Life support courses: are they effective?

The initiative for medical equity and global health (IMEGH) resuscitation training program: A model for resuscitation training courses in Africa

In high-income countries, outcomes following in hospital cardiac arrest have improved over the last two decades due to the introduction of rapid response teams, cardiac arrest teams, and advanced resuscitation training. However, in low-income countries, such as Rwanda, outcomes are still poor. This is due to multiple factors including lack of adequate resuscitation training, few trainers, and lack of equipment. To address this issue, the Initiative for Medical Equity and Global Health Equity (IMEGH), a training organization founded in 2018 by 5 local anesthesiologists has regularly taught resuscitation courses such as Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support in hospitals throughout Rwanda. The aims of the organization include developing a sustainable model to offer context relevant resuscitation training courses, building a cadre of local instructors to teach on the courses, as well as engaging funding partners to help support the effort. From October 2018 until September 2022, 31 courses were run in 11 hospitals across Rwanda training 1,060 healthcare providers (mainly of non-physician anesthetists, nurses, midwives, and general practitioners). Ongoing challenges include lack of local protocols, inability to tracking resuscitation outcomes, and continued inaccessibility by many healthcare providers. Despite these challenges, the IMEGH program is an example of a successful context-relevant model and has potential to inform the design of resuscitation programs in other similar settings. This article describes the development of the IMEGH program, accomplishments as well as lessons learned, challenges, and next steps for expansion.

Resuscitation team training in Rwanda: A mixed method study exploring the combination of the VAST course with Advanced Cardiac Life Support training

Introduction

The influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda.

Methods

Participants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention.

Results

Forty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p = <0.001; [137.3 (108.9) sec] versus [51.3 (37.9)], p = <0.001; and [218.5 (105.8) sec] versus [110.8 (87.1) sec], p = <0.001; respectively. These improvements were maintained following the Vital Anaesthesia Simulation Training Course, and at 3-month retention testing. Qualitative analysis highlighted five key themes: ability to initiate cardiopulmonary resuscitation; team coordination for task allocation; empowerment; desire for training and mentorship; and advocacy for system improvement.

Conclusion

A modified 2-day Advanced Cardiac Life Support course improved resuscitation time indicators with retention 3-months later. Combining the Vital Anaesthesia Simulation Training Course and Advanced Cardiac Life Support led to better team coordination, empowerment to act, and advocacy for system improvement. This pairing of courses has promise for improving Advanced Cardiac Life Support skills amongst healthcare workers in low-resource settings.ClinicalTrials.gov Identifier: NCT05278884.

Competencies of junior medical doctors in managing seriously ill and injured children: time to rethink our current training approach?

BACKGROUND

The correct treatment of very ill and injured children is critical, yet little is known about the competencies of South African (SA) junior doctors in managing these children.

METHODS

This survey documents SA junior doctors' reported resuscitation training opportunities, experience, skills and knowledge.

RESULTS

A total of 118 doctors (interns, medical officers and registrars) from paediatric departments affiliated with 7 medical schools, participated. Resuscitations were not rare events with 71% (84/118) reporting participation in >10 resuscitations during the preceding 2 years. Yet a third of doctors have not attended an accredited resuscitation training course within the last 2 years; 34% (12/35) medical officers and 29% (18/63) registrars, respectively, with 42% (49/118) of all participants never receiving any formal resuscitation training during employment. Feedback on performance is not standard practice with only 8% (10/118) reporting consistent debriefing after a resuscitation. Although 72% (85/118) reported their resuscitation knowledge as adequate, 56% (66/118) passed the knowledge test.

CONCLUSION

This study recognized missed learning opportunities in junior doctors' training, assessment, debriefing and knowledge which may adversely affect the quality of care in managing paediatric emergencies. This has implications for departmental and post-graduate training programmes.

Does participation in the European Trauma Course lead to new behaviours and organisational change? A Portuguese experience

BACKGROUND

Medical educational courses can be successful from an immediate feedback perspective but not lead to new behaviour or organisational changes in the workplace. The aim of this study was to assess the self-perceived impact of the European Trauma Course (ETC) on Reanima trainees' behaviour and organisational change.

METHODS

A 40-item questionnaire based on Holton's evaluation model was used to evaluate the candidate's perceptions. The results were analysed with descriptive and inferential statistical analysis using nonparametric tests with α = 0.05.

RESULTS

Out of 295 participants, 126 responded to the survey. Of these, 94% affirmed that the ETC modified their approach to trauma patients, and 71.4% described a change in their behaviour. Postcourse responders changed their behaviour in their initial approach to trauma care in the nontechnical skills of communication, prioritisation and teamwork. Being an ETC instructor strongly influenced the acquisition of new material, and this group was able to implement changes in attitudes. Individuals with no previous trauma course experience identified lack of self-efficacy as a significant obstacle to introducing new work-based learning. In contrast, responders with ATLS training noted a lack of ETC colleagues as the main impediment for moving from conceptualisation to experimentation in the workplace.

CONCLUSIONS

Participation in the ETC led to behavioural changes in the workplace. However, the ability to influence others and bring about wider organisational changes was more difficult to achieve. Major factors were the status of the person, their experience and self-efficacy. National organisational impact was obtained, which went far beyond our aspirations in acknowledging change in individual daily practice. Future research studies will include the effect of implementing the ETC methodology on the outcome of trauma patients.

Factors that influence the self-reported confidence of pediatric residents as team leaders during cardiopulmonary resuscitation: A national survey

Objective

The leadership skills of pediatric residents during cardiopulmonary resuscitation (CPR) may have major impacts on their performance. These skills should be addressed during the pediatric residency training program. Therefore, we aimed to identify the perceptions of residents regarding their level of confidence in providing or leading a real pediatric CPR code, and to identify different factors that might influence their self-confidence when assuming the role of a team leader during a real CPR.

Design & setting

Cross-sectional paper-based and online electronic surveys were conducted in February 2017, which included all Saudi pediatric residency program trainees.

Interventions

A survey questionnaire was distributed to Saudi pediatric residency trainees throughout the Kingdom. The main aim was to assess their perceived level of confidence when running a real pediatric CPR code either as a team leader or as a team member.

Results

The survey was distributed and sent by email to 1052 residents, where it was received by 640 and 231 responded (response rate = 36%). Almost one-fifth of the respondents (19.5%) did not have a valid pediatric advanced life support (PALS) certificate. The most frequently reported obstacles to life support training were lack of time (45.8%) and its financial cost (22.7%). The mean self-reported confidence as a CPR team member was reported significantly more frequently than being a CPR team leader (mean standard deviation, SD) = 7.8 (2.1) and 6.7 (2.4) respectively, P < .001). The self-reported confidence as a CPR team leader was reported significantly more frequently in males compared with female respondents (mean ± SD = 6.7 ± 2.4 and 5.9 ± 2.4, respectively; P < .013). There was a significant positive effect of recent attendance at a real CPR event on the perceived self-rated confidence of residents as a CPR team leader (P < .001). Residents who reported that they had often assumed a real CPR leadership role had significantly greater perceived self-confidence compared with those who assumed a member role (P < .05). Furthermore, residents without a valid PALS certificate had significantly less confidence in leading CPR teams than their peers who were recently certified (P < .05).

