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Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 842-846  

Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention in young doctors joining postgraduation program


Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India

Date of Web Publication28-Nov-2017

Correspondence Address:
Vidhu Bhatnagar
Department of Anaesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_239_16

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   Abstract 


Background: High-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation the cornerstone for resuscitation from cardiac arrest and increase the incidence of return of spontaneous circulation. Regular CPR training imparted to health-care personnel increases knowledge and helps in skill enhancing. Aims: The aim of this study is to evaluate background knowledge, percentage improvement in the skills, and residual knowledge after a period of 6 months of postgraduate (PG) students as well as the efficacy of the designed teaching program for CPR. Design: The study type was interventional, nonrandomized with end point classification as efficacy study. Study Interventional model was single group assignment. Methods: A questionnaire-based study was conducted on 41 first year PG students. Their educational qualification was Bachelor of Medicine and Bachelor of Surgery. The study was conducted; 3 months after, these PG students joined hospital for their PG studies. The questionnaire designed by the Department of Anesthesiology and Critical Care was given as the pretest (before the CPR training program was initiated), posttest (immediately after the CPR training program was concluded), and residual knowledge test (conducted after 6 months of the CPR training program). After collection of data, a descriptive analysis was performed to evaluate results. Statistical Analysis: Statistical analysis was conducted for determining the test of significance using two-tailed, paired t-test. Results: The average overall score was 25.58 (±5.605) marks out of a maximum of 40 marks in the pretest, i.e., 63.97%. It improved to 33.88 (±3.38) marks in posttest, i.e., 84.74%. After 6 months in the residual knowledge test, the score declined to 26.96 (±6.09) marks, i.e., 67.4%. Conclusion: The CPR training program being conducted was adequately efficacious, but a refresher course after 6 months could help taking the knowledge and skills acquired by our PG students a long way.

Keywords: Advanced cardiac life support, airway management, arrhythmias, cardiac, cardiopulmonary resuscitation, knowledge


How to cite this article:
Bhatnagar V, Tandon U, Jinjil K, Dwivedi D, Kiran S, Verma R. Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention in young doctors joining postgraduation program. Anesth Essays Res 2017;11:842-6

How to cite this URL:
Bhatnagar V, Tandon U, Jinjil K, Dwivedi D, Kiran S, Verma R. Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention in young doctors joining postgraduation program. Anesth Essays Res [serial online] 2017 [cited 2019 Aug 23];11:842-6. Available from: http://www.aeronline.org/text.asp?2017/11/4/842/205226




   Introduction Top


Excellent cardiopulmonary resuscitation (CPR) or high-quality CPR is the key to achieve adequate cerebral and coronary perfusion, thereby improving the patient's chances for neurologically intact survival. Although the 2010 and 2015 American Heart Association (AHA) Guidelines for basic life support (BLS) and advanced cardiovascular life support (ACLS) suggest several revisions, including the sequence for resuscitation, medications, electrical therapy, and monitoring, the emphasis on high-quality CPR and its critical role in resuscitative efforts remains unchanged. The survival rates from in-hospital cardiac arrest are estimated to be <20% despite advent of new techniques and technology.[1],[2] It has been shown by various studies that in hospital personnel perform inadequate or ineffective BLS due to irregular training and low retention skills.[1],[3] AHA recommends CPR update course once in 2 years. In our country, at present, CPR is a skill recommended as desirable for Bachelor of Medicine and Bachelor of Surgery (MBBS) graduate. Ours being a teaching institute, the recommendation followed in our institute is CPR training program to be conducted as soon as a new batch of postgraduate (PG) students join. All these doctors have a minimum 3 years of experience after MBBS and have been certified in BLS around 2 years before joining PG. At present, we conduct training on mannequins for all medical personnel for BLS every 2–3 years, but as yet, we have no recommendations on time interval for conducting repeat training.

The aim of this questionnaire-based study was to investigate background knowledge of PG students, evaluate the efficacy of the designed teaching program for CPR, evaluate percentage improvement in the skills of the PG students, and evaluate residual knowledge after a period of 6 months.


