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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 75-80

A comparative study of pediatric basic life support course for motivated laypersons and health-care personnel


1 Department of Pediatrics, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
2 Consultant Pediatrics, Max Superspeciality Hospital, Shahdara, Delhi, India
3 Consultant Pediatrics, KD Medicare Centre, Shahdara, Delhi, India
4 MO/E (Pediatrician), Department of Pediatrician, Tarapur Atomic Power Station Hospital, Tarapur, Thane, Maharashtra, India
5 Consultant Pediatric Intensivist, Manipal Hospital, Jaipur, Rajasthan, India
6 Bone Marrow Transplant Physician, South East Asia Institute of Thalassemia, Prem Niketan Hospital, Jaipur, Rajasthan, India

Date of Submission19-Nov-2018
Date of Acceptance10-Feb-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Col Rama Krishna Sanjeev
Rural Medical College, Pravara Institute of Medical Sciences, Loni (BK) - 413 736, Ahmednagar Distt, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_75_18

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  Abstract 


Background: Indian academy of pediatrics basic life support (IAP BLS) group runs BLS courses both with and without certification through accredited centers. The certification courses test both BLS and choking skills for all ages. This study is about work at an IAP-accredited BLS training center which runs certificate courses for health-care personnel (HCP) and laypersons (LPs). Majority of LPs were combatants who had few weeks' training in first aid as part of a regularly conducted first aid course among combatants. The LPs who were keen to acquire BLS certification undergo the certification after a 10-h precourse. Methods: This was a retrospective analysis of data about HCPs and LPs from 12 certificate course sessions dating from April 2015 to October 2017. The LPs underwent a 14-question bilingual multiple choice questions (MCQ)-based pretest followed by a 10 h precourse. The HCPs underwent the same before the certificate course without a precourse. The posttest was MCQ based as part of the course. The skill testing was done after the posttest. The BLS manual (IAP BLS manual, 2nd Edition) was made available to the participants at least 2 weeks before the certificate course. A Hindi translation of the manual was made available to the LPs, if needed. Results: There was statistically significant difference between the pre- and post-test scores of HCP and LP groups. The improvement was more pronounced in younger age in both groups of participants. Conclusions: The study highlights the efficacy of an instructor-led precourse with blended learning to aid in the training of motivated LPs to successfully complete a BLS course in pediatrics on par with health-care persons in a low-resource setting.

Keywords: Basic life support, choking, health-care personnel, laypersons, precourse


How to cite this article:
Sanjeev RK, Taneja LN, Sharma AK, Kumar A, Sharma SD, Soni R. A comparative study of pediatric basic life support course for motivated laypersons and health-care personnel. J Mar Med Soc 2019;21:75-80

How to cite this URL:
Sanjeev RK, Taneja LN, Sharma AK, Kumar A, Sharma SD, Soni R. A comparative study of pediatric basic life support course for motivated laypersons and health-care personnel. J Mar Med Soc [serial online] 2019 [cited 2019 Sep 22];21:75-80. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/75/260675




  Introduction Top


Basic life support (BLS) is the foundation for saving lives after cardiac arrest, and bystander cardiopulmonary resuscitation (CPR) is critical for saving lives in an out-of-hospital cardiac arrest (OHCA).[1] In 1960, Kouwenhoven, Jude, and Knickerbocker prophetically said in their initial publication on modern CPR – “Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed is two hands.”[2]

More than half a century later, there is widespread recognition worldwide about the utility of training CPR skills to laypersons (LPs). As enunciated by ERC 2015 guidelines, a primary educational goal in resuscitation should be the training of laypeople in CPR.[1] The succeeding paragraphs argue for training LPs for a conventional pediatric basic life course inclusive of training for choking skills.

The Cambridge dictionary defines LP as “someone who is not an expert in, or does not have a detailed knowledge of a particular subject.” The term “lay people” includes a wide range of capabilities from those without any formal health-care training to those with a role where it may be expected that they would provide CPR (e.g., lifeguards and first aiders). Most research in training in resuscitation involves training adult rescuers in adult resuscitation skills.[3] There is a need to focus on best methods for training lay adults in pediatric resuscitation and choking skills as elucidated below.

