Impact on awareness and knowledge of resuscitation by structured training of compression-only life support (COLS) among non-medical staff

ABSTRACT

Background and Aims:

This study intended to analyse the effectiveness of compression-only life support cardiopulmonary resuscitation (COLS CPR) training based on training knowledge acquired among non-medical staffs.

Methods:

The study was conducted among 300 non-medical staffs. Study design: It is an observational study where the effect of COLS CPR training was evaluated based on the pre-training and post-training assessment score. Google Forms questionnaire was used as an interventional tool. Participants in our study included security guards, ambulance drivers, housekeeping and facility staff of our hospital. Training was conducted for seven days through lecture, audio-visual display, demonstration and then hands-on session conducted at the end of each training. The Google Form questionnaires consisted of COLS meaning, rate, depth of compression, usefulness, etc. Corrective action preventive action (CAPA) analysis report was prepared along with corrective and preventive action, and onsite debriefing was also done.

Results:

Paired t-test was applied. For pre-test questions, 1,2,3,4,5 and 6 correct answers were 82.8%, 20.2%, 15%, 5%, >80% and <10%, respectively. In post-test, correct answers were 98.8%, 95%, 92.8%, 67%, 99.6% and 99.3%, respectively. P value 0.0022 suggested that training is highly effective and made statistically significant difference in knowledge of the participants.

Conclusion:

Among non-medical staff, this study emphasises the cognitive approach to the general perception and skill of COLS. Hence, formal refresher training and experience enhance the knowledge of CPR.

INTRODUCTION

Cardiovascular disease is one of the major global concerns. In India, out of hospital cardiac arrest (OHCA) is one of the leading causes of death. Seventy percent of cardiac arrest occurs either at home or workplace, and 90% of these victims die. Every minute delay in initiation of cardiopulmonary resuscitation (CPR) reduces 7–10% chance of survival.[1]

American Heart Association has described a cardiopulmonary resuscitation technique as a chain of survival that has increased the chance of survival of cardiac arrest patients.[2]

Cardiovascular disease causes sudden cardiac death in about 80% cases.[3] Sudden cardiac death is one of the major health problems worldwide. Approximately, six million deaths due to sudden cardiac arrest occur annually, and out of them, 85% occur outside hospital.[4,5] The most common pre-arrest rhythm is ventricular fibrillation, and if managed timely by resuscitation attempts, it can be reverted to sinus rhythm.[6] There is increased rate of survival if CPR is executed in time by the trained bystander. Hence, it is essential to provide CPR training to the laypersons as well.[7]

CPR needs to be performed as soon as possible by the laypersons to improve the survival rate with better neurological outcome. Therefore, compression-only CPR needs to be taught to all to save many lives.[2] However, awareness about CPR is less than 1% among Indian population.[4] So, there is an utter need to create not only awareness but also to provide proper structured training (knowledge and skill) among laypersons for compression-only life support (COLS).

So, we conducted this study primarily to study the effect of ‘CPR’ training among the non-medical staff. Secondary objective was to assess the prevailing knowledge and attitude about CPR.

METHODS

This cross-sectional observational study was conducted among non-medical persons including ambulance drivers, security, housekeeping staffs and attendants after obtaining institutional ethics committee approval. The study was registered with the Clinical Trials Registry of India. The information about the purpose and benefit of the study was explained to the participants.

A structured training curriculum and teaching material as validated by Indian Resuscitation Council were used for the training. About 310 non-medical staffs were encouraged to participate in the training, but only 300 participants successfully completed the training. Ten participants were excluded from the training, six participants did not meet the inclusion criteria, three participants declined to participate in the training, and one participant was excluded for some other reason. This compression-only CPR training was conducted for one-month duration from 1 June 2021 to 30 June 2021, in divided groups; each group consisted of 10–15 staffs per day. All the training was done by the certified instructors for teaching and training of resuscitation courses by Indian Resuscitation Council (IRC). These lectures emphasised on COLS survival chain and COLS algorithm. After the interactive session of teaching for around 30–45 minutes in a group of 10–20 participants, the participants demonstrated the skill. Thereafter, each participant was allowed to perform hands-on practice supervised by an instructor. The practice was repeated after debriefing till the participants acquired the skill for COLS. Hands-on session was conducted at the end of each training day.

Google Form questionnaire was given to all the non-medical staffs in the pre-training period, and the assessment score was recorded. The same Google Form questionnaire was given at the end of each training session, i.e. post-training period, and the assessment scores were recorded. The Google Form questionnaire consists of questions such as COLS full form, chest compression rate, depth of chest compression, usefulness, feedback, etc.

The analysis of Google Form questionnaire data was done by using Infosys business process management (IBPM) software version 2.0. Paired t-test was applied. A P value <0.05 was statistically significant. P value <0.05 suggests that training is highly effective and made statistically significant difference in the knowledge of the participants.

