|ORIGINAL RESEARCH REPORT
|Year : 2014 | Volume
| Issue : 1 | Page : 12-16
Grade of a doctor does not influence acquisition of knowledge and skill during CPR training in a developing country
Olufemi B Bankole1, Ibironke Desalu2, John O Olatosi2, Babawale T Bello3, Olanrewaju N Akanmu2
1 Department of Surgery, Neurosurgical Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Anaesthesia, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Medicine, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||21-Jul-2014|
Olufemi B Bankole
Department of Surgery, College of Medicine, University of Lagos, P.M.B 12003, Lagos
Source of Support: None, Conflict of Interest: None
Background: Our teaching hospitals have different grades of doctors with varied exposure to cardiac arrest settings and their resuscitation skills are often inadequate. Objectives: We investigated whether the grade of a doctor influenced acquisition of knowledge and skill during cardiopulmonary resuscitation (CPR) training in Nigeria. Materials and Methods: Doctors who attended a two-day resuscitation training program between December 2007 and April 2009 were scored on their knowledge of Basic Life Support, Advanced Life Support, and performance at five skill stations. A pass mark was awarded for a post-test score ≥ 75% and a pass in all skill stations. Results: A total of 130 doctors were studied with a mean of 10.99 ± 6.51 years since medical qualification (range, 2-28 years). The mean pre-test score was 54.43 ± 16.10% (range 30.5-91.8%) while the mean post-test score was 88.48 ± 6.8% (range, 54.6-94%), (P < 0.001). Mean post-test scores were not significantly different between grades. Mean scores for questions on Basic Life Support, defibrillator use, and drug therapy and in performance at skill stations were not significantly different between grades. A significant difference however existed in questions on cardiac arrest rhythms (P = 0.031). Sixty-five participants (50%) passed the post-test at first attempt. Consultants, senior registrars, and registrars had pass rates of 59.2%, 53.6%, and 43.5% respectively (P = 0.336). After re-training at performance stations, 124 doctors (95.4%) passed the test with no significant difference in overall pass in the various grades (P = 0.605). Conclusion : Grade of doctor did not affect the acquisition of knowledge and skill during resuscitation training.
Keywords: Cardiopulmonary resuscitation, knowledge acquisition, training
|How to cite this article:|
Bankole OB, Desalu I, Olatosi JO, Bello BT, Akanmu ON. Grade of a doctor does not influence acquisition of knowledge and skill during CPR training in a developing country. J Clin Sci 2014;11:12-6
|How to cite this URL:|
Bankole OB, Desalu I, Olatosi JO, Bello BT, Akanmu ON. Grade of a doctor does not influence acquisition of knowledge and skill during CPR training in a developing country. J Clin Sci [serial online] 2014 [cited 2019 Jan 21];11:12-6. Available from: http://www.jcsjournal.org/text.asp?2014/11/1/12/137243
| Introduction|| |
The need for formal training and education in cardiopulmonary resuscitation (CPR) has increasingly become more obvious in recent years. In Nigeria, most doctors do not receive sufficient exposure to CPR while in medical school and depending on their choice of specialty, very little even during residency training. With the changing epidemiology of disease from mostly communicable diseases to non-communicable diseases in resource poor environments like ours, this deficiency in skilled manpower can be devastating.
When asked, most clinicians recognized the importance of being competent in CPR; however, most were not usually confident of their own expertise to conduct successful CPR. Desalu et al.,  reported a low level of confidence in performing CPR amongst a sample of trainee anesthetists in Nigeria. It has been reported that a high confidence level impacts positively on outcome following CPR.  In our hospital there are no dedicated cardiac arrest teams, and most doctors are not engaged or empowered to perform CPR. Only anesthetists/intensivists are usually called out to intervene in the event of a cardiac arrest. This we think will have serious implications for the confidence and skill level of doctors in other specialties. Research showed that experience of CPR was associated with increased confidence but not necessarily with increased skill. 
While CPR is relatively easily taught, retention and proficiency of newly acquired skills and information is notoriously difficult, especially if not supported with regular use. The ability to learn and retain "new" clinical skills has been associated with years of clinical practice.  It is likely that recent graduates from medical school may find it easier to remember and adopt the emerging concepts involved in CPR. On the other hand, we think doctors many years post qualification may better appreciate the importance of CPR and hence, be more motivated to learn well.
In order to improve the knowledge and skills of its doctors, the Lagos University Teaching Hospital established a resuscitation training program patterned after the 2005 guidelines of the Resuscitation council (UK). The course includes both Basic Life Support (BLS) and Advanced Life Support (ALS) and is conducted over two days. Participants were drawn from various specialties and ranged from house officers to senior consultants, several decades old in the medical profession.
Local research has shown a very poor knowledge of CPR among medical and health workers generally. , The aim of our study was to determine if years of experience had any influence on acquisition of knowledge and skills in conducting CPR.
| Materials and Methods|| |
This was a prospective study carried out at the resuscitation training program of the Lagos University Teaching Hospital, Lagos, Nigeria between December 2007 and April 2009. The program was based on the 2005 Resuscitation Council (UK) Guidelines.  All participants attended the two-day program held at the hospital. Consultant anesthetists were resource persons during the training program and were not evaluated as participants.
