Znajomość podstawowych zabiegów resuscytacyjnych wśród lekarzy rezydentów, studentów medycyny, pielęgniarek, pracowników służby zdrowia i personelu pomocniczego w południowo-zachodnim Iranie

Introduction

Cardiopulmonary arrest (CPA) is a sudden respiratory stop or an effective blood circulation in patients, with the exception of patients with advanced and end stages of chronic illnesses and cancer [1]. According to the statistics of the World Health Organisation, cardiovascular disease is currently the most important and the most common cause of death in the world; in 2012 about 17.5 million people (46% of all deaths due to non-contagious diseases) died because of cardiovascular illness [2]. Furthermore, according to published statistics by the US Health and Medical Organisation, annually 300,000 people die due to cardiovascular disease in this country [3].
Basic life support (BLS) is a key component of the resuscitation process, which improves the survival chances of patients with cardiac arrest. Since the central nervous system, after a period of more than 3–4 min of hypoxia and/or lack of oxygen, can cause irreversible damage, the onset of non-delayed and high-quality BLS can greatly improve the survival chances of patients [4].
In this regard, the American Heart Association recommends the use of a survival chain for all patients requiring cardiopulmonary resuscitation (CPR). The links in this chain include rapid diagnosis of disease requiring CPR, fast and timely performance of CPR, fast and timely use of a defibrillator, advanced resuscitation measures, and post heart attack care [5]. Among the above-mentioned items, are the first three steps of resuscitation of initial resuscitation measures [6].
Knowing the BLS technique is essential for all individuals within the community in order to save lives in an emergency. Among all the community groups, it is at least expected that the staff involved in medical and paramedical sciences are educated about using CPRs to a good level. Studies show that if CPR is done by highly-skilled and trained people with minimum delay, it leads to reduction of mortality [7]. In the United States, BLS training has been recommended for all health care professionals since 1966 [8]. Since the late 1980s, numerous studies have been done on the knowledge and skills of performing CPR. Some of these studies showed the effect of the presence of trained people on the process of resuscitation. Based on the results of one of these studies, even the presence of one person with more skill can have a tremendous effect on the resuscitation process [9, 10].
Despite the importance of CPR, a recent study in Iran showed that only 9.7% of the medical treatment staff had the required skills in this regard [11, 12]. In Iran, although BLS education has been increasingly a part of the curriculum for medical and nursing students, the awareness level about the proper techniques of BLS is questionable among medical personnel.

Material and methods

Design and studied population

This prospective observational study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [13] from April 8, 2017 to July 17, 2017, After obtaining Ethics Committee approval from Ahvaz Jundishapur University and written consent.

Study method

During the period of this study, questionnaires were distributed to participants working hospital in Ahvaz. The current study questionnaire was set forth according to the new guidelines of the American Heart Association after reviewing previous studies [7, 14].
This questionnaire consists of 18 questions in two parts. The first part contains demographic information about the age, gender, field of study, and the history of participation in BLS formal education courses, as well as a second part, which includes 0–18 scores (Appendix). The questioned aspects included the following items: the preliminary stages of resuscitation, assessment and resuscitation techniques in relation to the airway, respiration, and blood circulation in the victims according to the age group, which, in a total of seven questions, referred to the principles of external massage of the chest. In addition, five questions were specifically devoted to airway management, and a joint question assessed the knowledge in both areas. The content validity method was used to assess the validity of the questionnaire.
Then, 10 copies of this questionnaire were distributed among 6 faculty members of the hospital and four of the educated CPR nurses. Finally, 10 copies of this questionnaire were given to medical students and professional medical assistants, and their corrective comments were ultimately applied in the final compilation of the questionnaire.

Statistical analysis

The reliability of the questionnaire was analysed by SPSS software using Cronbach’s  coefficient with  = 0.75. Number 1 was assigned for the correct option, 0 for the wrong option, and 2 was used for unanswered questions. Data were extracted and analysed by descriptive statistics, independent t-test, and Pearson correlation coefficient.

Results

In total, 202 people participated in this study (Figure 1); among them, 131 (64.9%) were female. The average age of participants was 30.22 ±8.44 years. The education level of studied population included resident doctors undergoing education (11.9%), medical interns (19.3%), medical externs (20.3%), nursing experts (28.7%), and health care providers (19.8%). In total, 109 (54.0%) of the participants in this study successfully passed the course of the previous CPR (Table 1).
The results showed that the average obtained scores in the total population was 7.93 ±2.61, the highest score was 15, and the lowest score was 1 (Figure 2). 34.7% of participants responded correctly to half or more than half of the questions about the principles of external chest massage. This rate regarding ventilation principles was significantly lower (p = 0.001) and was reported at 15.3%.

The relationship between gender and mean scores

The average test scores for women was 8.15 ±2.52 and in men was 7.52 ±2.74; no significant difference was seen among the respondents’ scores (p = 0.15).

The relationship between education and mean scores

The mean scores of people who had already passed BLS education courses was 8.45 ±2.45 and non-educated persons was 7.31 ±2.71 in (p = 0.002). This relationship was statistically significant.

