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Keywords:

  • cardiopulmonary resuscitation;
  • child;
  • education;
  • infant

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Aim:  To determine whether an e-learning resuscitation programme was able to improve the knowledge and competence of doctors and nurses in providing cardiopulmonary resuscitation to children in a simulated cardiac arrest.

Method:  A prospective before and after pilot study comprising of a simulated paediatric resuscitation before and after participants undertook an e-learning programme. Participants were emergency department doctors and new graduate nurses from The Children's Hospital at Westmead, Australia. Primary outcome measures were the ability to perform successful basic life support (BLS) and advanced life support (ALS) according to published guidelines. Secondary outcome measures were the individual steps in performing the overall resuscitation and subjective feedback from participants.

Results:  Fifty-six clinicians were enrolled in the study (29 doctors and 27 nurses). Thirty-seven were re-tested (25 doctors and 12 nurses). The mean time between tests was 49 days (17 standard deviation). The e-learning module led to an improvement in participants' ability to perform BLS by 51% (P < 0.001) and ALS by 57% (P= 0.001) overall resulting in an overall competence of 89% (BLS) and 65% (ALS). There were also significant improvements in time to rhythm recognition (P= 0.006), time to first defibrillation (P= 0.009) and participants' self-reported knowledge and confidence in BLS and ALS (P < 0.001).

Conclusions:  E-learning does improve both the knowledge and competence of doctors and nurses in providing cardiopulmonary resuscitation to children in the simulation environment.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Sudden cardiac arrest in children is a rare event, but with prompt and efficacious assessment and intervention, their survival can be much better than adults.1 Recent studies have shown that 14% of children who have in-hospital arrests have a primary defibrillatable rhythm, and up to 27% will have a defibrillatable rhythm at some time during their arrest.2,3 Current international recommendations are that a defibrillatable rhythm should be treated with cardioversion within 2 min of onset as each minute of delay beyond 2 min equates to a reduction in survival to hospital discharge.4,5 It is therefore essential that all health-care workers who may be either first responders or members of the resuscitation team are able to perform effective basic life support (BLS) and either perform or are familiar with advanced life support (ALS) including defibrillation.

The provision of appropriate and ongoing cardiopulmonary resuscitation (CPR) training to health-care workers is a requirement of many employers and professional colleges.6–9 However, in many institutions, there is a difficult balance between service provision and training.10 Traditional CPR courses such as Advanced Paediatric Life Support (APLS) or the shorter Paediatric Life Support (PLS) take workers away from their work environments for 1 to 3 days, and are expensive in monetary terms for participants who pay course fees and organisations that cover study leave,11 and even short courses may have adverse financial implications for organisations.12 New techniques for training in CPR have become accepted including CD ROM pre-learning and video instruction; however, these are all still combined with a practical course. E-learning has been demonstrated to be effective in educating health-care workers, and has the advantages of being cost-effective, flexibly accessed, self-paced, interactive and able to provide appropriate feedback.13

The Children's Hospital at Westmead (CHW) has developed an interactive resuscitation programme to teach BLS and ALS knowledge and skills to health-care workers. The programme is modular with a pre- and post-course multiple choice question knowledge test. Modules include airway positioning, mouth-to-mouth, mouth-to-mask and bag and mask airway skills, CPR, rhythm recognition, safe defibrillation and first-line cardiac drugs. The whole course is designed to be completed in stages but will take participants 1–2 h if finished in one sitting.

The aim of this pilot study was to determine whether the e-learning resuscitation programme was able to improve the resuscitation skills of doctors and nurses as well as improve their self-reported knowledge and confidence in providing CPR to children, the null hypothesis being that there is no difference after completing the e-learning programme.

What is already known on this topic

  • 1
    The provision of cardiopulmonary resuscitation (CPR) training to health-care workers is important.
  • 2
    CPR skill retention decays with time.
  • 3
    Current paediatric CPR courses are time consuming for organisations, instructors and participants.

What this paper adds

  • 1
    The general ability of clinicians to resuscitate a simulated infant is poor.
  • 2
    E-learning alone may improve this ability.
  • 3
    Previous attendance at paediatric life support courses does not equate to better performance in a simulated resuscitation.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

This study is a before and after study on emergency department (ED) junior medical staff and new graduate registered nurses working at the CHW in July 2007. All junior medical staff working in the ED at the time of the study were enrolled, and all of the nurses from the new graduate programme (first year postgraduate) were invited to participate. The medical staff in the ED came from both CHW and our secondment network. Ethics permission was gained prior to the commencement of the study.

Pre- and post-intervention subjective assessment of levels of knowledge and confidence was recorded by the participants on a 5-point Likert scale.

