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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

38585320
10.5005/jp-journals-10071-24690
Editorial
Cardiopulmonary Resuscitation Training and Reinforcement: A Bulwark against Death
Sinha Saswati https://orcid.org/0009-0008-9954-8514

Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
Saswati Sinha, Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India, Phone: +91 9831632329, e-mail: sashsinha@gmail.com
4 2024
30 3 2024
28 4 317319
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Sinha S. Cardiopulmonary Resuscitation Training and Reinforcement: A Bulwark against Death. Indian J Crit Care Med 2024;28(4):317–319.

Keywords

Advanced life support
BLS training
Cardiac arrest
Cardio pulmonary resuscitation
Cardiopulmonary resuscitation
Competency based training
Life-saving skill medical undergraduates
Questionnaires
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pmcSuccessful resuscitation from cardiac arrest requires early recognition, rapid activation of trained response teams, effective basic life support (BLS), and early defibrillation followed by advanced life support. High-quality cardiopulmonary resuscitation (CPR) aimed at achieving adequate coronary and cerebral perfusion which is the key to improving outcomes. Survival rates from in-hospital cardiac arrest are estimated at less than 20% despite advancements in skills and technology.1 This could be attributed to inadequate or ineffective BLS due to lack of uniformity in mandatory training programs as well as poor retention skills with advanced cardiac life support (ACLS) skills declining more rapidly than BLS skills on periodic assessment.2 This emphasizes the need for guideline-based training programs focusing on both knowledge about CPR and psychomotor skills with periodic refresher courses to assess and maintain competency.

In this issue of the journal, Agarwal et al.3 report the results from a study to assess the baseline knowledge among resident doctors and nurses about different domains of basic and advanced cardiopulmonary resuscitation based on a questionnaire covering scene safety, chest compression, airway, breathing and ventilation, defibrillation, team dynamics, management of arrhythmias and post-cardiac arrest care. This was followed by simulation-based training sessions which incorporated didactic lectures and skill stations covering case scenarios on manikins encompassing extensive training on the aforementioned domains of CPR by experts. The impact of this training was assessed immediately thereafter using a questionnaire to assess the theoretical knowledge and adequacy of practical skills was also tested following the training. The retention of knowledge was assessed by a repeat questionnaire after 6 months.

The study found that the participants had a reasonable baseline knowledge about recognition of cardiac arrest, activation of emergency response systems (EMS), cardiopulmonary resuscitation whereas they lacked in important domains, such as defibrillation, advanced life support, and post-cardiac arrest care. Post-training, a significant improvement was noted in all the domains with the maximum impact in post-cardiac arrest care; however, proficiency in defibrillation and ACLS was still lacking.

A repeat questionnaire-based assessment at 6 months revealed that the improvement in knowledge as compared with the baseline was sustained but there was a decline as compared with the scores immediate post-training, the major lacunae remaining identical in terms of defibrillation and advanced life support which reaffirms the need for periodic refresher programs to maintain skills and knowledge.

These results bear resemblance to prior studies conducted in India by Bhatnagar et al. in postgraduate students who also reported that the baseline knowledge on resuscitation did undergo significant improvement following training but the residual knowledge tends to wane over time and periodic sessions are invaluable to maintain the quality and proficiency.4 The unfortunate paucity of knowledge regarding resuscitation appears to be widespread as is evident from another study in Kerala by Chandran and Abraham which was conducted among new interns who had just graduated from medical college which again highlights the lack of baseline knowledge and skills among young doctors which remarkably improve following training.5 This should prompt policymakers to incorporate mandatory BLS training into the medical curriculum in the near future.