Day 1 of the program commenced with a pre-test (MCQ and SAQ style) at the end of which the course materials were distributed to the participants. Lectures were then given on: (1) Diagnosis and causes of cardiac arrest, patients at risk of cardiac arrest, the cardiac arrest team, (2) Basic Life Support, (3) Advanced Life Support, Cardiac arrest trolley, (4) Peri-arrest arrhythmias, (5) Post-resuscitation care, and (6) Ethics of Resuscitation. This was augmented by demonstration on mannequins. Each lecture was followed by an interactive session.
Day 2 commenced with videos depicting BLS, ALS with Automated External defibrillator (AED), and standard defibrillator use. Participants were then divided into groups for BLS practice and ALS practice both on mannequins and the Microsim (Laerdal Medical, SP1010rev A) interactive simulator CD-Rom. Airway management permitted practice on oro- and nasopharyngeal airway insertion, tracheal intubation, laryngeal mask airway, and combitube insertion as well as bag-mask ventilation. There were no facilities for cricothyrotomy or femoral vein cannulation.
At the end of the 2 nd day, an MCQ (including best of five and true or false questions) post-test was employed, and all participants had to undergo five skill stations that included opening of the airway (plus assessment of breathing), chest compressions in adult, pediatric, and infant mannequins, bag-mask ventilation, advanced airway insertion, and AED use.
A pass mark was awarded to those who scored 75% or more in the post-test and who passed all the skill stations. To pass the advanced airway station, the participant had to insert a correctly sized advanced airway of choice within 30 seconds or re-establish bag-mask ventilation if unable to do so. They were then expected to succeed at the second attempt.
The pre- and post-test were grouped into BLS (Diagnosis of cardiac arrest, pulse check, airway maintenance, compression, and ventilation-adults and pediatrics) and ALS (Recognition of cardiac arrest rhythms, defibrillation, and drug therapy) sections. Each section was awarded 10 marks. The skill stations were scored as pass or fail.
Demographic data obtained included gender, grade of participant, and year of medical qualification. All data collected were analyzed using Statistical Package for the Social Sciences (SPSS) version 15 and Epinfo version 6.0. Numerical data was expressed as mean ± SD and categorical data as frequencies. Chi-square was used to analyze the frequencies while analysis of variance was applied to determine the difference in means of the various grades of participants. The mean pre- and post-test scores were compared between different grades. A P < 0.05 was considered significant.
| Results|| |
One hundred and thirty doctors participated in six two-day training sessions. The male to female ratio was 1:1.15. The mean number of years since medical qualification was 10.99 ± 6.51 years (range, 2-28 years). The distribution of the grades of the participants is shown in [Table 1].
The mean pre-test score for all the participants was 54.43 ± 16.10% (range, 30.5-91.8%), while the mean post-test score was 88.48 ± 6.8% (range, 54.6-94%). This represented a significant change with P < 0.001. The mean percentage change in results from pre-test to post-test was 76.8 ± 52.04% with a range in improvement of performance of 1.12-209.51%. [Table 2] shows the breakdown of the mean pre- and post-test scores according to grade of the participants. With 75% as the pass mark, only 10 participants (7.7%) passed the pre-test, all of whom were senior registrars. There was no significant difference in the mean pre-test scores and post-test scores between the different grades [Figure 1].
|Figure 1: Difference between pre and post test scores according to grade|
Click here to view
Analysis of the post-test BLS questions showed no significant difference in the mean post-test scores to any of the questions on diagnosing cardiac arrest, pulse check, techniques of airway maintenance, chest compressions, and compression: Ventilation ratio of adults and pediatric patients [Figure 2].
Analysis of post-test ALS questions revealed significant difference in the answers to questions on cardiac arrest rhythms (P = 0.031) with registrars scoring the highest mean score of 9.06 followed by senior registrars with 8.78 [Figure 3]. The consultants had the lowest mean score of 8.11. There was no difference in the mean scores of the different grades on questions on defibrillator use and drug therapy [Figure 3].
There were no significant differences in the performance of the different grades of doctors in the skill stations [Figure 4]. In all, 92.5% consultants correctly performed chest compressions at the correct site, depth, rate, and coupling with ventilation compared to 75.6% of senior registrars and 75.8% of registrars, but this was not statistically significant. A total of 109 participants could insert an advanced airway within 30 seconds of which 63 (57.8%) inserted an endotracheal tube, 35 (32.1%) a laryngeal mask airway, and 11 (10.1%) successfully intubated the mannequin at the second attempt after re-establishing bag-mask ventilation.
Sixty-five participants (50%) passed the knowledge-based and performance-based aspects of the post-test at first attempt. Consultants and senior registrars had the highest pass rates of 59.2% and 53.6%, respectively, while registrars had the lowest with pass rate of 43.5%. This difference was not significant (P = 0.336).