Conclusions

The self-reported confidence as team leader during CPR was higher among residents who were certified in life support courses, exposed to CPR during their training, and those who assumed the role of a team leader during CPR. Our findings suggests the need to incorporate life support training courses and simulation-based mock code programs with an emphasis on the leadership in the curriculum of the pediatric residency training program.

Quality of Care during Neonatal Resuscitation in Kakamega County General Hospital, Kenya: A Direct Observation Study

Background

Birth asphyxia is the leading cause of neonatal mortality in Kenya. Quality care during neonatal resuscitation (NR) can contribute to a reduction in neonatal mortality related to birth asphyxia by 30 percent. This study assessed the quality of care (QoC) during NR for newborns with birth asphyxia.

Methods

Direct observations of 138 newborn resuscitations were done in labor ward and maternity theatre. Twenty-eight healthcare providers were observed 3–5 times using a structured checklist. Descriptive and inferential statistics were calculated and quality of care scores computed. Ordered logistic regression model identified HCPs characteristics associated with the QoC scores during NR.

Results

Overall QoC scores were good for airway clearance (83%). Suctioning in meconium presence (40%) was poorly performed. Years of experience working in maternity were associated with good drying/stimulation (β = 1.86, P = 0.003, CI = 0.626–3.093) and airway maintenance (β = 1.887, P = 0.009, CI = 0.469–3.305); nurses were poor compared to doctors during initial bag and mask ventilation (β = −2.338, P = 0.05, CI = −4.732–0.056).

Conclusion

Key steps in NR are poorly performed during drying and warmth, airway maintenance in meconium presence, and ventilation. Mentorship with periodic refresher training can improve the care provided during NR.

Implementing the Emergency Triage, Assessment and Treatment plus admission care (ETAT+) clinical practice guidelines to improve quality of hospital care in Rwandan district hospitals: healthcare workers' perspectives on relevance and challenges

Background

An emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.

Methods

HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.

Results

One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the “neonatal resuscitation and feeding” components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).

Conclusion

This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2193-4) contains supplementary material, which is available to authorized users.

Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention

The objective of this project was to improve birth outcomes for babies in a regional referral hospital in Uganda by strengthening factors that influence the retention and application of neonatal resuscitation skills. Initial training in neonatal resuscitation is not enough on its own. In order to better understand the gap between training and effective practice, an evaluation of a neonatal resuscitation program was carried out. This included practical skill testing of local midwives using a neonatal resuscitation doll pre- and post-training, as well as follow up testing at 1 month and 12 months, followed by focus groups and interviews. Test scores revealed that participants' knowledge grew significantly immediately following the workshop, and remained high after 1 month, but fell by 12 months post-training. Interviews with hospital staff revealed a number of facilitators and barriers to practice, namely knowledge retention and skill application. The most important barrier identified is the lack of refresher training post-workshop. Importantly, the findings demonstrated a need not for refresher training alone, but for improved organizational and administrative support for the newly assigned trainers.

Cardiopulmonary resuscitation knowledge and attitude among general dentists in Kuwait

BACKGROUND

Dentists as health care providers should maintain a competence in resuscitation. This cannot be overemphasized by the fact that the population in our country is living longer with an increasing proportion of medically compromised persons in the general population. This preliminary study aimed to assess the knowledge and attitude of general dentists towards cardiopulmonary resuscitation (CPR).

METHODS

A cross-sectional study was carried out among 250 licensed general dental practitioners working in ministry of health. Data were obtained through electronic self-administered questionnaire consisting of demographic data of general dentists, and their experience, attitude and knowledge about CPR based on the 2010 American Heart Association guidelines update for CPR.

RESULTS

Totally 208 general dentists took part in the present study giving a response rate of 83.2%. Only 36% of the participants demonstrated high knowledge on CPR, while 64% demonstrated low knowledge. Participants' age, gender, nationality, years of experience, career hierarchy, and formal CPR training were associated significantly with CPR knowledge. Almost all the participants (99%) felt that dentists needed to be competent in basic resuscitation skills and showed a positive attitude towards attending continuing dental educational programs on CPR.

CONCLUSION

This study showed that majority of general dental practitioners in Kuwait had inadequate knowledge on CPR. It was also found that CPR training significantly influenced the CPR knowledge of the participants. Therefore, training courses on CPR should be regularly provided to general dentists in the country.

An Analysis of the Top-cited Articles in Emergency Medicine Education Literature

Introduction

Dissemination of educational research is critical to improving medical education, promotion of faculty and ultimately patient care. The objective of this study was to identify the top 25 cited education articles in the emergency medicine (EM) literature and the top 25 cited EM education articles in all journals, as well as report on the characteristics of the articles.

Methods

Two searches were conducted in the Web of Science in June 2016 using a list of education-related search terms. We searched 19 EM journals for education articles as well as all other literature for EM education-related articles. Articles identified were reviewed for citation count, article type, journal, authors, and publication year.

Results

With regards to EM journals, the greatest number of articles were classified as articles/reviews, followed by research articles on topics such as deliberate practice (cited 266 times) and cognitive errors (cited 201 times). In contrast in the non-EM journals, research articles were predominant. Both searches found several simulation and ultrasound articles to be included. The most common EM journal was Academic Emergency Medicine (n = 18), and Academic Medicine was the most common non-EM journal (n=5). A reasonable number of articles included external funding sources (6 EM articles and 13 non-EM articles.)

Conclusion

This study identified the most frequently cited medical education articles in the field of EM education, published in EM journals as well as all other journals indexed in Web of Science. The results identify impactful articles to medical education, providing a resource to educators while identifying trends that may be used to guide EM educational research and publishing efforts.

Burn Care on Cruise Ships-Epidemiology, international regulations, risk situation, disaster management and qualification of the ship's doctor

With the increasing numbers of passengers and crew on board vessels that are becoming larger and larger, the demand for ship's doctors who can adequately treat burns on board has also increased. In the cruise ship industry it is usually those doctor's with internal and general medical training who are recruited from an epidemiological point of view. Training content or recommendations for the treatment of thermal lesions with the limited options available in ship's hospitals and where doctors with no surgical training operate do not yet exist. The guidelines recommended by the Cruise Lines International Association (CLIA) regarding medical staff have only included physicians with minor surgical skills until now. With the introduction of the ATLS(®) course developed by the American College of Surgeons, the requirements for the qualification of the ship's doctor on board cruise ships shall change from January 2017. The article discusses the question of whether having completed the ATLS(®) course, the ship's doctor is trained to adequately treat thermal lesions or severe burns persons on-board, and presents the current discussion on the training content for ship's doctors within the International Maritime Health Association (IMHA). It also provides an overview of existing international regulatory frameworks, the risks presented by a fire on board, the problem of treating burns victims out of reach of coastal rescue services, and alternative training concepts for ship's doctors regarding the therapy of thermal lesions on-board.