Conventional CPR is preferable to chest compression-only CPR, in pediatric out-of-hospital cardiac arrest. This has been seen in the study by Kitamura et al. of the all-Japan Utstein registry.[4] Fukuda et al. demonstrated that the use of public access defibrillation has a higher survival in pediatric OHCA.[5]

Choking in children is a leading cause of morbidity and mortality particularly in those under 3 years of age. LPs are usually the first responders in an out-of-hospital cardiac arrest. Their presence is also crucial in initiating a timely airway rescue maneuver like Heimlich or back slaps and chest thrusts in choking events among children.[6]

Many studies have highlighted that CPR education enhances bystander CPR.[7] Lee et al. have shown of bystander CPR with automated external defibrillator (AED) that increasing duration of CPR training (up to a maximum of 180 min) improves quality.[8] Training LPs in CPR with AED for all ages along with choking skills commensurate to the level required for a certificate course requires a greater investment in time and effort. Moreover, curricula should be tailored to the target audience and kept as simple as possible.

The present study is a comparison of data obtained from training LPs with a 10-h precourse followed by certification workshop. Health-care personnel (HCP) directly attended the workshop after being given the manual in advance without the benefit of the precourse.


  Methods Top


Study design and setting

This was a retrospective data analysis obtained from a program designed to train LPs for certification in BLS skills as required by the IAP. Most of the LPs were motivated combatants who did not have a medical background but had a basic first aid training. Schoolteachers, homemakers, policemen, etc., formed the remaining LPs. Majority of HCP were doctors, nurses, nursing assistants, and paramedical personnel from the Indian Army.

Time period

From April 2015 to October 2017, the manual used for the course was the IAP BLS manual, 2nd edition, based on 2010 ILCOR guidelines.

Institutional ethical committee approval for the analysis of the data obtained after running the courses in the above period was obtained.

Sample size

The study included 445 participants from 12 course sessions during the study period. The key interventions and terms used are explained below.

Precourse for laypersons

The LPs were subjected to a precourse of 10 h spread over 4 days [Appendix A]. Integrated learning was used with a BLS manual translated in Hindi. Training was done by instructors starting with the basics of anatomy and physiology, use of videos with practice while watching on manikins and AED simulators with emphasis on hands-on practice. Low fidelity manikins were used for BLS during training and the workshop. “Choking Charlie” (Laerdal) was used for hands-on teaching of Heimlich maneuver. The curriculum used for training is given in Appendix A. By the third day, actual case scenarios on manikins were used for simulation followed by debriefings. Although the precourse was for LPs, the paramedical persons were free to attend the same as per their convenience. Their attendance in the precourse was not recorded. The same pre- and post-test as well as skill testing were used for both groups.

For laypersons

The LPs were selected because of their keenness to do the course, out of large pool of combatants. Most of them had exposure to health-care training for being Battle Field Nursing Assistants. They were to be employed subsequently for giving first aid in the absence of HCP. Other LPs, such as schoolteachers and homemakers, were selected on a first-come first-serve basis after a course was advertised in the local media and by word of mouth. The precourse was designed with intent to enable them to do the BLS for HCP. Pulse check was mandated as part of BLS. The manual was made available in English and Hindi (translated), as majority of the LPs were more comfortable with use of Hindi. The posttest assessment was done at the end of the workshop which was followed by the skills evaluation.

For health-care personnel

Enrollment was done on a voluntary basis after dates were declared in the local media and by word of mouth. The manuals were distributed about 2–4 weeks before the workshop. The pretest was taken on the day of the workshop, before starting; and posttest or postcourse assessment was done at the end of the workshop followed by the skills evaluation.

Pretest

The pretest was a supervised test of 14 questions (in English and Hindi) in multiple choice questions (MCQs) format, testing awareness about BLS concepts and taken before the precourse.

