Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.[1
]In the United States and Canada, approximately 3,50,000 people per year (approximately half of them admitted in-hospitals) suffer a cardiac arrest and receive attempted resuscitation. This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted.[2
Cardiopulmonary resuscitation (CPR) is a series of life-saving actions that improve the chances of survival, following cardiac arrest.[3
] Successful resuscitation, following cardiac arrest, requires an integrated set of coordinated actions represented by the links in the Chain of Survival. The links include the following: immediate recognition of cardiac arrest and activation of the emergency response system, early CPR with an emphasis on chest compressions, rapid defibrillation, effective advanced life support (ALS), and integrated post-cardiac arrest care.[4
] The likelihood to achieveROSC increases with drug therapy, advanced airway management and physiological monitoring.
Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.In 1966 the AHA developed the first CPR guidelines which have been followed by periodic updates, the latest one being of 2010.[5
Knowledge of CPR is an important part of medical student’s training but there is still no routine training included in the medical UG teaching in developing countries like India, thus, medical graduates when they become interns and post graduates often face difficulty in emergency situations. In this study we aimed at finding the awareness of medical students of various professional years and interns regarding BLS and ACLSwhich can be provided by either trained medical personnels,emergency medical technicians or by ordinarypeopletrained in BLS. This ability to recognize and treat a respiratory or cardiac arrest is a basic skill that all doctors are expected to have mastered. However,not many junior doctors are competent to carry out effective CPR.[6
] There’s a lack of structured pattern of BLS/ACLS training in medical curriculum.Thus, they are not completely confident when they suddenly face a situation of resuscitation.There are not many studies to assess the knowledge of medical students regarding resuscitation, especially in India. Hence this study was conducted to assess BLS/ACLS knowledge among them.
AIM:To assess BLS/ACLSknowledge among medical students from different professional years inNew Delhi.
Study Design: A multi-centric study was planned as an analytical cross-sectional study.
Study sample: It included medical students enrolled in various professional years and interns during the session of 2012-2013 at 5 medical colleges of New Delhi. The samplewas randomly drawn from each professional year and interns of 5 teaching hospitals of New Delhi. Permission was taken from the head of institutions (Table 1).
Study Time:The study was conducted over a 4-month period from May to August 2013.
Study Tool: A predesigned self-administered objective questionnaire was given to each participant. Twenty questions were based on BLS while ten were based on ACLS.A questionnaire was prepared by the authors that encompassed 3 domains:
1. Demography and formal training of the participants in BLS/ACLS
2. Theoretical and practical knowledge of the participants related to BLS,a set of self-prepared 20 MCQs with 4 options based on BLS For Healthcare Providers Student Manual,2010.
3.Theoretical and practical knowledge of the participants related to ACLS,a set of 10 MCQs with 4 options based on Advanced Cardiovascular
Life Support (ACLS) Provider Manual, 2010American Heart Association Guidelines for CPR and ECC.
Each student was given 15 minutes for 30 questions.
Data Analysis: The collected data were calculated using Microsoft Excel and then statistical analysis was made by Stata S.E 9.0. Student’s independent ‘t’ test was applied and p value <0.05 was considered statistically significant.
Out of 300 questionnaires filled,12 were excluded as they were incomplete and remaining 288 were included in the study. Table 1 gives us the demographic details of the participants.
Participants (96%) felt BLS and ACLS training should be a part of routine training in UG curriculum.
The mean scores of first-year students in BLS and ACLS were the lowest, 4.56 + 2.76 and 1.65 + 1.35 respectively while the mean scores of second-,third- and final years in BLS and ACLS were 6.28 +3.03 and 2.6 + 1.68, 7.75 + 3.34 and 3.62 + 2.47, 10.17 + 2.4 and 6.1 +2.04, respectively. The mean scores of interns were the highest, 10.85 + 1.83 in BLS and 6.35 + 2.59, respectively. The mean score of study sample was 7.416 + 3.55 in BLS and 3.7 + 2.66 in ACLS(Table 2).
