Background: Even though anaesthetists do not resuscitate children on a daily basis, they need to perform paediatric life support regularly due to their different duties. As the knowledge of international guidelines varies widely, highly standardized European Paediatric Life Support (EPLS) courses have been introduced to improve standards of care. This national survey among Austrian anaesthetists and EPLS course participants evaluated the impact of this course at the end of the guideline period 2005-2010.
Methods: After approval by the institutional review board an online survey about paediatric resuscitation guidelines was sent to EPLS course participants of the guideline period 2005 (EPLS group) and members of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care (-GARI) two weeks before publication of the resuscitations guidelines 2010. Respondents without an EPLS course were assigned to the non-EPLS group.
Results: Of 333 respondents 247 finished the survey. One hundred eighty five persons were assigned to EPLS group and 62 to the non-EPLS group. Members of the EPLS group performed significantly better than the non-EPLS group (76±19% correct answers EPLS group vs. 63±18% correct answers non-EPLS group, p<0.0001). Furthermore, the EPLS group performed better than anaesthetists with regular resuscitation training and or resuscitation experience but without an EPLS course.
Conclusion: Participation in a single EPLS course during the guideline period 2005 increased the knowledge of resuscitation guidelines significantly.
Key Words: cardiopulmonary resuscitation; data collection; anaesthesiology
Anaesthetists rarely have to deal with children in cardiac arrest, while providing routine intraoperative anaesthesia care.1 However, challenging pre-arrest situations occur frequently in operation theatres and in post-anaesthesia care units.2 3 Furthermore, anaesthetists provide critical care medicine to children on intensive care units (ICUs), take care of paediatric in-house emergencies and are challenged by medical and traumatic conditions of children during their duty as prehospital emergency physicians.
Even though anaesthetists are trained to provide fundamental skills such as airway management and hemodynamic stabilization during routine anaesthesia and emergency care, the knowledge of and adherence to resuscitation guidelines varies widely amongst them.4-7 However, adherence to evidence based guidelines is important to improve the patients’ outcome.8
To improve the quality of resuscitation the European Resuscitation Council (ERC) together with the International Liaison Committee on Resuscitation an the American Heart Association update their guidelines upon cardiopulmonary resuscitation (CPR) and peri-arrest management every 5 years according to new scientific evidence (last update October 2010). Thereafter, these guidelines are implemented as standard of care throughout most parts of Europe.9 10 To transfer the guidelines into lived practice, the ERC has installed highly standardized European Paediatric Life Support (EPLS) courses that are conducted by specialized trainers throughout Europe. A detailed description of the course is given by Phillips and others and can be found on www.erc.edu. 11
In order to examine whether the highly standardized EPLS training does improve the knowledge of paediatric resuscitation guidelines, an online survey was conducted among Austrian anaesthetists and EPLS course participants at the end of the guideline period 2005. To evaluate the full impact of the guidelines the trial was started two weeks before the update of the ERC Guidelines for paediatric resuscitation. The number of correct answers was defined as main outcome parameter.
After approval by the Institutional review board of the Medical University of Vienna registered members of -GARI (Austrian Society of Anaesthesia, Resuscitation and Intensive Care) as well as all participants of Austrian EPLS courses (January 2006 – October 2010) were asked to participate in an anonymous online survey. Invitations were sent via email notification throughout the respective institutional mailing list. The survey itself was available through an international online survey website (www.surveymonkey.com) between 4th and 18th October 2010. The survey ended straight before the publication of the EPLS guidelines 2010 on the 18th October 2010.
Besides demographic data such as age, sex, previous work and CPR experience, number of CPR trainings within the 2005 guidelines period and participation in an EPLS course, the knowledge of the actual ERC EPLS guidelines was assessed within 15 multiple-choice questions. All questions were designed in coherence to the set of EPLS course test questions and assessed basic and advanced cardiac life support knowledge. The chosen multiple-choice style allowed the participants to choose one out of four answers. Before the start of the survey, experienced EPLS instructors reviewed the survey in order to eliminate questions that could be difficult to understand. The set of question (translated into English) is available as appendix to this article. The number of correct answers was defined as main outcome parameter, while a detailed analysis of the sub-categories was of secondary interest and hypothesis generating only.