Dearth of knowledge regarding resuscitation is not unique to India as there have been studies reported from other parts of the world which show a huge discrepancy regarding the awareness about resuscitation and its various aspects among various categories of health care providers across health care settings.6 A survey conducted among more than 1,000 medical students from 99 universities across 14 European countries by Baldi et al. just before their graduation also found that knowledge about cardiac arrest and CPR was scarce highlighting that this was probably a worldwide issue affecting patient care which needs to be addressed as a priority.7 Considering these aspects, there is a guidance note promoted by the European Resuscitation Council which proposes a step-wise approach whereby CPR training needs to be initiated from the first year of undergraduate training followed by annual refresher sessions leading up to advanced life support in senior undergraduate students.8 The instructors need to conduct the sessions adhering to international guidelines thereby imparting the knowledge as well as life-saving competencies to the students and trainees.

Do these Training Programs Impact Outcomes?

Although life support courses are widely advocated, there are very few studies which have assessed their effectiveness in improving CPR outcomes after formal resuscitation training. There have been reports of significant improvement in both return of spontaneous circulation (ROSC) as well as survival to discharge rates following training programs and the presence of even one team member who was ACLS trained showed a positive effect on outcomes.9–12 In a retrospective analysis, Sodhi et al. studied the impact of an AHA certified BLS/ACLS training program in 627 in-hospital cardiac arrest cases over a period of 18 months (284 before and 343 after training). They found a significant increase in ROSC (28.3% vs 18.3%) as well as a higher percentage of survivors to hospital discharge (69.1% vs 28.3%) following the training program for doctors in the code blue team and ICU which re-emphasizes the value of formal CPR training in improving CPR outcomes.13 A systematic review aimed at highlighting the effect of CPR training on knowledge and skill retention as well as the impact of different methods of training among nurses. They found that there is a significant improvement in knowledge acquisition and retention. However, skills start to decay as early as 2 weeks post-training while knowledge decline varies between 1 and 6 months which puts forward an unmet need to define the ideal timeline after the initial training for renewal or re-certification.14

What is the Way Forward in Improving Resuscitation Outcomes?

Deficient resuscitation skills are an important contributor to poor outcomes post-cardiac arrest. In 2003, the International Liaison Committee on Resuscitation Advisory (ILCOR) included a hypothetical formula—“the formula for survival” or the “Utstein Formula.” The Utstein Formula for Survival from cardiac arrest defines three factors to determine the potential survival rates: guideline quality, educational/training efficiency, and local implementation.15 The latter two factors play a key role in delineating the strengths and weaknesses of a training program.

The “Chain of Survival” in case of in-hospital cardiac arrest comprises of key components, such as early access, early CPR, rapid defibrillation and advanced life support. The audit of the processes in the chain of survival helps find gaps in the training/chain and helps correlate these gaps with survival outcomes. Nurses and resident doctors usually are the first responders and there is an emergent need to ensure high-quality structured CPR training of all health care workers in our country to improve the survival of victims after a sudden cardiac arrest.16

In order to improve upon the current situation—there are certain key areas which need to be focused on:

Record keeping, audit, and monthly analysis of all cardiac arrests to be done—identify lacunae.

Structured resuscitation training to be made mandatory for all health care personnel with periodic refresher courses to ensure maintenance of knowledge and skills.

Incorporating updated CPR training techniques, such as using real-time visual feedback in CPR manikins might help in improving the quality of chest compressions (rate and depth) which can help to adjust and perfect the technique during training sessions.

Simulation-based CPR training can help to gain and hone skills thereby improving the quality of training17 and provide exposure to scenarios; however, high-fidelity simulation manikins are expensive and may not be universally available.

Focused training on key skills such as high-quality chest compression and defibrillation as well as periodic reassessment—is of paramount importance in enhancing and maintaining CPR quality and skills.

Cardiopulmonary resuscitation is an indispensable skill which transcends the boundaries of medical training thereby making the knowledge and skills pivotal in saving lives. Comprehensive training and repeated practice empowers healthcare providers to recognize and perform all the essential steps flawlessly, even when life-threatening situations create an extremely stressful environment. It is time to incorporate CPR training early in our medical curriculum.