Workshops

Certificates were obtained from central IAP along with manuals, and faculty was assigned after approval from the IAP BLS group. The faculty was certified BLS instructors by the IAP BLS group. The workshops were carried out in the standard format for such courses with videos, practice while watching the manikins, and group activities in case-based scenarios. There was a minimum of five instructors for each course with a maximum of 40 candidates. The instructors were HCP (both doctors and paramedics) with a majority of doctors being pediatricians.

Postcourse test or posttest

This refers to the MCQ-based supervised test of 25 questions, in English, testing cognitive aspects of BLS.

Scoring of pre- and post-test

The marking for both MCQ-based tests is zero if all are correct and a minus mark for each wrong or missed question. Higher marking implies poorer performance. Zero means a perfect score.

Skill testing and evaluation

The skill testing was done for each candidate for adult BLS with AED (one and two rescuer), infant BLS with AED (one and two rescuer). Adult and infant choking were tested separately. The evaluation for skill stations was based on a system of checklists wherein each skill is broken into individual steps. For example, for initial assessment of an unresponsive child by a single rescuer, the checklists are: “scene safety-check for response-call for help-checks breath and pulse for 10 s-chest compressions and mouth-to-mouth breaths in a 30:2 ratio” and so on.

Those candidates who had performed poorly in the posttest and skill evaluation were subjected to remediation individually and reevaluated by the faculty as is done routinely for IAP BLS courses.

A score of -10/25 (with ten wrong answers) or more was considered fail in the posttest. Those in the −10 to −17 range were considered for remediation provided they had good performance in the skill stations. The remediation was done in vernacular language in view of the language barriers as the testing in posttest was in English.

Those who were unable to clear the skill stations satisfactorily (even if scores were below 10 in the posttest evaluation) were subjected to remediation by two of the faculty. In case of disagreement between the faculty, the course director had the final say after due remediation. Primacy was given to satisfactory demonstration of skills for overall passing.

The courses were mixed with both LPs and HCP participating. The testing methodology and instructions were kept the same for both the groups. The participants were not identified as either LP or HCP, but some instructors who taught in the precourse were also instructors for the workshop. Instructors could not be blinded about the type of participant. The courses were free for the participants, and the manuals were given to each participant on completion of the course. The results of each course were E-mailed to the IAP BLS group on completion and were thereby on record concurrently. The course director was always from outside the institution. Those who were unable to clear the test thereafter were failed with an option to reappear in the next course.

Flow of participants of the two groups in the study

  • LPs: Pretest → precourse and registration for the course and book distribution → workshop → posttest → skill station → results
  • HCP: Registration for the course and book distribution → pretest → workshop → posttest → skill station → results.


Statistical analysis

Compiled data were analysed using the Statistical Package for the Social Science version 16 software (SPSS for Windows, Version 16.0, SPSS Inc., Chicago, USA). Categorical data were presented in the frequencies, percentage distribution, and median values while continuous data were presented as mean and standard deviation. Association between categorical variables was done by applying Pearson's Chi-square test. Wilcoxon signed-ranks test was used to compare related variables, and Mann–Whitney U-test was used to compare nonrelated variables. For interpretation, P < 0.05 was considered as statistically significant.


  Results Top


During the study period, 499 participants were trained in the workshop. Out of them, 8 were absent for pretest and 42 of the 8th session had no pretest data and hence were excluded from the study. The study included 445 participants from different sessions during the study period.

Age of participants in the study ranged within 21–49 years with mean age of 32.5 years (±6.5 years standard deviation). HCP participants were within 22–49 years with mean age of 34.55 years, whereas LP participants were within 21–48 years having 31.36 years mean age.