Each participant completed a standardised simulated clinical event using a manikin (ALS Baby, Laerdal, Stavanger, Norway.), modified from a previously validated study.14 BLS and ALS progression was assessed according to current Australian Resuscitation Council (ARC) and APLS guidelines.15,16

Observations were performed by a single observer. Participants had one standardised faculty assistant to help them, who was more junior and could follow instructions but could not initiate management. The clinical event was based on a 10-kg infant in cardiorespiratory arrest due to ventricular fibrillation (VF). The airway was initially obstructed and was unable to be ventilated, but responded to an airway manoeuvre such as insertion of an oropharyngeal airway, repositioning, suctioning or a two-handed bag and mask approach. The simulation was stopped at completion of the scenario, at the request of the participant or when it became obvious to the observer that the participant was not progressing.

Primary outcome measures were the ability to perform successful BLS and ALS. Participants were deemed to have completed BLS if they correctly completed airway positioning, rescue breaths using bag and mask and effective chest compressions as determined by the expert observer. Participants needed to complete three correct dose defibrillations, with CPR in between, and identify the correct dose of adrenaline in order to be successful at ALS. Secondary outcome measures were the timed steps in performing the overall resuscitation.

Participants then completed an e-learning module produced by CHW, either at work via the intranet or in their own time via a CD-ROM. The e-learning module was completed some time in the period between testing and re-testing; the exact time lapse was not measured.

Re-testing was undertaken after approximately 6 weeks, with the patient in pulseless ventricular tachycardia (VT) rather than VF. The doctors were not informed prior to testing or re-testing, so testing was a surprise event much like a real arrest in the ED.

Statistics

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Data were entered into an electronic database (Access, Microsoft) and imported in SPSS 15.0 for analysis (SPSS, Chicago, IL, USA). Categorical data were analysed using χ2, Fishers exact test when total numbers were less than 40 and McNemar's test for paired categorical variables. The paired t-test was used to analyse paired means. For all statistical testing, a P-value <0.05 was considered statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Fifty-six clinicians were enrolled in the study (29 doctors and 27 nurses). The 29 doctors were 100% of the rotating junior doctors working in the ED. The 27 new graduate nurses were 56% of the 48 new graduates working at CHW. Thirty-seven were retested (25 doctors and 12 nurses). The mean time between tests was 49 days (17 standard deviation).

The demographics of the participants at enrolment and follow-up testing are described in Table 1.

Table 1. Demographics of participants
 Number of participants at enrolment%Number of participants at follow-up%
  1. ACEM, Australasian College of Emergency Medicine; PGY 2, postgraduate year 2 doctor; RMO, resident medical officer.

Doctors     
 Paediatric advanced trainee2425
 Paediatric basic trainee1018719
 Paediatric RMO47411
 ACEM advanced trainee59514
 ACEM provisional trainee1213
 ACEM RMO1213
 PGY 24738
 Unstreamed RMO2425
Nurses     
 New graduates27471232
Total5610037100

Eleven doctors had competed an APLS course, and 14 had completed a PLS course in the last 3 years. None of the nurses had completed an APLS or PLS course, but all had completed a work-based nursing CPR assessment sometime prior to testing (22 in the last year).

The resuscitation e-learning module led to an improvement in participants' ability to perform BLS by 51% (P < 0.001) and ALS by 57% (P= 0.001) overall, resulting in an overall competence of 89% (BLS) and 65% (ALS). Figure 1 illustrates subgroup analysis; data have been included for all participants as well as those who were able to be re-tested to demonstrate similarity in groups.

image

Figure 1. Primary outcome measures – the ability to perform BLS and ALS pre- and post-intervention. ALS, advanced life support; BLS, basic life support.

Download figure to PowerPoint

There were no significant differences between those who had completed formal APLS or PLS courses and the successful completion of BLS or ALS. The secondary outcomes are described in Table 2. There were significant improvements in time to rhythm recognition (P= 0.006) and time to first defibrillation (P= 0.009).

Table 2. Secondary outcome measures
Outcome measurePre-test – all participants (n= 56)Paired pre- and post-tests (n= 37)
Mean (s)SDPre-test meanPost-test meanMean of difference95% CI of difference P
  1. CI, confidence interval; CPR, cardiopulmonary resuscitation; SD, standard deviation.

Time to call for help30222936−7−46; 320.687
Time to check for response1381192−2; 60.328
Time to airway manoeuvre291428226−2; 150.128
Time to effective ventilations943599918−2; 180.124
Time to pulse check894386109−24−44; −30.026
Time to commencement of CPR13451132136−4−25; 180.714
Time to rhythm identification200412031653712–630.006
Time to defibrillation288522932237023–1170.009

There were significant improvements (P < 0.001) in participants' self-reported knowledge and confidence in BLS and ALS, Table 3.