Correlates of Performance of Healthcare Workers in Emergency, Triage, Assessment and Treatment plus Admission Care (ETAT+) Course in Rwanda: Context Matters

BACKGROUND

The Emergency, Triage, Assessment and Treatment plus Admission care (ETAT+) course, a comprehensive advanced pediatric life support course, was introduced in Rwanda in 2010 to facilitate the achievement of the fourth Millennium Development Goal. The impact of the course on improving healthcare workers (HCWs) knowledge and practical skills related to providing emergency care to severely ill newborns and children in Rwanda has not been studied.

OBJECTIVE

To evaluate the impact of the ETAT+ course on HCWs knowledge and practical skills, and to identify factors associated with greater improvement in knowledge and skills.

METHODS

We used a one group, pre-post test study using data collected during ETAT+ course implementation from 2010 to 2013. The paired t-test was used to assess the effect of ETAT+ course on knowledge improvement in participating HCWs. Mixed effects linear and logistic regression models were fitted to explore factors associated with HCWs performance in ETAT+ course knowledge and practical skills assessments, while accounting for clustering of HCWs in hospitals.

RESULTS

374 HCWs were included in the analysis. On average, knowledge scores improved by 22.8/100 (95% confidence interval (CI) 20.5, 25.1). In adjusted models, bilingual (French & English) participants had a greater improvement in knowledge 7.3 (95% CI 4.3, 10.2) and higher odds of passing the practical skills assessment (adjusted odds ratio (aOR) = 2.60; 95% CI 1.25, 5.40) than those who were solely proficient in French. Participants who attended a course outside of their health facility had higher odds of passing the skills assessment (aOR = 2.11; 95% CI 1.01, 4.44) than those who attended one within their health facility.

CONCLUSIONS

The current study shows a positive impact of ETAT+ course on improving participants' knowledge and skills related to managing emergency pediatric and neonatal care conditions. The findings regarding key factors influencing ETAT+ course outcomes demonstrate the importance of considering key contextual factors (e.g., language barriers) that might affect HCWs performance in this type of continuous medical education.

Newborn Resuscitation Training Programmes Reduce Early Neonatal Mortality

BACKGROUND

Substantial health care resources are expended on standardised formal neonatal resuscitation training (SFNRT) programmes, but their effectiveness has not been proven.

OBJECTIVES

To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve acquisition and retention of knowledge and skills, or change teamwork and resuscitation behaviour.

METHODS

We searched CENTRAL, MEDLINE, PREMEDLINE, EMBASE, CINAHL, Web of Science and the Oxford Database of Perinatal Trials, ongoing trials and conference proceedings in April 2015, and included randomised or quasi-randomised trials that reported at least one of our specified outcomes.

RESULTS

SFNRT in low- and middle-income countries decreased early neonatal mortality [risk ratio (RR) 0.85 (95% CI 0.75-0.96)]; the number needed to treat for benefit [227 (95% CI 122-1,667; 3 studies, 66,162 participants, moderate-quality evidence)], and 28-day mortality [RR 0.55 (95% CI 0.33-0.91); 1 study, 3,355 participants, low-quality evidence]. Decreasing trends were noted for late neonatal mortality [RR 0.47 (95% CI 0.20-1.11)] and perinatal mortality [RR 0.94 (95% CI 0.87-1.00)], but there were no differences in fresh stillbirths [RR 1.05 (95% CI 0.93-1.20)]. Teamwork training with simulation increased the frequency of teamwork behaviour [mean difference (MD) 2.41 (95% CI 1.72-3.11)] and decreased resuscitation duration [MD -149.54 (95% CI -214.73 to -84.34); low-quality evidence, 2 studies, 130 participants].

CONCLUSIONS

SFNRT in low- and middle-income countries reduces early neonatal mortality, but its effects on birth asphyxia and neurodevelopmental outcomes remain uncertain. Follow-up studies suggest normal neurodevelopment in resuscitation survivors.

Effect of a Neonatal Resuscitation Course on Healthcare Providers' Performances Assessed by Video Recording in a Low-Resource Setting

BACKGROUND

We assessed the effect of an adapted neonatal resuscitation program (NRP) course on healthcare providers' performances in a low-resource setting through the use of video recording.

METHODS

A video recorder, mounted to the radiant warmers in the delivery rooms at Beira Central Hospital, Mozambique, was used to record all resuscitations. One-hundred resuscitations (50 before and 50 after participation in an adapted NRP course) were collected and assessed based on a previously published score.

RESULTS

All 100 neonates received initial steps; from these, 77 and 32 needed bag-mask ventilation (BMV) and chest compressions (CC), respectively. There was a significant improvement in resuscitation scores in all levels of resuscitation from before to after the course: for "initial steps", the score increased from 33% (IQR 28-39) to 44% (IQR 39-56), p<0.0001; for BMV, from 20% (20-40) to 40% (40-60), p = 0.001; and for CC, from 0% (0-10) to 20% (0-50), p = 0.01. Times of resuscitative interventions after the course were improved in comparison to those obtained before the course, but remained non-compliant with the recommended algorithm.

CONCLUSIONS

Although resuscitations remained below the recommended standards in terms of quality and time of execution, clinical practice of healthcare providers improved after participation in an adapted NRP course. Video recording was well-accepted by the staff, useful for objective assessment of performance during resuscitation, and can be used as an educational tool in a low-resource setting.

Standardised formal resuscitation training programmes for reducing mortality and morbidity in newborn infants

BACKGROUND

Approximately 10% of all newborns require resuscitation at birth. Training healthcare providers in standardised formal neonatal resuscitation training (SFNRT) programmes may improve neonatal outcomes. Substantial healthcare resources are expended on SFNRT.

OBJECTIVES

To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve acquisition and retention of knowledge and skills, or change teamwork and resuscitation behaviour.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PREMEDLINE, EMBASE, CINAHL, Web of Science and the Oxford Database of Perinatal Trials, ongoing trials and conference proceedings in April 2014 and updated in March 2015.

SELECTION CRITERIA

Randomised or quasi-randomised trials including cluster-randomised trials, comparing a SFNRT with no SFNRT, additions to SFNRT or types of SFNRT, and reporting at least one of our specified outcomes.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and performed statistical analyses including typical risk ratio (RR), risk difference (RD), mean difference (MD), and number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH) (all with 95% confidence intervals (CI)). We analysed cluster-randomised trials using the generic inverse variance and the approximate analysis methods.