RESULTS

A total of 300 participants were included [Figure 1]. Study participants in the pre-training and post-training period were same during each training session day. The questions that were asked were: (1) In COLS, compression means what? (2) First step when patient collapses? (3) What next if response present? (4) What if response is not present? (5) During CPR where compression to be given? (6) How many compressions to be given and till when? Assessment scores were recorded, i.e. pre-training versus post-training period. For pre-test questions 1,2,3,4,5 and 6, correct answers given by the participants were 82.8%, 20.2%, 15%, 5%, >80% and <10%, respectively. In post-test, correct answers given by the participants were 98.8%, 95%, 92.8%, 67%, 99.6% and 99.3%, respectively. The percentage of staffs who gave correct answer for each question was recorded [Figure 2].

Figure 1.

Consolidated standards for reporting trials (CONSORT) diagram

Figure 2.

Pre- and post-training assessment score. CPR: Cardiopulmonary resuscitation; COLS: Compression-only life support

In our study, P value was found to be 0.0022; it is very statistically significant.

DISCUSSION

There are a few studies that have brought the concept of CPR teaching through videos to the laypersons. We conducted this COLS CPR training through videos, lecture, and demonstrations. Videos are an effective way of training as the visualisation of pictures increases thinking and reacting to the particular situation. Videos and demonstrations helped the participants in gaining knowledge about the CPR.

From our training, we could see the result of improvement about the knowledge of CPR. Staffs came to know about the rate, depth of chest compression and how to react and anticipate if they confront a cardiac arrest victim.

There are guidelines which focus on avoidance of any interruption of chest compression and thus rely primarily on chest compression-only CPR by laypersons.[1]

‘Compression-only’ CPR is an intervention to save lives and achieves two purposes, alleviating social discomfort by providing mouth-to-mouth respiration and to train a larger population in short time. Clinical trials have shown that the outcome of the patients by bystander COLS and bystander CPR is similar, which might be due to uninterrupted high-quality chest compressions. With the help of COLS programmes, we can train large number of non-medical persons to identify cardiac arrest and provide COLS till the arrival of medical help.[8]

Gain in knowledge about the compression-only CPR at the community level in a short period can be a lifesaving.[2] Our study also showed significant gain in knowledge pre- versus post-training (P = 0.0022).

There were many studies that suggest robust gain of basic knowledge and willingness to deliver CPR among volunteers undergoing training at community level.[9,10]

Video-based COLS training significantly improved the initial recognition and response to compression time (RCT) by 35% compared to traditional instructor-based training.[4] The authors believe that the RCT in video-based training decreased as compared to conventional method of training. Literature reveals that students’ teaching learning process would be more receptive if it can be through multimedia, audio-visual picture and images.[11] Enhanced video-based learning though seems to be passive, keeps the behaviourally inactive learners engaged by increasing their ability of thinking and learning. Our training was based on audio-visual, lecture and hands-on session which was more effective. The participants gained knowledge on proper way of providing chest compression to the cardiac arrest victims.

Training is a process of enhancing knowledge and skills of employees. Regular training of healthcare workers is important to enhance knowledge and improve outcome of the patients. Regular training influences and improves thinking and performance of employees. It is also a confidence booster. For all hospital personnel, National Accreditation Board for Hospitals has made resuscitation training mandatory.[12]

If CPR is not administered properly and immediately after cardiac arrest, victim begins to suffer irreversible brain damage four minutes after arrest. So immediately chest compression needs to be started.[13]

The preferred method for laypersons witnessing sudden collapse is compression-only CPR or hands-only CPR. If the victim is unknown, bystander is usually hesitant to provide mouth-to-mouth breathing for resuscitation.[1]

CPR training improves resuscitation attempts by the bystander in witnessed cardiac arrest. Only chest compression may be a more suitable method for bystander CPR, than mouth-to-mouth ventilation. CPR training plays a vital role in willingness to perform CPR. Due to decreased willingness to perform mouth-to-mouth resuscitation on a stranger, new CPR training programme for laypersons should be adapted to emphasise the skills of compression-only CPR and the use of automated electrical defibrillators.[10]

During foundation course of the medical students, basic cardiac life support (BCLS) training is given to improve knowledge and confidence regarding CPR.[14] We also provide BCLS training to our medical students, nursing staff and COLS training to the non-medical staff periodically to improve knowledge and provide confidence to perform CPR.

We have implemented an innovative teaching learning method, a combination of video-based learning and didactic lecture.

It is suggested to give COLS training to different populations like police, traffic policemen, security guards, teachers, school children, drivers, etc. Keeping in mind that the knowledge and awareness of COLS are important among laymen, the IRC has started celebrating the ‘World Restart a Heart Day’ all over the country by having COLS session.[15]

CPR is provided by the staffs also along with doctors of our institute in cardiac arrest patients. If CPR including chest compression rate or depth is not conducted properly, it is corrected and the correct method of providing proper CPR is demonstrated to them. Onsite debriefing is done about the CPR after each CPR event. Parallelly, monthly CPR analysis meeting is conducted to audit each CPR patient event.

CONCLUSION

Compression-only CPR can bring about changes in the survival in OHCA. This study emphasises the cognitive approach to the general perception and skill of COLS. Formal refresher training and experience can enhance the knowledge of CPR. This can save several lives in the future.

In the future, definitely it can save millions of lives!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.