Table 3. Participants self-reported change in knowledge and confidence
Outcome measurePre-test – all participants (n= 56)Paired pre- and post-tests (n= 37)
MeanSDPre-test meanPost-test meanMean of difference95% CI of difference P
  1. ALS, advanced life support; BLS, basic life support.

Knowledge2.80.7312.73.4−0.757−1.022; −0.491<0.001
Confidence in BLS2.60.7352.63.2−0.676−0.981; −0.371<0.001
Confidence in ALS2.00.7962.02.9−0.892−1.194; −0.590<0.001

There was a statistical association between participants' ability to perform BLS and their self-reported knowledge of BLS (P= 0.001) and their confidence in being able to perform BLS (P= 0.036). There was no statistical association between ability to perform ALS and self-reported knowledge of ALS (P= 0.391) or confidence in being able to perform ALS (P= 0.731).

Participants were asked to rate whether the e-learning module had improved their knowledge and confidence. Ninety-seven per cent of participants agreed or strongly agreed that the course had improved their knowledge, and 92% agreed or strongly agreed that the course had improved their confidence.

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

The International Liaison Committee on Resuscitation (ILCOR) recognises that acquisition and retention of skills are poor after conventional CPR, training and instruction methods should not be limited to traditional techniques as newer training methods may be more effective.17 This paper supports this hypothesis as it has shown that an e-learning programme alone is able to improve the practical ability of doctors and nurses to perform a resuscitation in a simulated environment subject to the confounders outlined below, as well as increase participants knowledge and confidence in delivering BLS and ALS to a collapsed child (P < 0.001).

The ARC supports the ILCOR principles but also states that learners must be able to physically demonstrate CPR skills and knowledge on a manikin.18 This paper has demonstrated that you can teach, or at least revise, psychomotor skills using a carefully designed e-learning programme. Our programme may have been successful because it is extremely interactive with participants having to practise airway positioning, pad placement, CPR rate and rhythm recognition within the modules.19 The majority of our participants had some form of resuscitation training in the past, so it may be that the e-learning is a good revision tool. Further studies are required to determine whether e-learning can teach practical skills de novo.

Of concern is the relatively low ability of paediatric ED doctors and new graduate nurses to perform effective BLS (41%) and ALS (7%) and, in particular, the ED registrars (29% and 12%) who are the front-line staff caring for sick children. We have shown that completion of a prior APLS or PLS course is not associated with the ability to perform BLS or ALS in this study, nor was completion of the work-based nursing CPR assessment. These findings are consistent with previous studies and emphasise that knowledge and skills decay quite quickly with time and that frequent revision or practice is needed to maintain competence.20–25 Many institutions and professional colleges require or recommend health-care workers to undertake formal courses such as APLS, but it must be remembered that while these courses are good at transferring knowledge and skills, decay occurs quite quickly. Perhaps these organisations should be focusing more on regular practice or revision, either with patients or in a simulation environment, to ensure that knowledge and skills are satisfactory.

Of additional concern is the discrepancy between the participants' knowledge and confidence in ALS and their actual ability to perform it. If medical and nursing staff are overconfident and do not appreciate their knowledge gaps, then they may not seek regular training, and when faced with a real arrest, they may not have the skills and knowledge to perform appropriately. Further work is required to explore this interesting phenomenon.

This study has demonstrated the most improvement in skills with ALS, including time to correct rhythm recognition and first defibrillation. VF and pulseless VT are not actually that rare in paediatrics and may occur in up to 27% of in-hospital arrests.3 Time to first defibrillation improved by just over a minute; however, the mean post-test time was still 223 s which is over 100 s slower than international guidelines. This may be a feature of the serial approach to CPR adopted by single rescuers, for example Danger, Response, Airway, Breathing, Circulation, Disability (DRABCD), and may not be a realistic representation of the parallel approach of a team16; however, the need to determine the rhythm in a collapsed child needs to be emphasised as early defibrillation does improve outcome.5 Of additional interest is the significant increase in time to pulse check (mean of 24 s). This may also be an effect of a more robust adherence to the DRABCD protocol with post-test participants undertaking the earlier interventions more effectively.

Without a formal control group, it is possible that some of the improvement seen was due to a ‘learning effect’, that is the fact that the students had been subjected to a scenario may have stimulated them to improve without the e-learning, either through extra study or familiarity with the scenario. Now this pilot study has confirmed an improvement; the next stage is to undertake a blinded, controlled study comparing the intervention group with no intervention. Another weakness of the study was the relatively low percentage of nurses who were re-tested. Although the results from the nurses were significant, the low numbers increase the chance of a type 1 error, especially as the nurses who were re-tested self-selected themselves. While the mean time to retesting was 49 days, further research is required to determine the optimum period when health-care workers should redo the e-learning module in order to maintain their knowledge and skills.