Orcid

Saswati Sinha https://orcid.org/0009-0008-9954-8514

Source of support: Nil

Conflict of interest: None
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References

1. Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest Incidence, prognosis and possible measures to improve survival Intensive Care Med 2007 33 2 237 245 10.1007/s00134-006-0326-z 17019558
2. Smith KK Gilcreast D Pierce K Evaluation of staff's retention of ACLS and BLS skills Resuscitation 2008 78 1 59 65 10.1016/j.resuscitation.2008.02.007 18406037
3. Agarwal A Baitha U Ranjan P Swarnkar NK Singh GP Baidya DK et al. Knowledge and skills in cardiopulmonary resuscitation and effect of simulation training on it among Healthcare workers in a tertiary care center in India Indian J Crit Care Med 2024 28 4 336 342 38585308
4. Bhatnagar V Tandon U Jinjil K Dwivedi D Kiran S Verma R Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention in young doctors joining postgraduation program Anesth Essays Res 2017 11 842 846 10.4103/aer.AER_239_16 29284836
5. Chandran KV Abraham SV Basic life support: Need of the hour-a study on the knowledge of basic life support among young doctors in India Indian J Crit Care Med 2020 24 5 332 335 10.5005/jp-journals-10071-23442 32728324
6. Einav S Wacht O Kaufman N Alkalay E Cardiopulmonary arrest in primary care clinics: More holes than cheese: A survey of the knowledge and attitudes of primary care physicians regarding resuscitation Isr J Health Policy Res 2017 6 22 10.1186/s13584-017-0148-1 28616160
7. Baldi E Contri E Bailoni A Rendic K Turcan V Donchev N et al. Final-year medical students’ knowledge of cardiac arrest and CPR: We must do more! Int J Cardiol 2019 296 76 80 10.1016/j.ijcard.2019.07.016 31375334
8. Baldi E Savastano S Contri E Lockey A Conaghan P Hulme J et al. Mandatory cardiopulmonary resuscitation competencies for undergraduate healthcare students in Europe: A European Resuscitation Council guidance note Eur J Anaesthesiol 2020 37 10 839 841 10.1097/EJA.0000000000001272 32925434
9. Tok D Keleş GT Toprak V Topcu I Assessment of in-hospital cardiopulmonary resuscitation using Utstein template in a university hospital Tohoku J Exp Med 2004 202 4 265 273 10.1620/tjem.202.265 15109124
10. Borimnejad L Nasrabadi AN Mohammadi H Kheirati L Improving the outcomes of CPR: A report of a reform in the organization of emergency response Internet J Emer Med 2008 4 2 Available from: http://ispub.com/IJEM/4/2/12618
11. Moretti MA Cesar LA Nusbacher A Kern KB Timerman S Ramires JA Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest Resuscitation 2007 72 3 458 465 10.1016/j.resuscitation.2006.06.039 17307620
12. Sanders AB Berg RA Burress M Genova RT Kern KB Ewy GA The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community Ann Emerg Med 1994 23 1 56 59 10.1016/s0196-0644(94)70009-5 8273960
13. Sodhi K Singla MK Shrivastava A Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital Indian J Crit Care Med 2011 15 4 209 212 10.4103/0972-5229.92070 22346031
14. Ahmed S Ismail I Lee K Lim P Systematic review on knowledge and skills level among nurses following cardiopulmonary resuscitation (cpr) training. Res Square 2021 10.21203/rs.3.rs-951043/v1
15. Søreide E Morrison L Hillman K Monsieurs K Sunde K Zideman D et al. Utstein formula for survival collaborators. The formula for survival in resuscitation Resuscitation 2013 84 11 1487 1493 10.1016/j.resuscitation.2013.07.020 23917078
16. Wyllie J Bruinenberg J Roehr CC Rüdiger M Trevisanuto D Urlesberger B European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth Resuscitation 2015 95 249 63 10.1016/j.resuscitation.2015.07.029 26477415
17. Kulkarni AP Simulation: Is it the future of training in critical care medicine? Indian J Crit Care Med 2019 23 11 495 496 10.5005/jp-journals-10071-23290