The online survey was performed anonymously and no techniques were used to identify participants. All retrieved data were handled with strict confidentiality.
Participants of Austrian EPLS courses typically achieve an average of 94% (± 10%) correct answers in written assessments at the end of the course. As this survey was performed online without time pressure and by keeping a time dependent loss of knowledge in mind, an amount of 80% (± 10%) of correct answers was expected in the group of former EPLS course participants during this trial. To show a relevant difference of 10% in correct answers between the EPLS and non-EPLS group at an alpha level of 0.05 at a power of 95% a total sample size of 54 questionnaires was needed. As we wanted to assess the level of knowledge at the very end of a guideline period, a return rate of above 20% in the EPLS group and 10% in the non-EPLS group was expected.
After retrieving raw data and data summaries from www.surveymonkey.com local data management was done using Microsoft Excel (Microsoft Word 2008 for Mac) and R 2.8.1 for Mac12 (The R Foundation for Statistical Computing, Vienna University of Technology, Vienna, Austria) for statistical analysis. Questionnaires that were returned incomplete were excluded from the trial. Analysis of the data was performed using Chi-Square-Test, Student’s T-Test and Pearson correlation where appropriate. Data are presented as percentage, mean and standard deviation. A P value of 0.05 or below is rated as statistically significant.
In total, 333 respondents participated in the survey. Out of these, 247 finished the survey. Eighty-six questionnaires were excluded because not all questions were answered. Among Austrian anaesthetists a response rate of 15% (210 of 1362) was reached, whereas 33% (242 of 737) of EPLS course participants answered the survey. Within the group of respondents 126 participants were members of both mailing lists. Out of the 247 participants who finished the survey 127 participated in an EPLS course within the last two years (2009-2010) whereas 115 responders attended an EPLS course between 2006 and 2008. Out of the non-EPLS group 71 never attended an EPLS course and 20 were participants of an EPLS course in a former guideline period. A detailed table of demographic variables is shown in Tab. 1.
Whereas 37 responders have never been confronted with paediatric life support in clinical practice, 6 reported to resuscitate a child at least once per week. In general 90 % of all respondents had at least some clinical experience in paediatric life support.
EPLS course participants answered 76% (±19%) questions correctly whereas there were only 63% (±18%) correct answers in the non-EPLS group (p<0.0001). When looking at the basic life support (BLS) section 67% (±29%) questions in EPLS group vs. 49% (±29%) in the non-EPLS group were correctly answered (p<0.0001). Out of 10 advanced life support (ALS) questions 80% (±16%) were answered adequately in the EPLS group vs. 70% (±19%) in the non-EPLS group (p<0.001). People who attended an EPLS course within the last two years answered more questions correct than their colleagues who attended such a course within the three years before (p=0.006). However, participants with an EPLS course within 2006 and 2008 had significantly more correct answers than the non-EPLS group (p=0.006). There was no difference in the non-EPLS group between persons who participated in an EPLS course in a former EPLS guideline period (i.e. 2000-2005) and those who never attended an EPLS course. An analysis of the performance of subgroups is shown in Fig. 1. A detailed analysis of ALS and BLS questions is presented in Tab. 2.
Regarding age, work or CPR experience and proficiency we could not show any correlation with the number of correct answers within the groups.
According to our results, the single attendance of an EPLS course within the guideline period 2005-2010 improved resuscitation knowledge significantly above the level that was reached by other resuscitation trainings or without any course. Even regular refresher courses and real life paediatric resuscitation experience seem to be not so effective in generating guideline knowledge.