Conclusions

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

The e-learning programme is able to significantly improve doctors' and nurses' ability to successfully perform paediatric BLS and ALS, at least in a simulation setting, with time to rhythm recognition and first defibrillation also significantly improved. The e-learning also improved participants' self-reported knowledge and confidence in providing CPR to a collapsed child.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

The author would like to thank the other members of the CHW resuscitation committee, particularly Amanda Elliott, and those doctors and nurses who took part in the study.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Statistics
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References
  • 1
    Topjian AA, Nadkarni VM, Berg RA. Cardiopulmonary resuscitation in children. Curr. Opin. Crit. Care 2009; 15: 2038.
  • 2
    Nadkarni VM, Larkin GL, Peberdy MA et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006; 295: 507.
  • 3
    Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA. Outcomes of in-hospital ventricular fibrillation in children. N. Engl. J. Med. 2006; 354: 232839.
  • 4
    Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the ‘chain of survival’ concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991; 83: 183247.
  • 5
    Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N. Engl. J. Med. 2008; 358: 917.
  • 6
    The Royal Australasian College of Physicians. Basic training requirements. Requirements for Physician and Paediatric Training 2008 Handbook Australia. Sydney: Adult Internal Medicine and Paediatrics and Child Health, 2008; 11.
  • 7
    The Australasian College of Emergency Medicine. Learning and examination processes 2.3 Life Support. Training and Examination Handbook. Melbourne, 2008: 106.
  • 8
    New South Wales Health Nursing and Midwifery Office. Resuscitation Equipment and Training. Sydney: NSW Department of Health, 2005.
  • 9
    The Royal Australasian College of General Practitioners. Criterion 3.2.1 – General practitioner qualifications. Standards for General Practices, 3rd edn. Melbourne: The Royal Australasian College of General Practitioners, 2007; 49.
  • 10
    Garling P. Final Report of the Special Commission of Inquiry, Acute Care Services in NSW Public Hospitals. Sydney: Special Commission of Inquiry, Acute Care Services in NSW Public Hospitals, 2008.
  • 11
    Lindy C, Reiter P. The financial impact of staff development. J. Contin. Educ. Nurs. 2006; 37: 1217. quiz 28–9, 20.
  • 12
    Kaye W, Mancini ME, Richards N. Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival. Resuscitation 1995; 30: 1516.
  • 13
    Franck LR, Langenkamp ML. Mandatory education via the computer: cost-effective, convenient, and creative. J. Nurses Staff Dev. 2000; 16: 15763.
  • 14
    Brady RM, Raftos J. Emergency management skills of South Australian paediatric trainees. J. Paediatr. Child Health 1997; 33: 1136.
  • 15
    Advanced Life Support Group. Advanced Paediatric Life Support. The Practical Approach, 4th edn. London: BMJ Publishing Group, 2005.
  • 16
    Australian Resuscitation Council. Paediatric Advanced Life Support: Australian Resuscitation Council. 2006.
  • 17
    2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 8: interdisciplinary topics. Resuscitation 2005; 67: 30514.
  • 18
    Australian Resuscitation Council. Cardiopulmonary resuscitation training. Guideline 9.1.1. Melbourne. 2007.
  • 19
    Bryce E, Yassi A, Maultsaid D et al. E-learning of infection control: it's contagious. Can. J. Infect. Control 2008; 23: 228. 30, 32 passim.
  • 20
    Durojaiye L, O'Meara M. Improvement in resuscitation knowledge after a one-day paediatric life-support course. J. Paediatr. Child Health 2002; 38: 2415.
  • 21
    Grant EC, Marczinski CA, Menon K. Using pediatric advanced life support in pediatric residency training: does the curriculum need resuscitation? Pediatr. Crit. Care Med. 2007; 8: 4339.
  • 22
    Hunt EA, Vera K, Diener-West M et al. Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests. Resuscitation 2009; 80: 81925.
  • 23
    Tok D, Keles GT, Tasyuz T, Yentur EA, Toprak V. Basic life support skills of doctors in a hospital resuscitation team. Tohoku J. Exp. Med. 2004; 203: 1238.
  • 24
    Hopstock LA. Cardiopulmonary resuscitation; use, training and self-confidence in skills. A self-report study among hospital personnel. Scand. J. Trauma Resusc. Emerg. Med. 2008; 16: 18.
  • 25
    Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008; 78: 5965.