MAIN RESULTS

We identified two community-based and three manikin-based trials that assessed the effect of SFNRT compared with no SFNRT. Very low quality evidence from one study suggested improvement in acquisition of knowledge (RR 5.96, 95% CI 3.60 to 9.87) and skills (RR 170, 95% CI 10.8 to 2711) and retention of knowledge (RR 3.60, 95% CI 2.43 to 5.35) and the other study suggested improvement in resuscitation and behavioural scores.We identified three community-based cluster-randomised trials in developing countries comparing SFNRT with basic resuscitation training (Early Newborn Care). In this setting, there was moderate quality evidence that SFNRT decreased early neonatal mortality (typical RR 0.88, 95% CI 0.78 to 1.00; 3 studies, 66,162 neonates) and when analysed by the approximate analysis method (typical RR 0.85, 95% CI 0.75 to 0.96; RD -0.0044, 95% CI -0.0082 to -0.0006; NNTB 227, 95% CI 122 to 1667). Low quality evidence from one trial showed that SFNRT may decrease 28-day mortality (typical RR 0.55, 95% CI 0.33 to 0.91) but the effect on late neonatal mortality was more uncertain (typical RR 0.47, 95% CI 0.20 to 1.11). None of our a priori defined neonatal morbidities were reported. We did not identify any randomised studies in the developed world.We identified two trials that compared SFNRT with team training to SFNRT. Teamwork training of physician trainees with simulation may increase any teamwork behaviour (assessed by frequency) (MD 2.41, 95% CI 1.72 to 3.11) and decrease resuscitation duration (MD -149.54, 95% CI -214.73 to -84.34) but may lead to little or no difference in Neonatal Resuscitation Program (NRP) scores (MD 1.40, 95% CI -2.02 to 4.82; 98 participants, low quality evidence).We identified two trials that compared SFNRT with booster courses to SFNRT. It is uncertain whether booster courses improve retention of resuscitation knowledge (84 participants, very low quality evidence) but may improve procedural and behavioural skills (40 participants, very low quality evidence).We identified two trials on decision support tools, one on a cognitive aid that did not change resuscitation scores and the other on an electronic decision support tool that improved the frequency of correct decision making on positive pressure ventilation, cardiac compressions and frequency of fraction of inspired oxygen (FiO2) adjustments (97 participants, very low quality evidence).

AUTHORS' CONCLUSIONS

SFNRT compared to basic newborn care or basic newborn resuscitation, in developing countries, results in a reduction of early neonatal and 28-day mortality. Randomised trials of SFNRT should report on neonatal morbidity including hypoxic ischaemic encephalopathy and neurodevelopmental outcomes. Innovative educational methods that enhance knowledge and skills and teamwork behaviour should be evaluated.

Understanding and improving low bystander CPR rates: a systematic review of the literature

Objectives:

Cardiopulmonary resuscitation (CPR) is a crucial yet weak link in the chain of survival for out-of-hospital cardiac arrest. We sought to understand the determinants of bystander CPR and the factors associated with successful training.

Methods:

For this systematic review, we searched 11 electronic databases, 1 trial registry and 9 scientific websites. We performed hand searches and contacted 6 content experts. We reviewed without restriction all communications pertaining to who should learn CPR, what should be taught, when to repeat training, where to give CPR instructions and why people lack the motivation to learn and perform CPR. We used standardized forms to review papers for inclusion, quality and data extraction. We grouped publications by category and classified recommendations using a standardized classification system that was based on level of evidence.

Results:

We reviewed 2409 articles and selected 411 for complete evaluation. We included 252 of the 411 papers in this systematic review. Differences in their study design precluded a meta-analysis. We classified 22 recommendations; those with the highest scores were 1) 9-1-1 dispatch-assisted CPR instructions, 2) teaching CPR to family members of cardiac patients, 3) Braslow's self-training video, 4) maximizing time spent using manikins and 5) teaching the concepts of ambiguity and diffusion of responsibility. Recommendations not supported by evidence include mass training events, pulse taking prior to CPR by laymen and CPR using chest compressions alone.

Conclusion:

We evaluated and classified the potential impact of interventions that have been proposed to improve bystander CPR rates. Our results may help communities design interventions to improve their bystander CPR rates.

Access to and value of information to support good practice for staff in Kenyan hospitals

Background

Studies have sought to define information needs of health workers within very specific settings or projects. Lacking in the literature is how hospitals in low-income settings are able to meet the information needs of their staff and the use of information communication technologies (ICT) in day-to-day information searching.

Objective

The study aimed to explore where professionals in Kenyan hospitals turn to for work-related information in their day-to-day work. Additionally, it examined what existing solutions are provided by hospitals with regard to provision of best practice care. Lastly, the study explored the use of ICT in information searching.

Design

Data for this study were collected in July 2012. Self-administered questionnaires (SAQs) were distributed across 22 study hospitals with an aim to get a response from 34 health workers per hospital.

Results

SAQs were collected from 657 health workers. The most popular sources of information to guide work were fellow health workers and printed guidelines while the least popular were scientific journals. Of value to health workers were: national treatment policies, new research findings, regular reports from surveillance data, information on costs of services and information on their performance of routine clinical tasks; however, hospitals only partially met these needs. Barriers to accessing information sources included: ‘not available/difficult to get’ and ‘difficult to understand’. ICT use for information seeking was reported and with demographic specific differences noted from the multivariate logistic regression model; nurses compared to medical doctors and older workers were less likely to use ICT for health information searching. Barriers to accessing Internet were identified as: high costs and the lack of the service at home or at work.

Conclusions

Hospitals need to provide appropriate information by improving information dissemination efforts and providing an enabling environment that allows health workers find the information they need for best practice.

In-service training for health professionals to improve care of seriously ill newborns and children in low-income countries

BACKGROUND

A variety of in-service emergency care training courses are currently being promoted as a strategy to improve the quality of care provided to seriously ill newborns and children in low-income countries. Most courses have been developed in high-income countries. However, whether these courses improve the ability of health professionals to provide appropriate care in low-income countries remains unclear. This is the first update of the original review.

OBJECTIVES

To assess the effects of in-service emergency care training on health professionals' treatment of seriously ill newborns and children in low-income countries.

SEARCH METHODS

For this update, we searched the Cochrane Database of Systematic Reviews, part of The Cochrane Library (www.cochranelibrary.com); MEDLINE, Ovid SP; EMBASE, Ovid SP; the Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library (www.cochranelibrary.com) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register); Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge/Science and eight other databases. We performed database searches in February 2015. We also searched clinical trial registries, websites of relevant organisations and reference lists of related reviews. We applied no date, language or publication status restrictions when conducting the searches.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before and after studies and interrupted-time-series studies that compared the effects of in-service emergency care training versus usual care were eligible for inclusion. We included only hospital-based studies and excluded community-based studies. Two review authors independently screened and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study risk of bias and confidence in effect estimates (certainty of evidence) for each outcome using GRADE (Grades of Recommendation, Assessment, Development and Evaluation). We described results and presented them in GRADE tables.

MAIN RESULTS

We identified no new studies in this update. Two randomised trials (which were included in the original review) met the review eligibility criteria. In the first trial, newborn resuscitation training compared with usual care improved provider performance of appropriate resuscitation (trained 66% vs usual care 27%, risk ratio 2.45, 95% confidence interval (CI) 1.75 to 3.42; moderate certainty evidence) and reduced inappropriate resuscitation (trained mean 0.53 vs usual care 0.92, mean difference 0.40, 95% CI 0.13 to 0.66; moderate certainty evidence). Effect on neonatal mortality was inconclusive (trained 28% vs usual care 25%, risk ratio 0.77, 95% CI 0.40 to 1.48; N = 27 deaths; low certainty evidence). Findings from the second trial suggest that essential newborn care training compared with usual care probably slightly improves delivery room newborn care practices (assessment of breathing, preparedness for resuscitation) (moderate certainty evidence).