After re-training at performance stations, a total of 124 doctors (95.4%) passed the test while 6 doctors (4.6%) failed to satisfy the criteria for a pass. There was no significant difference in overall pass in the various grades (P = 0.605).
| Discussion|| |
Confidence in a clinical setting is linked to years of training and experience, knowledge base and skill.  Few clinical scenarios are more intense and require the coordination of various interventions simultaneously than a cardiac arrest situation. Such a setting would typically favor an individual with sufficient experience at that level. In our study, the mean number of years of clinical experience was 10 years; however, since the study group was drawn from a wide variety of specialties, this did not necessarily translate into many hours of CPR experience.
Improvement in knowledge and skill for CPR is best obtained using a combination of didactic lectures and performance stations where specific skills are taught and assessed. We have demonstrated a statistically significant increase in the post test scores when compared with pre-test scores after our locally adapted resuscitation training program. Overall, whereas less than 10% of the participants scored greater than 75% during the pre-test, this figure increased to 95% following the resuscitation training.
The number of years of clinical experience did not have a statistically significant effect on the pass rates. Results from other studies have been inconsistent. Cowie  demonstrated that amongst anesthetists, the consultants scored lowest in the pre-test evaluation while Miottoab et al.,  observed that older age and longer period since graduation was associated with the lowest level of resuscitation knowledge. On the other hand, Heitmiller  reported that respondents who had been in practice for >10 years scored significantly better on all resuscitation questions in a survey of knowledge of CPR. The lowest scores in the pre-test in our study were in the consultant grade. This is likely a reflection of the lack of resuscitation training since graduation or specialist training. However, the highest overall post-test scores with an average of 91% were also found in the consultant group, probably a reflection of the value of such a refresher course when the initial knowledge base is established. This observation agrees with an earlier report by Seraj  who observed that the degree of retention of theoretical knowledge at post-test was significantly related to exposure and prior training.
Paradoxically and of interest is the fact that junior doctors seemed to perform better in the theoretical aspects of ALS (P = 0.031) while the Consultants fared better at the skill stations. This may be explained by the fact that junior doctors are still studying for various examinations therefore are up to date on theoretical knowledge while the consultants have over the years had more time to acquire the skills. This again highlights the volatile nature of knowledge of resuscitation protocols and the need for continuous updates for all cadres of staff, even the "specialist" as skills decay rapidly, and their retention depends on the frequency with which the skill is used. 
Overall, there was no statistical difference in the performance of CPR among the various categories of doctors assessed; all showed poor knowledge of CPR before the training and all were able to bridge this gap during the course of the two-day training. This study, however, did not assess the retention of the knowledge and skills among the different cadres.
| Conclusion|| |
This study has shown that there is a general paucity of knowledge of CPR guidelines and ability to perform effective CPR among the various cadres of doctors in our institution. However, this gap can be readily bridged by regular training of the staff. There was no significant difference in the ability to learn CPR techniques among various cadres of doctors; therefore, resources should be deployed to training junior doctors in CPR skills as they are usually the first on scene.
| References|| |
|1.||Desalu I, Oyedepo O, Olatosi JO. Training and confidence level of junior anaesthetists in CPR-Experience in a developing country. Indian J Anaesthesia 2008;52:297-300. |
|2.||Marteau TM, Wynne G, Kaye W, Evans TR. Resuscitation: Experience without feedback increases confidence but not skill. BMJ 1990;300:849-50. |
|3.||Seraj MA, Naguib M. Cardiopulmonary resuscitation skills of medical professionals. Resuscitation 1990;20:31-9. |
|4.||Sadoh WE, Osariogiagbon W. Knowledge and practice of cardiopulmonary resuscitation amongst doctors and nurses in Benin city, Nigeria. Niger Hosp Pract 2009;3:12-6. |
|5.||Solagberu BA. Knowledge and practice of cardiopulmonary resuscitation among Nigerian doctors. Niger J Surg Res 2002;4:12-21. |
|6.||Advanced Life Support Course. Providers' manual. 4 th ed. UK: Resuscitation Council and ERC; 2005. |
|7.||Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Teaching resuscitation to pediatric residents: The effects of an intervention. Arch Pediatr Adolesc Med 2000;154:1049-54. |
|8.||Cowie DA, Story DA. Knowledge of cardiopulmonary resuscitation protocols and level of anaesthetic training. Anaesth Intensive Care 2000;28:687-91. |
|9.||Miotto HC, Couto BR, Goulart EM, Amaral CF, Moreira Mda C. Advanced cardiac life support courses: Live actors do not improve training results compared with conventional manikins. Resuscitation 2008;76:244-8. |
|10.||Heitmiller ES, Nelson KL, Hunt EA, Schwartz JM, Yaster M, Shaffner DH. A survey of anesthesiologists' knowledge of American Heart Association Pediatric Advanced Life Support Resuscitation Guidelines. Resuscitation 2008;79:499-505. |
|11.||Jewkes F, Phillips B. Resuscitation training of paediatricians. Arch Dis Child 2003;88:118-21. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]