   Methods Top


The study took place in August 2015 in our institution, which is an 840 bedded, super-specialty, tertiary care center and a teaching Institute. Clearance from the Institutional Ethics Committee was taken for the study. The hospital offers 10 h, instructor-led BLS, and ACLS program with incorporated lecture series and hands-on training on mannequins. The CPR program was based on 2015 AHA guidelines for BLS and ACLS. The CPR training program was divided into lecture series and hands-on training. The lecture series consisted of BLS guidelines, airway anatomy and devices, and ACLS guidelines and total time allocated for these lecture series were 90 min. The hands-on training was given a time frame of 8 h. BLS hands-on training was imparted for 180 min whereas 300 min were exclusively kept for ACLS training. The students were divided into ten batches of four each, thus the student to mannequin ratio was 1:4. The stations during BLS training were (a) chest compression station, (b) pocket mask ventilation, (c) chest compression and pocket mask ventilation together, (d) infant compression and ventilation, and (e) assessment and application. Each batch of four students got 18 min/station and was rotated ten times, thus giving them enough time to practice on each station.

During their ACLS training, each batch got 30 min on a station and was rotated ten times for enough practice. The stations were (a) airway assessment and airway adjuncts, (b) bag-valve-mask ventilation, (c) drugs and defibrillation, (d) electrocardiogram (ECG) and defibrillation, and (e) mega codes. The last station was an assessment of the psychomotor skills and the application of whatever was taught during the training program. Each batch during BLS and ACLS training received the opportunity to work on the same station twice.

Participant characteristics

The study population consisted of the 41 first year PG students who had joined PG program in their respective departments 3 months earlier. The educational qualification of the study population is MBBS. Since the PG students join the institute from a varied background and are expected to perform their duties in their respective departments as well as in emergency department on rotation, it is an institutional practice to incorporate resuscitation training in their academic curriculum. The resuscitation training is conducted by the Department of Anaesthesiology and Critical Care, of our institution, with the help of lecture series and hands-on training. The study population consisted of first year PG students from all departments and belonged to age bracket 24–28 years. The participation in the questionnaire study was voluntary and anonymous though the name of the department was added. No demographic variables were registered.

Questionnaire development

The questionnaire was developed by the Department of Anesthesiology and Critical care of our Institution and consisted of total forty questions with 30% of the questionnaire dedicated to questions on BLS while the rest 70% were dedicated to ACLS. The ACLS questions were divided as follows 35% on airway management, 15% on the identification of ECG rhythm, and 15% on tachycardia and bradycardia protocol, 35% was dedicated to drugs. BLS questions composed of all the steps suggested in 2015 AHA BLS guidelines.

Data collection

The pretest data were collected by questionnaire handed over to the participants at the beginning of the course, without prior notice. Posttest data were collected immediately after the CPR training program was concluded. Residual knowledge test data were collected in an academic meeting in the hospital after 6 months from the date of the CPR training program. The participants were given 15 min to complete the evaluation, on all three times.

Statistical analysis

The study type was interventional (intervention being the CPR program conducted to enhance knowledge and skills), study design being nonrandomized with end-point classification as efficacy study (posttest data to test knowledge and skills). Study Interventional model was single group assignment (study population consisting of doctors, post-MBBS enrolled as first year PG students). Statistical analysis was conducted for determining the test of significance using two-tailed, paired t-test. A confidence interval of 0.05 was taken for P value.

The primary purpose was enhancement of knowledge and skills in the study population, and testing efficacy of the intervention (CPR program) conducted.

Primary outcome measures

Prior knowledge of CPR in accordance with 2015 AHA guidelines and enhancement in knowledge and skills post-CPR training program were the outcome measures.

The secondary outcome measures

Evaluation of the efficacy of the CPR program designed, and evaluation of the deficiency areas in knowledge after 6 months were the outcome measures.


   Results Top


None of the participants from the study population had any exposure to AHA certified BLS and ACLS programs. No demographic variables were present as the study was voluntary and anonymous, but by virtue of being a single group assignment, the age group could be deduced to between 24 and 28 years of age. There was 100% participation in all the three tests (pre, post, and residual knowledge test). Maximum retention was seen in the streams of anesthesiology, medicine, and surgery. Their retention was 78%, 74.5, and 72%, respectively.

Overall score

The average overall score was 12.79 (±5.605) marks out of a maximum of 20 marks in the pretest, i.e., 63.97%. It improved to 16.94 (±3.38) marks in posttest, i.e., 84.74%. This was statistically significant (P = 0.0037). After 6 months in the residual knowledge test, the score declined to 13.48 (±6.09) marks, i.e., 67.4% [Figure 1]. This decline between the posttest and residual knowledge test was again statistically significant (P < 0.05). However, the mild improvement between the pretest and residual knowledge test was not significant (P = 0.824).
Figure 1: Percentage scores in basic life support, advanced cardiovascular life support, and total scores at pre, post, and 6 months

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Pass percentage

A score of 50% was considered as “Pass.” In the pretest, 4 (9.7%) PG residents failed the test. In the posttest, there was 100% pass rate. Whereas in the residual knowledge test, 2 (4.8%) PG residents failed the test. Therefore, the number of failures halved in comparison to the pretest.