AUTHORS' CONCLUSIONS

In-service neonatal emergency care courses probably improve health professionals' treatment of seriously ill babies in the short term. Further multi-centre randomised trials evaluating the effects of in-service emergency care training on long-term outcomes (health professional practice and patient outcomes) are needed.

Basic life support knowledge and skills of Iranian general dental practitioners to perform cardiopulmonary resuscitation

BACKGROUND

When cardiopulmonary arrest occurs, the dentist's ability to perform cardiopulmonary resuscitation (CPR) is the most important factor to minimize morbidity and mortality. This study assessed the basic life support (BLS) knowledge and performance of general dental practitioners in Hamadan, Iran.

MATERIALS AND METHODS

The participants in the study were 80 Iranian general dental practitioners who were chosen randomly. Their CPR knowledge was evaluated by verbal questions and their CPR skills were determined by CPR execution on a special manikin. Nearly 39% (n = 31) of dentists answered none of the questions and only 2.50% (n = 2) answered all of the questions correctly. Thirty six dentists had been participated CPR course after graduation.

RESULT

There was a significant difference between dentists who participated in CPR training course and those that did not participate (P value = 0.000). Only 3.75% (n = 3) were able to perform CPR properly.

CONCLUSION

The results showed that the amount of CPR knowledge and skills were low in participated Iranian general dental practitioners. However, CPR training courses after graduation increased the amount of knowledge significantly, thus, retraining CPR courses is necessary for dentists.

Spaced scenario demonstrations improve knowledge and confidence in pediatric acute illness management

OBJECTIVES

Nationally accredited simulation courses such as advance pediatric life support and pediatric advance life support are recommended for health care professionals (HCPs) at two yearly intervals as a minimum requirement, despite literature evidence suggesting rapid decline in knowledge shortly after course completion. The objective of this study was to evaluate an observation-based, educational intervention program aimed at improving previously acquired knowledge and confidence in managing critical illnesses.

METHODS

A prospective cohort longitudinal study was conducted over a 6-month period. Participants were assessed with a knowledge based questionnaire immediately prior to and after observing 12 fortnightly critical illness scenario demonstrations (CISDs). The outcome measure was performance on questionnaires. Regression analysis was used to adjust for potential confounders. Questionnaire practice effect was evaluated on 30 independent HCPs not exposed to the CISDs.

RESULTS

Fifty-four HCPs (40 doctors and 14 nurses) participated in the study. All participants had previously attended nationally accredited simulation courses with a mean time since last attendance of 1.8 ± 0.4 years. The median number of attendances at CISD was 6 (2-12). The mean questionnaire scores at baseline (17.2/25) were significantly lower than the mean post intervention questionnaire scores (20.3/25), p = 0.003. The HCPs self-rated confidence in managing CISD was 6.5 times higher at the end of the program in the intervention group (p = 0.002) than at baseline. There was no practice effect for questionnaires demonstrated in the independent sample.

CONCLUSION

The educational intervention program significantly improved the knowledge and confidence of the participants in managing pediatric critical illnesses. The CISD program provides an inexpensive, practical, and time effective method of facilitating knowledge acquisition and retention. Despite the distinctively different approach, this study has shown the effectiveness of the participant being an observer to enhance pediatric resuscitation skills.

Review of quality assessment tools for the evaluation of pharmacoepidemiological safety studies

OBJECTIVES

Pharmacoepidemiological studies are an important hypothesis-testing tool in the evaluation of postmarketing drug safety. Despite the potential to produce robust value-added data, interpretation of findings can be hindered due to well-recognised methodological limitations of these studies. Therefore, assessment of their quality is essential to evaluating their credibility. The objective of this review was to evaluate the suitability and relevance of available tools for the assessment of pharmacoepidemiological safety studies.

DESIGN

We created an a priori assessment framework consisting of reporting elements (REs) and quality assessment attributes (QAAs). A comprehensive literature search identified distinct assessment tools and the prespecified elements and attributes were evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the percentage representation of each domain, RE and QAA for the quality assessment tools.

RESULTS

A total of 61 tools were reviewed. Most tools were not designed to evaluate pharmacoepidemiological safety studies. More than 50% of the reviewed tools considered REs under the research aims, analytical approach, outcome definition and ascertainment, study population and exposure definition and ascertainment domains. REs under the discussion and interpretation, results and study team domains were considered in less than 40% of the tools. Except for the data source domain, quality attributes were considered in less than 50% of the tools.

CONCLUSIONS

Many tools failed to include critical assessment elements relevant to observational pharmacoepidemiological safety studies and did not distinguish between REs and QAAs. Further, there is a lack of considerations on the relative weights of different domains and elements. The development of a quality assessment tool would facilitate consistent, objective and evidence-based assessments of pharmacoepidemiological safety studies.

End-user evaluations of a personal computer-based pediatric advanced life support simulator

INTRODUCTION

: To inform further development of a personal computer-based Pediatric Advanced Life Support (PALS) simulator, we wished to understand users' perceptions of this new technology. Specifically, we sought to determine whether the simulator was perceived as an effective training tool, whether it filled a gap in the users' current training regimen, and whether these perceptions were impacted by professional affiliation and PALS training history.

METHODS

: We surveyed multidisciplinary health care workers in a tertiary care pediatric hospital who used our simulator.

RESULTS

: A total of 789 users completed an evaluation of the simulator. Ninety-five percent of respondents agreed that the PALS simulator is an effective educational tool. Eighty-nine percent agreed that the simulator filled a gap in their training, although physicians agreed with this statement more strongly than nurses (P = 0.001). Prior resuscitation training history did not impact whether users perceived that the simulator filled a curricular gap. Users most commonly cited the simulator's realism, its capacity to facilitate practice, and its help feature as the top three qualities they most appreciated. Users' top three suggestions for improving the simulator included provision of a structured tutorial, specific user interface improvements, and encouragement of more widespread access to the simulator.

CONCLUSIONS

: Hospital-based pediatric providers are open to using personal computer-based simulation to provide on-demand refresher training in the cognitive aspects of PALS. Through its capacity to reach a large number of health care workers without the need for instructor presence, this technology could be used to help develop a more targeted role for mannequin simulation.

Increase in early mechanical ventilation of burn patients: an effect of current emergency trauma management?

BACKGROUND

Data relating to patients admitted with extensive burn injuries in the Netherlands have revealed a marked increase in patients whose initial care included mechanical ventilation (MV). The increase was abrupt, dating from 1997, and has been sustained since. The aim of this study is to quantify this observation and to discuss possible causes.

METHODS

The study included 258 consecutive patients with burns >30% total body surface area admitted to the Beverwijk burns center. Patients were divided into two groups based on admission date: group 1 from 1987 to 1996 (n=135) and group 2 from 1997 to 2006 (n=123). Data were analyzed using χ or analysis of variance.