There were 22 female and 423 male participants. Majority (422) were army personnel, while 23 were civilians. Workshop results of 437 were satisfactory and declared pass while 8 were declared fail, a failure rate of 1.8%. In the workshop, 157 were HCP while 288 were layperson (LP) participants. Out of 157 HCP, 99.4% were declared pass while 0.6% had failed. In LP participants, 97.6% had passed while 2.4% had failed. There was statistically no significant (P > 0.05) difference of the outcome of training on the two groups [Table 1].
Table 1: Comparison of basic life support workshop results within the type of participants

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In HCP pretest, score ranged within −14–0 while posttest score was within −12–0 range. Pretest BLS score in HCP was within −100% to 0% and posttest score ranged between −48% and 0%. In LP, pretest score in workshop was within −12 to −1 range while posttest score was within −17–0 range. In LP, pretest BLS score was within −85.7% to −7.1% while posttest score was within −68% to 0%. There was statistically very highly significant (P < 0.001) difference of theory score in LP and HCP participants [Table 2].
Table 2: Intergroup Comparison of pre- and post-test score within health-care personnel and layperson participants

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As shown in [Table 2], mean BLS score was −34.7% in pretest which changed to −14.5% posttest. In LP, pretest score changed from −41.8% to −22.7% after BLS training. There was more improvement in score after BLS training in HCP than LP.

Among HCPs, 22 candidates scored 0 (with no wrong answers) out of 25 in the posttest, of whom 17 were adjudged as instructor potential. Seven candidates among LPs scored 0. However, they were not evaluated for instructorship due to the lack of a mechanism to place them as instructors.

In HCP group among 4 participants having pretest score within −76% to 100%, there was improvement so that 50% each had 0 to −25% or −26% to −50% range posttest score. Similarly, 33 participants in HCP group with pretest score within −51% to −75% had improvement in the posttest score. There was statistically significant (P < 0.01) difference of the pre- and post-test score after workshop in HCP group [Table 3].
Table 3: Improvement of percent score from pretest to posttest in health-care personnel group

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In LP group of 5 participants having pretest score within −76% to 100%, there was improvement after BLS workshop so that 1 had posttest score 0 to −25%, 3 had score within −26% to −50%, and in 1, the score was −51% to −75%. The total number of LP participants with pretest score in the range 51-75% were 70. Among them,33(47.1%) scored 0-25%in the post-test. In 31 (44.3%) participants, the score was −26% to −50% and 6 (8.6%) had −51% to –75% score after BLS workshop. There was statistically significant (P < 0.001) improvement of the score after BLS workshop in LP group [Table 4].
Table 4: Improvement of percent score from pretest to posttest in layperson group

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As shown in [Table 5], in 21–30 years age group, there was statistically highly significant (P = 0.001) improvement of score after BLS training in HCP participants. While in 31–40 years and 41–50 years age group, BLS training caused improvement in BLS score but was statistically not significant (P > 0.05).
Table 5: Age groupwise improvement of percent score from pretest to posttest in health-care personnel group

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As shown in [Table 6], according to age group, 21–30-year-old and 31–40-year-old LP patients had statistically very highly significant (P < 0.001) improvement of score after BLS training. While in 41–50 years age group, BLS training caused little improvement in BLS score which was statistically not significant (P > 0.05).
Table 6: Age groupwise improvement of percent score from pretest to posttest in layperson group

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  Discussion Top


Bhoi et al. did a similar study which involved both health-care workers and LPs in AIIMS. The study involved a 1-day training with pre- and post-course evaluation of CPR, choking, and special scenarios.[9] They used a score of more than 80% for the participants to be successful with a 99.81% becoming providers on completion. In our study too, there was better knowledge gain among HCP with significant improvement in both groups. Our percentage for passing successfully was 60% (score of −10 in 25 questions). However, performance in skill stations was used as a determinant for passing in our course. We had seven failures among LPs with scores ranging from −12 to −16 and one failure in HCP with a score of −12. We had 15 LPs who had scores from −11 to −17 who were remediable and had satisfactory performance at skill stations and hence passed. Similarly, there were 7 HCPs with scores from −11 to −12 who were remediable with satisfactory skill performance and could pass. This experience is similar to that of Rodgers et al. who found no correlation between written evaluation and skill performance in their study among nursing students undergoing advanced cardiac life support.[10] We had 25 HCPs having 0 (all correct) scores with 17 of them adjudged as potential instructors. There were 7 LPs with 0 score. Since a mechanism was not in place for utilizing them as instructors, they were not formally adjudged for the same.