Knowledge of basic life support

The average pretest score of BLS knowledge was 4.84 (±2.05), i.e., 80.6% out of a total score of 6. This score improved to 5.86 (±0.94), i.e., 97.74%. This was statistically significant (P = 0.00001). After 6 months in the residual knowledge test, it declined to 4.92 (±2.49), i.e., 82%. This decline between the posttest and 6 months was again statistically significant (P = 0.00016). However, the mild improvement between the pretest and 6 months was not statistically significant (P = 0.184).

Knowledge of advanced cardiac life support

The average pretest score of ACLS knowledge was 7.94 (±4.70), i.e., 56.7% out of a total score of 14. This score improved to 11.27 (±3.65), i.e., 80.5%. This was statistically significant (P = 0.00000002). After 6 months in the residual knowledge test, it declined to 8.56 (±4.08), i.e., 61.1%. This decline between the posttest and 6 months was again statistically significant (P = 0.0007). However, the mild improvement between the pretest and 6 months was not statistically significant (P = 0.412).

In the breakup of ACLS questions, asystole identification was done correctly by 11% in pretest, 96% in posttest, whereas 62% in residual knowledge test. Ventricular tachycardia rhythm on ECG was correctly identified by 40, 81, and 62% in the pretest, posttest, and residual knowledge test, respectively. The question on tachycardia protocol was answered correctly by 73, 81, and 68.75% in the pretest, posttest and residual knowledge test, respectively. The questions on bradycardia protocol fared poorly though with 39, 50, and 6.25% correct answers in the pretest, posttest, and residual knowledge test, respectively [Figure 2]. The questions on airway management were correctly answered by 46.88, 68.75, and 50% of the study population in the pretest, posttest, and residual knowledge test, respectively [Table 1].
Figure 2: Percentage of subjects who correctly identified the various advanced cardiovascular life support protocols at pre, post, and 6 months

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Table 1: The average percentages of scores obtained by respondents and the correct responses in various ACLS protocols

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   Discussion Top


High-quality CPR and rapid defibrillation are two very important steps in resuscitation.[1] Adequate knowledge with skills is required for correct delivery of CPR. Thus, it is advisable to provide training for resuscitation, in accordance with latest guidelines of AHA, in the teaching institutes.[2] CPR skills degrade quickly and require training at regular intervals.[3],[4],[5] Evidence is also available to prove that experienced and trained physicians, working in acute care settings or critical care have satisfactory CPR performance skills.[6],[7],[8] There are no systematic reviews available on the efficacy and retention of training of CPR skills. Few studies are available, but there is requirement of multicentric, long-term studies on a larger study sample with standardized course program.

A study about effectiveness and retention of training for CPR and automated external defibrillator (AED) was conducted by Roppolo et al. in 2007 and he concluded that performance following 30-min training was either equivalent or superior (P < 0.007) to the multi-hour heart saver- AED training in all measurements, both immediately and 6 months after training. Although retention of certain skills deteriorated over the period of 6 months in test and control group, but the test group was still performing the chest compressions adequately and applied AED correctly and delivered shocks correctly.[9] A study to assess and compare the theoretical knowledge on BLS and ALS in nurses and doctors was conducted in 2011 by Passali et al. 134 doctors and 82 nurses responded to the questionnaire-based study consisting of questions on demography, experience in resuscitation, and theory knowledge. The results demonstrated deficiencies in knowledge of current BLS and ACLS guidelines, both in doctors and nurses. Those from the study population worked in high-risk areas for cardiac arrest scored higher than those working in low-risk areas.[10]

We conduct CPR training as a routine part of our academic schedule followed in our institute, for our first year PG students; however, this study was conducted with the intentions to evaluate the efficacy of our 10 h training program with lecture series and hands-on training. The secondary objective was to find out the time frame when the deficiencies in the knowledge are pronounced. The residual knowledge test after 6 months was conducted with these intentions.