RESULTS

There were no differences between groups in demographics, facial burns, inhalation injury, and % total body surface area. However, the number of patients subjected to MV at admission increased from 38% to 76% (group 1 vs. 2; p<0.001). In 57% of patients who were intubated based on the suspicion of inhalation injury, this condition could not be confirmed (p<0.05 vs. 9% [1987-1996]).

CONCLUSIONS

This study has confirmed that a higher proportion of patients were treated with MV since 1997, whereas the severity of burn injury remained unchanged throughout the study period. In the absence of a clinical explanation, we surmise that there has been a change within Dutch casualty departments in the initial management of major burn injury. The change coincides with the implementation of the Advanced Life Trauma Support training course as the accepted standard of trauma care in Dutch hospitals.

Impact of essential surgical skills with an emphasis on emergency maternal, neonatal and child health training on the practice of doctors: a cluster randomised controlled trial in Pakistan

INTRODUCTION

Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non-clinical or traditional testing manner. Such surrogate outcomes may not necessarily reflect vital changes in practice. The aim of this study was to determine if and to what extent, specific training in the management of life threatening emergencies resulted in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan.

METHODS

A cluster randomised controlled trial was conducted in three districts hospitals in three cities (Khairpur, Vehari and Peshawar) of Pakistan. Thirty-six doctors, 18 in intervention (trained in ESS-EMNCH training) and 18 in control (untrained), were enrolled and 248 life threatening emergency events, 124 in each group, were observed for the correct use of the Airway, Breathing, Circulation (ABC) structured approach. The outcome measure was structured approach defined a priori. Data was analysed by using STATA software.

RESULTS

At individual level, 79 (63.7%) life threatening episodes were managed according to the structured approach in the intervention group and 46 (37.1%) were managed according to the structured approach in controls (OR 2.98, 95%CI 1.78-4.99, p-value=0.0001). At cluster level, the mean percentage (95% CI) of the structured approach used by doctors in the intervention group [62.9% (50.4-75.3%)], was significantly higher than those in the control group, [36.3% (26.3-46.4)] (p-value=0.001).

CONCLUSIONS

5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan.

Development quality criteria to evaluate nontherapeutic studies of incidence, prevalence, or risk factors of chronic diseases: pilot study of new checklists

OBJECTIVE

To develop two checklists for the quality of observational studies of incidence or risk factors of diseases.

STUDY DESIGN AND SETTING

Initial development of the checklists was based on a systematic literature review. The checklists were refined after pilot trials of validity and reliability were conducted by seven experts, who tested the checklists on 10 articles.

RESULTS

The checklist for studies of incidence or prevalence of chronic disease had six criteria for external validity and five for internal validity. The checklist for risk factor studies had six criteria for external validity, 13 criteria for internal validity, and two aspects of causality. A Microsoft Access database produced automated standardized reports about external and internal validities. Pilot testing demonstrated face and content validities and discrimination of reporting vs. methodological qualities. Interrater agreement was poor. The experts suggested future reliability testing of the checklists in systematic reviews with preplanned protocols, a priori consensus about research-specific quality criteria, and training of the reviewers.

CONCLUSION

We propose transparent and standardized quality assessment criteria of observational studies using the developed checklists. Future testing of the checklists in systematic reviews is necessary to develop reliable tools that can be used with confidence.

A simulation-based acute care curriculum for pediatric emergency medicine fellowship training programs

OBJECTIVES

Currently, many pediatric hospitals are using simulation technology to teach trainees the skills required to effectively succeed in managing critically ill patients. Unfortunately, no curricula integrating the use of simulation have been described for pediatric emergency medicine (PEM) fellowship programs. Our objective was to outline our experience with the development, integration, and evaluation of a simulation-based, acute care curriculum into our current PEM fellowship training program.

METHODS

Using the American Board of Pediatrics and the Royal College of Physicians and Surgeons of Canada learning objectives for PEM as a guide, 12 modules composed of 43 scenarios were developed to address the skill sets required for PEM fellows. Six modules were identified as "core," allocated for completion in year 1 of fellowship, whereas the remaining modules were "subspecialty," designed for completion in year 2 of training. A 12-question survey (5-point Likert scale) was used to evaluate trainee satisfaction with regard to 4 domains: level of realism, utility of debriefing, quality of instruction, and overall satisfaction.

RESULTS

A total of 66 surveys were collected between March and July 2007. Twenty-five surveys were completed by PEM fellows. Trainees responded favorably for all 4 domains, reporting that the new simulation curriculum provided realistic scenarios with high-quality debriefing, instruction, and an overall excellent learning experience.

CONCLUSIONS

We have successfully integrated a simulation-based acute care curriculum into our PEM fellowship program. Satisfaction ratings were high for this program. Research to assess educational outcomes related to this curriculum is necessary.

In-service training for health professionals to improve care of the seriously ill newborn or child in low and middle-income countries (Review)

BACKGROUND

A variety of emergency care training courses based on developed country models are being promoted as a strategy to improve the quality of care of the seriously ill newborn or child in developing countries. Clear evidence of their effectiveness is lacking.

OBJECTIVES

To investigate the effectiveness of in-service training of health professionals on their management and care of the seriously ill newborn or child in low and middle-income settings.

SEARCH STRATEGY

We searched The Cochrane Register of Controlled Trials (CENTRAL), the Specialised Register of the Cochrane EPOC group (both up to May 2009), MEDLINE (1950 to May 2009), EMBASE (1980 to May 2009), CINAHL (1982 to March 2008), ERIC / LILACS / WHOLIS (all up to October 2008), and ISI Science Citation Index Expanded and ISI Social Sciences Citation Index (both from 1975 to March 2009). We checked references of retrieved articles and reviews and contacted authors to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-randomised trials (CRTs), controlled clinical trials (CCTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that reported objectively measured professional practice, patient outcomes, health resource /services utilization, or training costs in healthcare settings (not restricted to studies in low-income settings).

DATA COLLECTION AND ANALYSIS

We independently selected studies for inclusion, abstracted data using a standardised form, and assessed study quality. Meta-analysis was not appropriate. Study results were summarised and appraised.

MAIN RESULTS

Two studies of varied designs were included. In one RCT of moderate quality, Newborn Resuscitation Training (NRT) was associated with a significant improvement in performance of adequate initial resuscitation steps (risk ratio 2.45, 95% confidence interval (CI) 1.75 to 3.42, P < 0.001, adjusted for clustering) and a reduction in the frequency of inappropriate and potentially harmful practices (mean difference 0.40, 95% CI 0.13 to 0.66, P = 0.004). In the second RCT, available limited data suggested that there was improvement in assessment of breathing and newborn care practices in the delivery room following implementation of Essential Newborn Care (ENC) training.

AUTHORS' CONCLUSIONS

There is limited evidence that in-service neonatal emergency care courses improve health-workers' practices when caring for a seriously ill newborn although there is some evidence of benefit. Rigorous trials evaluating the impact of refresher emergency care training on long-term professional practices are needed. To optimise appropriate policy decisions, studies should aim to collect data on resource use and costs of training implementation.