Even though previous data have shown some impact of an EPLS course by an improved care of a dehydrated child within the EPLS group compared to their non-EPLS trained control group this is the first report that could show that the highly structured EPLS course has a higher impact on the knowledge of resuscitation guidelines than other CPR trainings and not participating in any training. 13 As there is an ongoing discussion about the ideal course design to improve learning outcome these data are important in the implementation of new training concepts and remodelling of older course structures.13-15
Interestingly, participants with an EPLS course within the last two years performed significantly better than their colleagues who attended this course between 2006-2008. The latter group, however, was significantly better than the responders who did not attend an EPLS course within the guideline period 2005-2010. This decay in the knowledge of resuscitation guidelines over time is reflected by previously published data that could show that an initial gain in knowledge deteriorates over one and two years.15-17 Regular retraining is recommended to retain a high level of skills and knowledge as a decline starts within 2 weeks of initial training. 18 19
Even though basic life support with defibrillation seems to be the only measure in cardiac arrest that really helps to improve survival and therefore is taught to even lay-persons all participants but 55 (50 EPLS, 5 non-EPLS) had some difficulties in answering the BLS question out of this survey correctly. 20 Most of non-EPLS members would immediately call for an advanced life support team instead of performing one minute of basic life support in a child. However, none of the non-EPLS members would wait for at least 5 minutes before calling the emergency team while performing BLS. Whereas 66% of the EPLS group would provide a series of 5 back blows and 5 chest compressions in an infant below one year of age with signs of complete airway obstruction caused by foreign body aspiration the majority of non-EPLS members would perform back blows only and 7 out of 62 persons would even head for upper abdominal thrusts (Heimlich manoeuvre). When to use an automatic external defibrillator was not clear for an equal amount of EPLS and non-EPLS members and does reflect the not so clearly defined cut off age in the ERC guidelines 2005.
In the ALS section nearly half of the non-EPLS participants would administer adrenalin (epinephrine) in a concentration and/or timing that is not recommended by international guidelines. Doses 10 times higher than in the recommendations as well as the late application of adrenalin seemed to be appropriate for many non-EPLS participants.
Even though the clinical assessment of hemodynamic parameters is routine practice for all anaesthetists and emergency care providers, survey participants that did not participate in an EPLS course had difficulties to answer this question correctly. Whereas nearly all EPLS provider knew that the assessment of heart rate, pulse, capillary refill time and skin colour are valuable parameters to get a first clinical impression more than a fourth of the non-EPLS participants could not answer this question correctly. As this part of the EPLS guidelines is not solely important in cardiopulmonary resuscitation but is part of daily routine in the care of compromised patients, this result is surprising. Therefore, participation in an EPLS course probably helps to improve clinical skills above the level of chest compression and ventilation.
By assessing the knowledge at the very end of a guideline period, a maximum of penetration of these recommendations into the clinical routine could be assumed. Clinicians that probably have not been reached by this information in an early guideline period may have gained a sufficient amount of knowledge until the start of the survey. Emergency care providers that were not reached by the guidelines until the survey will not improve their guideline knowledge any more as the recommendations were replaced by a new consensus as the survey ends.
As this survey did not assess the resuscitation capabilities in clinical CPR situations and did not use manikin testing our results may not reflect the real resuscitation performance of the participants. However, knowledge of guidelines is fundamental to deliver adequate basic and advanced cardiac life support. 21 22
Finally, a low return rate among the members of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care may have resulted in positive selection and therefore in an overestimation of the resuscitation knowledge in the non-EPLS group as it can be speculated that only anaesthetists with a specific interest in resuscitation may have answered the survey.
Attendance of an EPLS course within the guideline period 2005 significantly increased the theoretical knowledge of paediatric resuscitation guidelines. Furthermore, participants of an EPLS course did perform better than those without such a course but regular resuscitation training and resuscitation experience.
This work was not supported by any grant or other funding source.
We wish to acknowledge the support of the Paediatric Working Group of the Austrian Resuscitation Council and the -GARI for their support by sending the survey to participants of the EPLS courses and their members. Furthermore, we thank all survey participants for making this study possible.