How much do we Remember after CPR Training? – Experience from a Sub-Saharan Teaching HospitalAdekola OO1*, Menkiti DI2 and Desalu I1
AbstractBackground: Our hospital developed a locally adapted 3 – day CPR training programme for all doctors and nurses which consisted of lectures, practical sessions and hands-on practice using the American Heart Association guidelines. A multiple choice question pretest and a posttest on completion of the training were administered. Re-evaluation of skills acquired during such training is essential.
Aim: To evaluate the retention of knowledge in resident doctors after CPR/BLS training at the Lagos University Teaching Hospital (LUTH), Nigeria.
Patients method: Resident doctors who had undergone CPR training greater than one year preceding were administered a questionnaire (retention test) to evaluate their knowledge of BLS. The participants also self-evaluated their knowledge of BLS and their responses were compared to the mean values obtained in the retention test (RT). The results of the RT were compared to the posttest (PT) rendered at the end of their training. The paired t test and chi-square were used to determine difference between means, a p<0.05 was considered significant.
Results: Seventy-eight resident doctors from 9 different departments were recruited, 76 doctors responded (response rate 97.44%). The median interval between CPR training and RT was 1.96 (1-3) years, and 43.4% of the residents had not performed CPR in the preceding 3 months.
The mean total score for the RT was 56.39 ± 14.47% compared to the PT score of 85.67 ± 6.98%, p<0.001. Significantly lower results were observed in the RT versus the PT scores in; diagnosis of cardiac arrest in children 49.34 ± (SEM) 1.64% versus 98.36 ± SEM 5.66% p<0.001 and compression and ventilation in paediatric BLS (RT28.67 ± SEM 3.82% versus PT91.80 ± SEM 2.39%, p<0.001). 87.5% of residents self-rated themselves higher than result obtained in their RT. The self-evaluation mean score on adult BLS was 66.06 ± 16.15% versus RT score of 56.69 ± 17.64%, p<0.001. In their knowledge of paediatric BLS, RT score was 48.61 ± 36.55% versus self-evaluation score of 69.86 ± 16.97%, p<0.001. There was no significant association betweenRT score and the interval between CPR training andRT or the last time the residents performed CPR.
Conclusion: The retention of knowledge after CPR training in
*Corresponding author: Adekola OO, Department of Anaesthesia and Intensive care unit, College of Medicine University of Lagos & Lagos University Teaching Hospital, P.M.B 12003, Lagos Nigeria, E-mail: [email protected]
Received: June 17, 2013 Accepted: July 22, 2013 Published: July 25, 2013
IntroductionIn-hospital survival rate after cardiac arrest is low and depends
on the quality of cardiopulmonary resuscitation (CPR), the alarm response time, and the time to defibrillation [1-2]. All medical practitioners should be able to perform CPR with competence [3]. Level of competence has been linked to the knowledge and skill of CPR, which is a factor of continuous training. The 2010 guidelines on the initiation of BLS during a cardiac arrest consists of recognizing the cardiac arrest, calling for help, initiating chest compressions and ventilations [4].
The training and/or certification of health care professionals in cardiopulmonary resuscitation skills such as basic life support, advanced cardiac life support, pediatric advanced life support, and the neonatal resuscitation is universal worldwide [5]. It has been documented that though different health professionals such as doctors, nurses, and medical emergency technicians can successfully learn to perform CPR, the retention of knowledge and skill in CPR deteriorates among them with time [5-7]. The CPR skills have been shown to deteriorate faster than the CPR knowledge [7-9]. The observed interval for skill deterioration varied from 2 weeks of initial training with progressive deterioration until participants reach pre training levels at 1 and 2 years after initial training [8], this has led to the suggestion for regular training, follow-up interventions and annual recertification [9].
The effect of different factors on the skill of CPR has been widely investigated. Various researchers have reported no relationship between skill deterioration and advanced educational back-ground, years of experience, responsibility for patient care, self-perceived level of competence, motivation, or the potential for use of skills [8,10].