The efficacy of pediatric advanced life support training in emergency medical service providers

Pediatric advanced life support (PALS) teaches skills unique to pediatric resuscitation. The purpose of this study was to assess the effect of PALS training among emergency medical service (EMS) providers in out-of-hospital trauma and medical resuscitations. A physician panel evaluated all EMS run sheets of pediatric traumas and medical resuscitations brought to a tertiary children's hospital/regional trauma center over a 3-year period. In 183 responses, EMS personnel were the sole providers of medical stabilization. Evaluation included the ability to secure an airway, establish vascular access, shock recognition, and appropriate cardiac rhythm assessment and resuscitation. The panel was blinded to the PALS training status of the responding EMS squad until completion of the review. Pediatric advanced life support-trained EMS personnel responded to 36% of the resuscitations reviewed. A significant difference in successful intubations was noted in PALS-trained squads compared with squads with no PALS training (85% vs 48%; P < 0.001). A significant difference was also noted in the ability to obtain vascular access in shock/arrest cases (100% vs 70%; P < 0.001). Similarly, PALS-trained squads were more successful in intraosseous line placement than non-PALS-trained squads (100% vs 55%; P < 0.01). However, despite better procedural skills, there was no difference in mortality rates between the groups (37% PALS vs 32% non-PALS). We conclude that PALS training improves procedural skills among EMS personnel and should be strongly considered as part of EMS training.

A practical approach to paediatric emergencies in the radiology department

Acute life-threatening events involving children in the radiology department are rare. Nonetheless, radiologists should be competent in the relatively simple procedures required to maintain or restore vital functions in paediatric patients, particularly if their practice involves seriously ill or sedated children. This article gives a practical overview of the immediate management of paediatric emergencies that the radiologist is likely to encounter, using a structured (ABCD) approach. Emphasis is given to the early recognition of respiratory embarrassment and shock, and early intervention to prevent deterioration towards circulatory arrest. The management of cardiorespiratory arrest, anaphylaxis and convulsions in children is also addressed.

Improving Workplace Safety Training Using a Self-Directed CPR-AED Learning Program

RESEARCH ABSTRACT Adequate training in cardiopulmonary resuscitation (CPR) and use of an automated external defibrillator (AED) is an important component of a workplace safety training program. Barriers to traditional in-classroom CPR-AED training programs include time away from work to complete training, logistics, learner discomfort over being in a classroom setting, and instructors who include information irrelevant to CPR. This study evaluated differences in CPR skills performance between employees who learned CPR using a self-directed learning (SDL) kit and employees who attended a traditional instructor-led course. The results suggest that the SDL kit yields learning outcomes comparable to those obtained with traditional instructor-led courses and is a more time-efficient tool for CPR-AED training. Furthermore, the SDL kit overcomes many of the barriers that keep individuals from learning CPR and appears to contribute to bystanders' confidently attempting resuscitation.

Improving Workplace Safety Training Using a Self-Directed CPR-AED Learning Program

Adequate training in cardiopulmonary resuscitation (CPR) and use of an automated external defibrillator (AED) is an important component of a workplace safety training program. Barriers to traditional in-classroom CPR-AED training programs include time away from work to complete training, logistics, learner discomfort over being in a classroom setting, and instructors who include information irrelevant to CPR. This study evaluated differences in CPR skills performance between employees who learned CPR using a self-directed learning (SDL) kit and employees who attended a traditional instructor-led course. The results suggest that the SDL kit yields learning outcomes comparable to those obtained with traditional instructor-led courses and is a more time-efficient tool for CPR-AED training. Furthermore, the SDL kit overcomes many of the barriers that keep individuals from learning CPR and appears to contribute to bystanders' confidently attempting resuscitation.

An evaluation of 9-1-1 calls to assess the effectiveness of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions: design and methodology

Background

Cardiac arrest is the leading cause of mortality in Canada, and the overall survival rate for out-of-hospital cardiac arrest rarely exceeds 5%. Bystander cardiopulmonary resuscitation (CPR) has been shown to increase survival for cardiac arrest victims. However, bystander CPR rates remain low in Canada, rarely exceeding 15%, despite various attempts to improve them. Dispatch-assisted CPR instructions have the potential to improve rates of bystander CPR and many Canadian urban communities now offer instructions to callers reporting a victim in cardiac arrest. Dispatch-assisted CPR instructions are recommended by the International Guidelines on Emergency Cardiovascular Care, but their ability to improve cardiac arrest survival remains unclear.

Methods/Design

The overall goal of this study is to better understand the factors leading to successful dispatch-assisted CPR instructions and to ultimately save the lives of more cardiac arrest patients. The study will utilize a before-after, prospective cohort design to specifically: 1) Determine the ability of 9-1-1 dispatchers to correctly diagnose cardiac arrest; 2) Quantify the frequency and impact of perceived agonal breathing on cardiac arrest diagnosis; 3) Measure the frequency with which dispatch-assisted CPR instructions can be successfully completed; and 4) Measure the impact of dispatch-assisted CPR instructions on bystander CPR and survival rates.

The study will be conducted in 19 urban communities in Ontario, Canada. All 9-1-1 calls occurring in the study communities reporting out-of-hospital cardiac arrest in victims 16 years of age or older for which resuscitation was attempted will be eligible. Information will be obtained from 9-1-1 call recordings, paramedic patient care reports, base hospital records, fire medical records and hospital medical records. Victim, caller and system characteristics will be measured in the study communities before the introduction of dispatch-assisted CPR instructions (before group), during the introduction (run-in phase), and following the introduction (after group).

Discussion

The study will obtain information essential to the development of clinical trials that will test a variety of educational approaches and delivery methods for telephone cardiopulmonary resuscitation instructions. This will be the first study in the world to clearly quantify the impact of dispatch-assisted CPR instructions on survival to hospital discharge for out-of-hospital cardiac arrest victims.

Trial Registration

ClinicalTrials.gov NCT00664443

A survey of attitudes and factors associated with successful cardiopulmonary resuscitation (CPR) knowledge transfer in an older population most likely to witness cardiac arrest: design and methodology

BACKGROUND

Overall survival rates for out-of-hospital cardiac arrest rarely exceed 5%. While bystander cardiopulmonary resuscitation (CPR) can increase survival for cardiac arrest victims by up to four times, bystander CPR rates remain low in Canada (15%). Most cardiac arrest victims are men in their sixties, they usually collapse in their own home (85%) and the event is witnessed 50% of the time. These statistics would appear to support a strategy of targeted CPR training for an older population that is most likely to witness a cardiac arrest event. However, interest in CPR training appears to decrease with advancing age. Behaviour surrounding CPR training and performance has never been studied using well validated behavioural theories.