This study demonstrated that the current CPR training program of the hospital is efficacious in instilling the basic knowledge about BLS and ACLS among PG Residents. The score immediately after the training program was nearly 100%. However, the residual knowledge after a period of 6 months was almost similar before the training program with no statistical significance, signifying that the knowledge about CPR as assessed by this test reduced to pretraining levels after 6 months. The number of candidates who “failed” the test decreased from 9.7% to 4.8% in the period. It is pertinent to note that the knowledge about BLS remained almost static whereas the residual knowledge of ACLS showed an improvement even after the 6 month period though it was not statistically significant. The standard deviation of the scores reveals that post the training program, the knowledge of the PG residents is homogenous; whereas, after 6 months, it is widely disparate. The anesthesiology, medicine, and surgery PG residents scored 78%, 74.5%, and 72%, respectively in their residual knowledge test. The most probable reason for this disparity was involvement of the residents of these streams in the hospital's code blue team. Dissimilar exposure to critical cases among the various specialties to which the PG residents belonged to also could be the culprit for this disparity. Hence, the need to utilize and retain this knowledge differed. Therefore, this study highlights the requirement of refresher training in CPR after a period of 6 months with more emphasis on BLS. The residual knowledge test assessed only the cognitive skills while the psychomotor skills were not assessed. The need for psychomotor assessment after period of 6 months was also projected to the academic council of our Institution. It can be said that this refresher is perhaps more useful particularly for those specialties that witness lesser number of critical cases. However, the reason for this wide disparity after 6 months of PG training needs to be researched by follow-up study.


   Summary Top


The primary purpose of conducting this study was knowledge and skill enhancement in the study population and testing the efficacy of the CPR program, which was fulfilled. As a primary outcome measure, we could also evaluate the knowledge and skills in accordance with 2015 AHA guidelines in the study population. We could also evaluate the enhancement in knowledge and skills post-CPR training program in the study population. As a secondary outcome measure, we could evaluate the efficacy of the CPR training program after a period of 6 months. We could also demarcate the deficiency areas which required reinforcement of knowledge.

Strengths of the study

The same subjects were followed up for a period of 6 months.

Limitation of the study

The sample size is less, and the subjects may be followed up for a longer period of time for retention of knowledge and skills.

There are no controversies raised by this study. Future research directions should be directed toward intra-specialty CPR skill retention so that targeted refresher courses and hands-on training can be designed.


   Conclusion Top


There are deficiencies in knowledge and skills of doctors, especially those working outside critical areas as seen by the pretest. On the basis of our percentage improvement in posttest and residual knowledge test, we came to conclusion that the training program being conducted by the Department of Anaesthesia and Critical care was adequately efficacious but a refresher course after 6 months could help taking the knowledge and skills acquired by our PG students a long way. The recommendations on similar lines were sent to the academic cell of our institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Valenzuela TD, Kern KB, Clark LL, Berg RA, Berg MD, Berg DD, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation 2005;112:1259-65.  Back to cited text no. 1
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Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: Incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007;33:237-45.  Back to cited text no. 2
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Weil MH, Fries M. In-hospital cardiac arrest. Crit Care Med 2005;33:2825-30.  Back to cited text no. 3
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Hamilton R. Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: A review of the literature. J Adv Nurs 2005;51:288-97.  Back to cited text no. 4
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Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008;78:59-65.  Back to cited text no. 5
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Buck-Barrett I, Squire I. The use of basic life support skills by hospital staff; what skills should be taught? Resuscitation 2004;60:39-44.  Back to cited text no. 6
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Skrifvars MB, Castrén M, Kurola J, Rosenberg PH. In-hospital cardiopulmonary resuscitation: Organization, management and training in hospitals of different levels of care. Acta Anaesthesiol Scand 2002;46:458-63.  Back to cited text no. 7
    
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Losert H, Sterz F, Köhler K, Sodeck G, Fleischhackl R, Eisenburger P, et al. Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Arch Intern Med 2006;166:2375-80.  Back to cited text no. 8
    
9.
Roppolo LP, Pepe PE, Campbell L, Ohman K, Kulkarni H, Miller R, et al. Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Airlines Study. Resuscitation 2007;74:276-85.  Back to cited text no. 9
    
10.
Passali C, Pantazopoulos I, Dontas I, Patsaki A, Barouxis D, Troupis G, et al. Evaluation of nurses' and doctors' knowledge of basic & advanced life support resuscitation guidelines. Nurse Educ Pract 2011;11:365-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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