This study evaluated the retention of knowledge in resident doctors after previous CPR training of more than one year duration.
Methods and Data CollectionA non experimental survey design that used a 13 item
questionnaire to collect information on the knowledge and self-rated perception of ability to perform CPR/BLS was employed. The participants consisted of a convenience sample of resident doctors at the Lagos University Teaching Hospital who had been trained on BLS more than one year previously. Exclusion criteria included residents in the department of anaesthesia and refusal to participate in the study. Informed consent was obtained from all eligible participants.
resident doctors is poor, a greater proportion of the residents overate their residual knowledge. There is therefore a need for frequent refresher courses with emphasis on paediatric resuscitation.
KeywordsCPR training; Retention of knowledge; Resident doctors
Citation: Adekola OO, Menkiti DI, Desalu I (2013) How much do we Remember after CPR Training? – Experience from a Sub-Saharan Teaching Hospital. Analg Resusc: Curr Res S1.
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doi:http://dx.doi.org/10.4172/2324-903X.S1-009
In-hospital Cardiac Arrest
Our hospital CPR programme was based on the 2010 resuscitation guideline of the American Heart Association. Day1 commenced with a pretest (single answer MCQ) at the end of which course material were distributed to the participants. Lectures were delivered on (1) Diagnosis and causes of cardiac arrest, Patients at risk of cardiac arrest and The cardiac arrest team, (2) Basic life support – adult, child and infant, (3) Advanced life support – adult, child and infant (including defibrillator use), Cardiac arrest trolley, (4) Peri-arrest arrhythmias, (5) Post-resuscitation care and (6) Ethics of Resuscitation. This was augmented by demonstrations on manikins. Each lecture was followed by an interactive session.
On Day 2, the participants were then divided into small groups of 5-6 for the BLS, ALS and defibrillator practice sessions using appropriate manikins. Airway management involved practice on oropharyngeal and nasopharyngeal airway insertion, tracheal intubation, laryngeal mask airway and combitube insertion as well as bag-mask ventilation. There were no facilities for cricothyrotomy, intraosseous access or femoral vein cannulation.
Day 3 comprised of mainly practice sessions and team clinical scenarios. At the end of the third day, the posttest was carried out. (MCQ paper as well as a skill test). Skill testing was made up of 5 skill stations; Opening of the airway (plus assessment of breathing), Chest compressions in adult, paediatric and infant manikin, Bag mask ventilation, Advanced airway insertion and AED use. A pass was awarded to participants who scored > 75% in the post-test and passed all 5 skill stations.
The retention test was extracted from the CPR posttest. Questions focused on Diagnosis of cardiac arrest as well as Adult and Paediatric BLS appendix I. The retention test questions were subjected to internal validation prior to use. Participants were asked to self-rate their knowledge on the Diagnosis of cardiac arrest, Adult BLS and Paediatric BLS using a VAS scale of 0-100%. All data collected was analysed using the SPSS version 20 software, the paired t test was used to determine the difference between the means of the posttest (PT) and retention test (RT), the means of the self-rated perception of ability to perform CPR/BLS and the actual retention test (RT) scores. The Chi-square test was used to determine if there was an association between the retention score and confounding factors such as age, department of training and length since CPR training.The spearman’s correlation was used to determine a relationship between the RT scores and the last time CPR was performed by the residents, age, interval after CPR training and experience as a physician. A p<0.05 was considered significant.
ResultsSeventy-eight resident doctors were recruited and 76 responded
(response rate 97.44%). The mean age and M:F ratio were 31.89 ± 3.72 years and 4:3 respectively.
The doctors were from 9 different departments with most 19 (25%) from the Department of Surgery as shown in Figure 1. The median interval between CPR training and retention test was 1.96 (1-3) years. 56.4% of the residents had not performed CPR in the preceding 3 months as shown in Table 1. There was no association between the retention test and age, years of experience, or interval since CPR training. There was no significant correlation (Spearman’s) between the last time CPR was performed and the retention test scores (rho =-0.155, p =0.195), age (rho =-0.035, p=0.862), year of
experience as a physician (rho -0.128, p=0.338) and the interval after CPR training (rho -0.023, p=0.847).