METHODS/DESIGN

The overall goal of this study is to conduct a survey to better understand the behavioural factors influencing CPR training and performance in men and women 55 years of age and older. The study will proceed in three phases. In phase one, semi-structured qualitative interviews will be conducted and recorded to identify common categories and themes regarding seeking CPR training and providing CPR to a cardiac arrest victim. The themes identified in the first phase will be used in phase two to develop, pilot-test, and refine a survey instrument based upon the Theory of Planned Behaviour. In the third phase of the project, the final survey will be administered to a sample of the study population over the telephone. Analyses will include measures of sampling bias, reliability of the measures, construct validity, as well as multiple regression analyses to identify constructs and beliefs most salient to seniors' decisions about whether to attend CPR classes or perform CPR on a cardiac arrest victim.

DISCUSSION

The results of this survey will provide valuable insight into factors influencing the interest in CPR training and performance among a targeted group of individuals most susceptible to witnessing a victim in cardiac arrest. The findings can then be applied to the design of trials of various interventions designed to promote attendance at CPR classes and improve CPR performance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00665288.

Pediatric resident confidence in resuscitation skills relates to mock code experience

To assess confidence in resuscitation skills among pediatric residents and its relationship to training and experience, all pediatric residents at one institution were surveyed regarding their confidence in technical and leadership resuscitation skills and their prior experience with real and mock codes. Respondents (61/82, 74%) reported participation in 4.9 +/- 3.6 mock and 3.9 +/- 5.0 real codes. Confidence score for all skills was 2.7 +/- 0.6 (scale 1-5). Senior residents were more confident than interns (2.8 +/- 0.5 vs 2.3 +/- 0.5). Residents were more confident in basic (3.9 +/- 0.6) than in advanced (2.6 +/- 0.6) or expert resuscitation skills (1.6 +/- 0.7). Confidence correlated with mock codes (r = 0.52) and to a lesser degree with real codes attended (r = 0.36). Performance of active roles and debriefing occurred more commonly with mock than with real codes. The data indicate that pediatric residents have limited confidence in resuscitation skills and that mock code training with active participation and debriefing may be an effective educational tool.

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Effect of newborn resuscitation training on health worker practices in Pumwani Hospital, Kenya

BACKGROUND

Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya.

METHODS/PRINCIPAL FINDINGS

We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group, n = 55). The training was adapted locally from the approach of the UK Resuscitation Council. The primary outcome was the proportion of appropriate initial resuscitation steps with the frequency of inappropriate practices as a secondary outcome. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. Trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.75-3.42], p<0.001, adjusted for clustering). In addition, there was a statistically significant reduction in the frequency of inappropriate and potentially harmful practices per resuscitation in the trained group (trained 0.53 vs control 0.92; mean difference 0.40, [95% CI 0.13-0.66], p = 0.004).

CONCLUSIONS/SIGNIFICANCE

Implementation of a simple, one day newborn resuscitation training can be followed immediately by significant improvement in health workers' practices. However, evidence of the effects on long term performance or clinical outcomes can only be established by larger cluster randomised trials.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN92218092.

Review of resuscitation training amongst consultants and middle grade paediatricians

AIMS

To review the resuscitation training of senior and middle grade paediatricians.

METHODS

A questionnaire was sent to all paediatricians above the level of senior house officer in the Eastern Region of the UK to determine: (1) completion of basic life support (BLS) training in the previous year; (2) previous attendance at a paediatric/neonatal advanced life support course; (3) resuscitation provider accreditation; (4) instructor status.

RESULTS

Replies were received from 153 out of 160 paediatricians. During the study period 48% 95% CI (36% and 60%) of general hospital consultants (GC), 40% (21% and 61%) of community consultants (CC), 75% (59% and 87%) of specialist registrars (SpRs) and 53% (28% and 77%) of non-consultant grade doctors (T/SG) had received BLS training. 86% (76% and 93%) GC, 24% (9% and 45%) CC, 100% (91% and 100%) SpRs and 82% (57% and 96%) of T/SG had previously attended an advanced life support (ALS) course. Accredited provider skills were maintained by 54% (41% and 65%) GC, 12% (3% and 31%) CC, 83% (67% and 93%) SpRs and 53% (28% and 77%) of T/SG. Only 28% GC, 4% CC, 20% SpRs and 6% T/SG were instructors on any of the advanced courses.

CONCLUSIONS

Most paediatricians have attended an ALS courses at some point during their training. Consultants are poor at maintaining/re-certifying their advanced resuscitation skills. Few paediatric consultants and residents instruct on ALS courses.

Using pediatric advanced life support in pediatric residency training: does the curriculum need resuscitation?

OBJECTIVE

The Pediatric Advanced Life Support (PALS) course is used throughout North American pediatric residency programs to provide a core pediatric resuscitation curriculum. Despite this widespread use, its effectiveness has not been formally assessed in pediatric residents. This study aimed to evaluate the PALS curriculum's effectiveness in providing pediatric residents with knowledge, skill and confidence in pediatric resuscitation.

DESIGN

Course evaluation.

SETTING

Tertiary care pediatric hospital.

SUBJECTS

Pediatric residents.

INTERVENTIONS

Subjects were followed prospectively for 1 yr following completion of an annual PALS course. Multiple choice and short answer questionnaires were used to evaluate residents' knowledge immediately before and after completion of the course and throughout the following year. Confidence in ten aspects of pediatric resuscitation was assessed. Scores were compared before and after the PALS course to evaluate acquisition of knowledge and confidence. Scores at 12 months were compared with the immediate post-PALS course scores to evaluate maintenance of knowledge and confidence over time. Technical skills were evaluated by staff anesthetists using a 3-point scale.

MEASUREMENTS AND MAIN RESULTS

Knowledge questionnaire scores were significantly higher post-PALS compared with pre-PALS, but knowledge of the details of PALS algorithms decreased significantly over the following 12 months. Confidence ratings improved post-PALS on only two of ten measures and remained very low overall. Residents could complete the four core technical skills but required assistance or multiple attempts.

CONCLUSIONS

PALS is successful in providing basic resuscitation knowledge to pediatric residents, but knowledge of critical algorithm details is not sustained. The course does not provide for the expected level of competency in relevant technical skills. Residents do not achieve the confidence to feel well prepared to provide comprehensive care to pediatric patients in cardiopulmonary arrest. These findings support the hypothesis that the PALS course alone is insufficient to provide pediatric residents with competency in cardiopulmonary resuscitation.

Bridging the knowledge-resuscitation gap for children: Still a long way to go

The American Heart Association, along with the International Liaison Committee on Resuscitation, recently made changes to the paediatric resuscitation guidelines.Knowledge translation (KT) is imperative, but there is a lack of sufficient evidence for appropriate methodologies for implementation of these guidelines. Paediatric resuscitation presents many challenges; cases happen infrequently, affording few opportunities for implementation of the new guidelines, and are highly stressful and filled with uncertainty. Some KT strategies have shown some success in causing a notable degree of change in behaviour, but none have shown a striking difference when used alone.Previous efforts to disseminate current guidelines centred on development of courses for health care providers and preparing paediatric residents and paediatricians for circumstances they could encounter with paediatric acute illness. None of the studies assessing these techniques measured direct patient outcomes, and only a few demonstrated some long-term knowledge acquisition among trainees. The purpose of the present review was to illuminate the challenges, offer future directions for KT and outline potentially more effective methodologies and strategies to overcome current barriers.