An association was seen between the qualification of medical students/internsand their knowledge in BLS (p value <0.005) (Table 2).
Also an association was observed between the trained participants in BLS/ACLS and their mean scores(p<0.001) (Table 3).
Figures 1 and 2 show us the percentage score of the study group in BLS and ACLS respectively.Tables 4 and 5 show us theoretical and practical knowledge of the participants in BLS and ACLS respectively.
The study results showed that medical students in Delhi failed to show adequate knowledge in both BLS and ACLS (see Tables 4 and 5). Percentageof students who scored less than 50% in BLS was 65, only 2%(6) students scored 70%-79% and only 1% (3) studentsscored>80% (see Figure 1). Similar results were shown by ShantaChandrasekaran et al where none of the participants scored above 85% while 85% of participants scored less than 50%.[8
]Only (48.1%) of the students from Switzerland could give correct answers on knowledge based questions.[9
] Similarly low levels (54.3%, 25%) of knowledge have been reported from medical students in Poland and interns from southern India, respectively.[10
Early institution of CPR can double or triple the victim’s chances of survival fromsudden cardiac arrest.[12
]However in our study only 41% had knowledge about the AED usage (see Table 5).In other study by Avabratha KS et al 37.4% of medical interns were aware of the AED usage.[13
The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the BLS sequence ofsteps from airway, breathing, chest compressions (ABC) tochest compressions, airway, breathing (CAB) for adultsand pediatric patients (children and infants, excluding newborns) as the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation.[5
] However, in our study only 4% of the participants were able to answer all questions regarding chest compressions correctly.
Very few participants (9%) had undergone formal training in BLS and only 3.6% in ACLS. HN Harsha Kumar et al have also shown poor level of training among the UG medical students.[14
]Low levels of training have been reported from Pakistan and the UK.[15
Statistically significant correlation was seen between the formal training of the participants and their knowledge in both BLS and ACLS(see Table 3).Shrestha Roshana et al. also showed that CPR training significantly influenced BLS knowledge of the participants as those who had received some CPR training within 5 years obtained the highest mean score of 8.62±2.49.[17
]Other studies have also concluded that the knowledge of trained personnels was better than those of untrained ones.[18
Also a significant correlation was observed between the qualification of medical students and their knowledge (see Table 2).Interns who get training in BLS in their anaesthesia rotations had a significantly higher knowledge than the medical UGs who had no such exposure. Chaudhari A et al showed improvement in knowledge and skill of CPR followinga BLS training.[19
]Elif et al also observed that past experience in real life resuscitation improved the awareness.[20
According to the General Medical Council of the UK, preregistration house officers shouldhave training in BLS before they join their post and that theyshould receive ACLS training during the first year.[21
]The royalcollege of physicians has also stated that ALS should be taught in theUG courses and the preregistration house officers should be capable ofinstituting ALS.[22
]Participants (96%) felt BLS and ACLS training should be a part of routine training in the UG curriculum which is similar to other study, thus, reflecting that these are “felt needs” of the students.[14
Training of resuscitation skills is poor due to lack of resources in developing countries like India.[23
]Moreover, as the guidelines are updated every 5 years, the need for repetitive training is a must so as to ensure that these changes are implemented. Medical schools are expected to produce well-trained doctors who are competent in clinical practice which include the techniques ofbasic resuscitation, thus, it is time that we standardize training in BLS and ACLS and make it a mandatory component of all medical UG curricula. The Medical Council of India has already incorporated emergency medicine as a separate speciality. Spreading awareness and teaching the basics of ALS to the medical and paramedical team as well as teaching BLS and first aid to the community will be the prime responsibility of this new emergency specialty.[13
In conclusion, this study has revealed a critical issue that medical students in New Delhi lack adequate knowledge in BLS and ACLS which should be addressed promptly. Since prior CPR training and
clinical exposure influence the retention of knowledge, standard BLS/ACLS training should be incorporated in the UG curriculum and should be repeated periodically. It is also necessary to evaluate and update the knowledge of medical students in BLS and ACLS for better patient outcome and bringing about uniformity in healthcare delivery.