Relationship between the level of education and the awareness level of CPR

The results show that resident doctors (24 people) attained the highest score in this test (9.58), and for the next categories: nursing experts (58 people) scored 8.69, medical interns (39) scored 8.05, and health care providers and their assistants (40 people) scored 6.88. The last group, medical externs (41 people), scored 6.80 (Figure 3). Knowledge of specialised assistants was significantly higher than the health care providers, their assistants groups (p < 0.001), and medical students (p < 0.001). In addition, the knowledge of nursing experts was significantly higher than the health care providers, their assistants (p = 0.004), and medical students (p = 0.002).

Discussion

Cardiopulmonary resuscitation has always been considered as one of the most important factors in protecting the lives of patients with CPA; its correct and timely performance can save these patients to a large extent from certain death [15]. It seems that having good knowledge of the theory is an important prerequisite for successful CPR.
Various studies in different countries indicate that, in general, the theory of knowledge is in the context of the resuscitation of the base; in a study conducted in India on 1054 people from different medical courses 894 (84.82%) participants had a score of less than 50% [16]. Similarly, in foreign studies, similar results have been reported in domestic studies. As an example, a study conducted on nurses’ knowledge about CPR showed that their mean scores for theoretical and practical knowledge is 48% [17].
The low level of theoretical knowledge seems to be partly explained by the fact that only 54% of the respondents who participated in our study were educated with CPR-related courses. According to various studies, lack of or non-continuing education is one of the main causes of low scores among the majority of students in various studies. In the study conducted by Plagisou et al., only 13.2% of respondents in the past 6 months participated in a CPR course [7].
Mellor et al., examined the role of education in the knowledge level about BLS in 34 health workers who had been tested before and after participation in a BLS education course [18]. It was showed that after passing the education course, a significant improvement was made in the correct actions and safe approach of the participants. In all cases, including checking the response, asking for help, opening the airway, checking the breathing, asking help from the heart resuscitation team, having the appropriate breathing rate, making appropriate heart resuscitation, making appropriate heart massage, doing massage with appropriate depth and the number of massages per minute, significant progress has been made.
Smith et al. examined the ability to maintain theoretical knowledge and performance of nurses in relation to BLS and advanced cardiovascular life support (ACLS), and they showed that the theory of knowledge and practical skills of resuscitation rapidly reduce over time. Regarding BLS, after three months of education, the number of accepted people in the test was 63%, and after 12 months it reduced to 58% [19].
Of these studies, it can be concluded that although doctors and nurses participate in CPR education programs during their employment and education period, participating in education courses every 6 months leads to preservation of knowledge and theoretical skills. This issue indicates the need for continuing education [20, 21]. Our study showed that, although there is a serious shortage of knowledge about BLS, this shortage among the groups of medical interns, assistant nurses, and health care providers was worse. In addition, the results of Reddy et al.’s study indicated that there is insufficient knowledge about BLS among different groups. It is required that the knowledge and skills associated with BLS are increased, as well as holding courses and workshops to update their information [22]. A similar study showed that the average response to questions in the field of theoretical knowledge in medical and nursing fields was significantly higher than among public health students (non-therapeutic) (60% vs. 45%, respectively) [23]. One of the cases found in this study was the lack of knowledge among medical students in internship in comparison with other respondents – they gained the lowest scores.
The evaluations suggested that the cause of lower score in this category of people may be related to less educating of students. The importance of this issue is because some studies indicate that medical interns who passed CPR programs in their early education years, compared to other practitioners who study CPR in their late years of study, are more willing to improve their knowledge and skills [24, 25]. In addition, Aroor showed that having knowledge about BLS consecutively can be increased during the different educational levels. This matter shows the need to strengthen and refresh BLS education courses at regular intervals [26].
The results of our study showed that 34.7% of participants responded correctly to half or more than half of the questions about the principles of external chest massage. This rate regarding ventilation principles was reported significantly lower, at 15.3%. These results were similarly reported in the study by Baduni et al.; in this study, 32.11% of the participants responded correctly to questions about the external massage of the chest. This figure for respiration and making an airway was merely 17.49% [1]. Similarly, in the study conducted by Alotaibi et al., 45.52% of respondents responded to questions about the external chest massage, and 25.92% of respondents responded correctly to the question about respiration problems [27].
From all the studies, it can be concluded that theoretical knowledge about breathing and making an airway occur in less time in comparison with chest massage. Perhaps the cause of this reduced knowledge is due to the lower importance of the airway in comparison with chest massages in resuscitation. Because it seems that some CPR volunteers are unwilling to do it, they probably would not feel the need to learn about this matter. On the other hand, in the recent edition, mouth-to-mouth breathing has also been optionally mentioned.

Conclusions

This study showed that the knowledge level about CPR among different health care departments (physicians, nurses, and health care providers) is low and the need for continuing education courses with a minimum of 6-months intervals is necessary. In addition, for medical students, CPR should start from basic medical sciences. Further emphasis on the importance of airway ventilation training in the codified courses should be considered as part of the basic principles of resuscitation.

Conflict of interest

The authors declare no conflict of interest.

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