The mean score for the retention test was 56.39 ± 14.47% while that of the post test was 85.67 ± 6.98%, (p<0.001).
Significantly lower results were observed in the retention versus the post-test scores in the; Diagnosis of cardiac arrest in children 49.34 ± (SEM) 1.64% versus 98.36 ± SEM 5.66% p<0.001 and compression and ventilation in paediatric BLS (RT28.67 ± SEM 3.82% versus PT91.80 ± SEM 2.39% p<0.001) as shown in Table 2.
When the paediatric residents were analysed separately, there was no difference in their RT scores (39.98 ± 14.98%) compared to residents from other departments (30.96 ± 26.02%), p=0.448. Residents in the adult emergency department obtained a significantly higher RT score (55.55 ± 40.38%) than those from the other departments (29.88 ± 23.14%), p=0.017.
No difference was observed between the overall knowledge of diagnosis of cardiac arrest in the RT (72 ± 30.11%) and the self-rated score (73.57 ± 18.61%), p=0.680. Significantly lower results were however obtained in the RT versus the self-rated scores inthe knowledge of BLS in children (48.61 ± 36.55%) versus (69.86 ± 16.97%), p=<0.001, and knowledge of BLS in adults (RT score of 56.69 ± 17.64% versus self-rated score of 66.06 ± 16.15%, p =<0.001 as shown in Table 3. The residents in paediatric department did not perform better than their counterparts in other departments.
Discussion
Figure 1: The distribution of Resident Doctors by department.
Time CPR was last performed No (n) Frequency (f)
< 3 months 33 43.40%
3-6 months 15 19.80%
>6 months-1 year 4 5.20%
>1 year 24 31.60%
Total 76 100%
Table 1: Frequency distribution of time CPR was last performed.
Citation: Adekola OO, Menkiti DI, Desalu I (2013) How much do we Remember after CPR Training? – Experience from a Sub-Saharan Teaching Hospital. Analg Resusc: Curr Res S1.
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doi:http://dx.doi.org/10.4172/2324-903X.S1-009
In-hospital Cardiac Arrest
This study has demonstrated a significant decline in knowledge of CPR amongst resident doctors at our institution despite having received adequate training. Significant lapses in knowledge were identified in diagnosing of paediatric cardiac arrest, adult basic life support and paediatric basic life support. Our hospital is a 770 bed referral hospital which established a multi-disciplinary Resuscitation Training unit with the aim of training all doctors and nurses in the hospital in BLS, ALS and other resuscitation skills.
The median time since CPR training and the retention test of 1.9 yearsis close to an average time of 1.6 years reported before a group of nurses received update training in CPR [10]. This time interval has been shown to fall short of the recommendations that update should be done every six months for one to maintain adequate knowledge and skills in the urgent/emergency field [11]. This is important for continuous professional education. The less frequently an individual updates their knowledge, the lower the retention of knowledge/skills expected, since theoretical knowledge and skills tend to decline over time [11,12]. However, Galinski et al. [13] reported that the theoretical knowledge on CPR was still insufficient and fell short of international standards in 64% of nurses despite the fact that they recently attended an update programme.
Poor results obtained after CPR training may be as a consequence of infrequent participation in CPR [8]. This was demonstrated in our study as a greater proportion of the respondents had not participated in CPR for cardiac arrest in the preceding three months. Though there is a resuscitation team in place who are routinely informed of any cardiac arrest in our hospital, it is expected that basic life support would have commenced and be on-going before the resuscitation team arrived. Survival rate after cardiac arrest is dependent on prompt diagnosis and commencement of chest compressions. It is therefore imperative that other health care professionals should play an active role during CPR, and should not consider resuscitation as the main duty of the members of the resuscitation team only. As our
resuscitation team is made up of mainly anaesthetic resident doctors, they were excluded from the study.
