANZCOR suggests that more frequent manikin-based refresher training for students of ALS courses may be better to maintain competence compared with standard retraining intervals of 12 to 24 months [CoSTR 2020, weak recommendation, very-low-certainty evidence].

ANZCOR considers the rapid decay in skills after standard ALS training to be of concern for patient care.

Governance structures

Governance structures and processes are the essential systems and procedures of oversight for consistent delivery, maintenance of standards, and review of outcomes.  They should guide all courses making statements to the rules, procedures, and other informational guidelines. In addition, governance frameworks define, guide, and provide for the enforcement of these processes.

Models for the governance will vary but should incorporate aspects of:

• Defined rules and regulations
• Organisational and individual accountability
• Administration requirements before/during and following the course
• Review processes.
• Information storage
• Health and safety requirements
• Fiscal probity
• Equity
• Participant requirements
• Instructor proficiency and conduct
• Candidate selection /eligibility
• Assessment systems
• Appeal process

Governance should comply with statutory legislative requirements and be available to all participants for review. Ongoing review of the material, structures, and participant feedback of the course should occur to ensure the substance of the course is current in the clinical and governance scope.

ANZCOR suggests that all ALS courses should have a robust process for continuous evaluation and quality improvement [Good Practice Statement].

Faculty Development

Faculty development for resuscitation course instructors remains an important element contributing to improved teaching and the learners’ outcomes in accredited life support courses. Faculty development should have an intentional focus on optimising the delivery of resuscitation curriculum in a contextualised manner for different learner groups.²

However, no clear picture of the most appropriate and most effective faculty development programs has been identified from the studies reviewed. It is recommended that any organisation offering resuscitation education should also provide faculty development programs for the teaching staff of their resuscitation programs. Different approaches need to consider the local training environment and resource availability, as well as instructors’ needs to maximize learning outcomes of such programs. The best ways to maintain and assess instructor competency whilst concurrently maximizing cost-effectiveness needs to be established by organisations individually.^1,2

Instructor training should include content on, practice with, and evaluation of key instructor competencies, including:

• Knowledge and skills associated with the science of resuscitation and the science of education.
• Use of feedback devices and approaches to dealing with the most common challenges.
• Ability to effectively debrief others and facilitate peer coaching.
• Contextualisation of content to various audiences and practice settings.
• Facilitation of the development of teamwork training skills.
• Giving and receiving feedback (e.g., peer coaching).
• Reflective practice.
• Helping instructors to recognise themselves as change agents.²

ANZCOR suggests trainers/facilitators (for courses for laypersons or healthcare professionals) must have received appropriate instruction qualifications in facilitation of learning and must receive facilitation updates on a regular basis [Good Practice Statement].

ANZCOR suggests that educators who use high-fidelity manikins and simulators must have adequate knowledge and familiarity with the capabilities of their training devices [Good Practice Statement].

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Pre Course Learning 

Simulation

Feedback

When citing the ANZCOR Guidelines we recommend:

ANZCOR, 2025, Guideline 10.2 – Advanced Life Support (ALS) Training, accessed 2 July 2025, https://www.anzcor.org/home/education-and-implementation/guideline-10-2-advanced-life-support-als-training/