- Lloyd-Jones D, Adams RJ, Brown TM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation.2010;121:e46-e215.
- Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423-1431.
- Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. CircCardiovascQual Outcomes. 2010;3:63-81.
- Lee K. Cardiopulmonary resuscitation: new concept.TubercRespir Dis (Seoul).May 2012;72(5):401-408.
- John M. Field, Mary Fran Hazinski, Michael R. Sayre, et al.Part 1: Executive summary 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2010;122:S640-S656.
- Skinner D, Camm A, Miles S. Cardiopulmonary skills of preregistration house officers.BMJ.1985; 290: 1549-1550.
- Zaheer H, Haque Z. Awareness about BLS (CPR) among medical students: status and requirements. JPMA.2009; 59(1):57-59.
- Chandrasekaran S, Kumar S, Bhat SA, et al. Awareness of basic life support among medical, dental, nursing students and doctors. Indian J Anaesth. 2010;54:121-126..
- Businger A, Rinderknecht S, Blank R, Merki L, Carrel T. Students’ knowledge of symptoms and risk factors of potential life-threatening medical conditions. Swiss Med Wkly. 2010;140:78-84.
- Chojnacki P, Ilieva R, Kolodziej A, Krolikowska A, Lipka J, Ruta J. Knowledge of BLS and AED resuscitation algorithm amongst medical students–preliminary results. AnestezjolIntensTer 2011;43:29-32.
- Sharma R, Attar NR. Adult basic life support (BLS) awareness and knowledge among medical and dental interns completing internship from deemed university. NUJHS. 2012;2:6-13.
- Larren MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out of hospital cardiac arrest: a graphic method. Ann Emerg Med.1993; 22:1652-1658.
- K.ShreedharaAvabratha, Bhagyalakshmi K, GanapathyPuranik,VaradarajShenoy,SanjeevaRai.A study of the knowledge of resuscitation among interns.Al Ame en J Med Sci (2 012 )5 (2 ) :1 5 2 -1 5 6
- HN Harsha Kumar, P SwasthikUpadhya, P Shruthi Ashok.A cross-sectional study on awareness and perception about basic life support/cardio-pulmonary resuscitation among undergraduate medical students from coastal South India.Int J Med Pub Health. 2013(3) ;146-150.
- Zaheer H, Haque Z. Awareness about BLS (CPR) among medical students: status and requirements. J Pak Med Assoc. 2009;59:57-59.
- Mastoridis S, Shanmugarajah K, Kneebone R. Undergraduate education in trauma medicine: the students’ verdict on current teaching. Med Teach. 2011;33:585-587.
- Shrestha Roshana1, Batajoo KH, Piryani RM, Sharma MW.Basic life support: knowledge and attitude of medical/paramedical professionals.World J Emerg Med, vol 3, no 2, 2012.
- Abbas A, Bukhari SI, Ahmed F. Knowledge of first aid and basic life support amongst medical students:a comparison between trained and un-trained students. JPMA.2011; 61: 613-616.
- Chaudhary A, Parikh H, Dave V. Current scenario: knowledge of basic life support in medical college. Natl J Med Res. 2011; 1: 80-82.
- Elif AA, Zeynep K. Knowledge of basic life support: a pilot study of the Turkish population by Baskentuniversity in Ankara. Resuscitation.2003; 58: 187-192.
- Philips PS, Nolan JP. Training in basic and advanced life support in UK medical schools: questionnaire survey.BMJ.2001; 323(7303): 22-23.
- Royal College of Physicians of London.Resuscitation from cardiopulmonary arrest.J R Coll Physicians Lond.1987; 21:175-182.
- Garg RH. Who killed Rambhor?:the state of emergency medical services in India. J Emerg Trauma Shock. 2012;5:49-54.
- Jakob de Vries. Learning by (re)searching.J Young Med Researchers. 2013.