There was no association between retention test and age, years of experience, department of resident, interval since CPR training or the last time the respondents performed CPR in this study. There are conflicting reports on the effect of confounding factors on the retention score. Some researchers had reported that none of these factors influenced the retention score in their studies [8,10]. They, however, suggested that adequate practice may have a positive influence on retention of either the knowledge or skill of CPR [8,10]. In contrast, Yang et al. [14] in a systematic review reported that clinical experience, either prior to or after the courses, had a positive impact on retention of knowledge and skills. The observation in our study should be taken with caution as this was a convenient sample of resident doctors, there may be a need to stratify the study population either by their age or interval since CPR training as this may result in a different observation.
Interestingly, Olivetto de Almeida et al. [11] observed significantly higher median scores on ALS in male nurses than their female counterparts, while Filgueiras et al. [15] observed that female nurses scored significantly higher average score on knowledge of ALS than their male colleagues. We however observed no association between the knowledge of BLS and genders.
Though this study revealed worse results in BLS in children, we were not able to demonstrate any significant differences in retention test scores between paediatric residents when compared to their counterpart. This may be because most of the paediatric residents sampled were on posting in the paediatric in-patient unit of the hospital. If they had been in the paediatric emergency department where patients are acutely ill and therefore more likely to need CPR, the observation might have been different. This was clearly shown
Table 2: The Comparison of the Posttest and Retention test scores among Resident Doctors.
The data represents the mean ± SD of scores obtained from the posttest after resuscitation training and retention of knowledge test, a p value <0.05 was considered significant.
Parameter Self-rated score Mean ± SD (%) Actual retention score Mean ± SD (%) p value
Knowledge of Diagnosis of CPR 73.57 ± 18.61 72 ± 30.11 0.68
Table 3: The presentation of self-rating score among resident doctors.
The data represents the mean ± SD of scores obtained from the self-rated assessment of CPR knowledge by residents and actual score obtained from the retention of knowledge test, a p value <0.05 was considered significant.
Citation: Adekola OO, Menkiti DI, Desalu I (2013) How much do we Remember after CPR Training? – Experience from a Sub-Saharan Teaching Hospital. Analg Resusc: Curr Res S1.
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doi:http://dx.doi.org/10.4172/2324-903X.S1-009
In-hospital Cardiac Arrest
as the residents in the adult accident and emergency department performed better than all the other residents. This may be because they are exposed to victims with trauma and critically ill patients that require triage, they also have the posters and guidelines for BLS and ALS CPR around them to refresh their memory. Although at the time of this survey the residents were not in the areas where the posters were attached. It is suggested that in future studies more attention should be paid to the unit of posting of the resident doctors.
We also observed that the mean retention test score was significantly lower than the mean score obtained when the residents were asked to self-rate their knowledge on Adult and Paediatric BLS. This may suggest that our residents lack insight into their knowledgeon CPR. It is suggested that for adequate retention of knowledge and skill on CPR, health care professional require regular update and performance of CPR during cardiac arrest.
ConclusionThe retention of knowledge after CPR training in our resident
doctors was poor; a greater proportion of them over-rated their residual knowledge. This may translate into poor management of cardiac arrest when the need arises. There is therefore a need for our hospital to organize frequent refresher courses with emphasis on paediatric resuscitation. References
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Author Affiliations Top1Department of Anaesthesia and Intensive Care Unit, College of Medicine University of Lagos & Lagos University Teaching Hospital, P.M.B 12003, Lagos, Nigeria2Department of Anaesthesia and Intensive Care Unit, Lagos University Teaching Hospital, P.M.B 12003, Lagos, Nigeria
This article is published in the special issue, In-hospital Cardiac Arrest and has been edited by Dr. Niels Henrik Krarup, Aarhus University Hospital, Denmark
