Effectiveness of Cascade Basic Life Support (BLS) Training for Ambulance Drivers in Nepal: A Cluster Randomized Controlled Trial

Last registered on March 10, 2026
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Pre-Trial

Trial Information

General Information

Title
Effectiveness of Cascade Basic Life Support (BLS) Training for Ambulance Drivers in Nepal: A Cluster Randomized Controlled Trial
RCT ID
AEARCTR-0017992
Initial registration date
March 03, 2026

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
March 10, 2026, 10:15 AM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

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Primary Investigator

Name
Deepak C. Bajracharya
Affiliation
G.T.A. Foundation
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Other Primary Investigator(s)

PI Name
Kshitij Karki
PI Affiliation
G.T.A. Foundation
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PI Name
Priyadarshini Shah Singh
PI Affiliation
G.T.A. Foundation
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PI Name
Rakchya Amatya
PI Affiliation
G.T.A. Foundation
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PI Name
Surabhi Regmi
PI Affiliation
G.T.A. Foundation
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PI Name
Binay Rauniyar
PI Affiliation
Shree Gangalal National Heart Center
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Additional Trial Information

Status
In development
Start date
2026-03-08
End date
2027-01-31
Keywords
Behavior, Education, Health
Additional Keywords
Basic Life Support, Training, CPR
JEL code(s)
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
Out-of-hospital cardiac arrest (OHCA) remains a major cause of preventable mortality worldwide, with survival critically dependent on the early initiation of high-quality cardiopulmonary resuscitation (CPR) by first responders. Global systematic reviews report survival to hospital discharge after OHCA to be below 10%, with substantial variation related to the timeliness and quality of CPR and system preparedness. In low- and middle-income countries (LMICs), including Nepal, prehospital emergency care systems are still developing, and ambulance personnel often have limited access to standardized Basic Life Support (BLS) training and refreshers.
This cluster randomized controlled trial evaluates the effectiveness of a cascade Training of Trainers (ToT) model for BLS training among ambulance drivers across selected urban (Parsa, Kaski), semi-urban (Rautahat, Sarlahi, Bara, Dhanusha), and rural (Tanahun, Gorkha) districts of Nepal. Thirty health professionals (20 intervention, 10 control) will be trained as master trainers, who will subsequently deliver standardized BLS training to 360 ambulance drivers (240 intervention, 120 control). The intervention integrates low-cost simulation, blended e-learning, and regular recall sessions, an approach that has been shown to improve CPR quality and long-term skill retention.
The primary outcome is CPR knowledge and skill performance assessed through standardized simulation-based evaluation, and OHCA survival assessed through Utstein measure. Secondary outcomes include return of spontaneous circulation (ROSC), skill retention and implementation outcomes, including training fidelity. A mixed-methods approach will integrate cluster-adjusted quantitative analyses with qualitative exploration of contextual barriers. The findings will generate nationally relevant evidence to inform the National Health Training Centre, Ministry of Health and Population, and National Health Research Council on scalable strategies for strengthening prehospital BLS training and improving survival from cardiac arrest in Nepal.
External Link(s)

Registration Citation

Citation
Amatya, Rakchya et al. 2026. "Effectiveness of Cascade Basic Life Support (BLS) Training for Ambulance Drivers in Nepal: A Cluster Randomized Controlled Trial." AEA RCT Registry. March 10. https://doi.org/10.1257/rct.17992-1.0
Sponsors & Partners

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Experimental Details

Interventions

Intervention(s)
In the intervention arm, a Training of Trainers (ToT) program will be conducted for twenty health professionals across four selected districts. Participants will be health workers who work closely with ambulance drivers, including nurses, emergency medical technicians (EMTs), and paramedics.
Following the completion of the Training of Trainers (ToT), the trained health professionals will cascade the BLS training to 240 ambulance drivers in the intervention districts.
The training will be conducted in-person over a 3 to 4 hours session, combining interactive lectures with simulation-based practical exercises. The program is designed to improve drivers’ knowledge, skills, and confidence in providing BLS during out-of-hospital cardiac emergencies.

Recall sessions will be provided to both Trainers (health professionals) and ambulance drivers to reinforce knowledge and skills.
• Trainers: Each trainer will receive one refresher session, which will consist of modules from the HeartCode online learning platform. This will ensure that trainers remain up-to-date with BLS guidelines and instructional techniques.

• Ambulance Drivers: Each driver will receive the monthly recall sessions, considering their demanding emergency duties and limited availability for extended training. The recall sessions will focus on reinforcing BLS skills and scenario-based practice.
Intervention Start Date
2026-05-01
Intervention End Date
2026-10-31

Primary Outcomes

Primary Outcomes (end points)
• Improvement in BLS knowledge and skills of the participants
Primary Outcomes (explanation)

Secondary Outcomes

Secondary Outcomes (end points)
• Improvement in OHCA outcome (e.g., Survival, Return of spontaneous circulation)
• Retention of CPR skills and knowledge
• Improvement in training fidelity
• Scalable training model for Nepal’s ambulance drivers and EMT in Nepal
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
This study will be a cluster randomized controlled trial (cRCT) conducted across selected eight districts of Nepal. Districts will serve as the unit of randomization to minimize contamination between participants.
Experimental Design Details
Not available
Randomization Method
The randomization will be done through public lottery method.
Randomization Unit
The study will be conducted in eight districts, with four districts allocated to the intervention arm and four to the control arm, selected from each stratum (urban, semi-urban, and rural) to ensure representation across different settings. Each district will be considered as a single cluster to minimize contamination between trained and untrained ambulance drivers. All eligible ambulance drivers within each district will be enrolled, and participants will be allocated proportionally based on the number of eligible drivers in each district to reach the target sample size.
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
8 districts
Sample size: planned number of observations
360 ambulance drivers; and 30 health professionals
Sample size (or number of clusters) by treatment arms
Ambulance drivers (240 intervention, 120 control) and
Health professionals (20 intervention, 10 control)
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
The study employs a cluster-randomized design to minimize contamination between trained and untrained ambulance drivers, inspired by the NAA 2019 India RCT. Sample size was calculated using G*Power v3.1.9.7 for detecting a moderate effect size (Cohen’s d = 0.5) with 80% power, α = 0.05, and a 2:1 allocation ratio (intervention: control). Accounting for clustering effects (ICC = 0.05), 20% potential attrition, and operational feasibility.
Supporting Documents and Materials

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IRB

Institutional Review Boards (IRBs)

IRB Name
IRB Approval Date
IRB Approval Number
Analysis Plan

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