In our study among HCPs, ages of 21–30 showed highly significant improvement in score after BLS training, whereas in ages 31–40 and 41–50, there was improvement which was statistically not significant. Similarly, among LPs, statistically not significant improvement was seen among 40–50 years age groups. This is similar to the results of Papalexopoulou et al. who reported that age and education affected skill retention in layrescuers.[11] Sandroni et al. in their study with candidate outcome in European Resuscitation Council's ALS provider courses also showed older age having a significantly higher risk of failing.[12] This could be related to age-related decay in learning capability among the older candidates.

We utilized a precourse for training LPs and bridging the gap between the two disparate groups of LPs and HCPs. We could not come across a study with a similar design for comparing the two groups. The Bhoi et al.'s study, in contrast, did not utilize a precourse for LPs. The ILCOR website too does not mention about any precourse for BLS courses (which would be pertinent for LPs undergoing a pediatric BLS certificate course, given our experience. I have added a comment in this context at the ILCOR CoSTr website which has been published in the website for discussion).


  Conclusions Top


We found that on comparison, the performance of LPs is on par with that of HCP. We found that it is feasible to use a single platform for imparting pediatric BLS education to both motivated layrescuers and HCP in the manner outlined above. We found cognitive performance, as tested by MCQ tests, particularly among LPs to not match actual skill performance at the skill stations. This could be linked to the questioning format, felicity in English language, and issues related to learning ability.

However, we found that a 10 h instructor-led precourse for LPs helped them in developing the understanding and skills required to successfully complete such a course. Further improvement in education and testing with greater emphasis on skill and testing in well-simulated scenarios in local languages with lesser emphasis on didactic learning could cut down the length of such a precourse. Skill retention needs checking periodically to verify efficacy of such courses.

The utility of certificate courses for LPs could be for employing such LPs as assistants in prehospital care as drivers of ambulances, combatants engaged in operations, firemen, etc. A certification course could also be the tool for picking up instructors among LPs. It would also fulfill the need among those LPs who have a desire to excel in this set of skills. A precourse could make such a certificate course accessible to LPs and adds to the demystification of such a course among LPs.

Limitations

Follow-up for skill retention was not done in the course. HCP were allowed to attend the precourse informally. Precourse instructors were also conducting the certificate courses, due to paucity of instructors.

Acknowledgment

We wish to acknowledge the significant contribution of Indian Army personnel, in the conduct of the courses, at the 13th IAP BLS training centre. In particular, the concerted efforts of Maj Gen CE Fernandes, Mrs. Anita Fernandes, Sub Ajeet Singh and Maj Navneet Kumar were invaluable in bringing the courses to fruition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman JM, et al. Part 14: Education: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S561-73.  Back to cited text no. 1
    
2.
Jude JR, Kouwenhoven WB, Knickerbocker GG. A new approach to cardiac resuscitation. Ann Surg 1961;154:311-9.  Back to cited text no. 2
    
3.
Finn JC, Bhanji F, Lockey A, Monsieurs K, Frengley R, Iwami T, et al. Part 8: Education, implementation, and teams: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2015;95:e203-24.  Back to cited text no. 3
    
4.
Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM, et al. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: A prospective, nationwide, population-based cohort study. Lancet 2010;375:1347-54.  Back to cited text no. 4
    
5.
Fukuda T, Ohashi-Fukuda N, Kobayashi H, Gunshin M, Sera T, Kondo Y, et al. Conventional versus compression-only versus no-bystander cardiopulmonary resuscitation for pediatric out-of-hospital cardiac arrest. Circulation 2016;134:2060-70.  Back to cited text no. 5
    
6.
Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics 2010;125:601-7.  Back to cited text no. 6
    
7.
Møller Nielsen A, Lou Isbye D, Knudsen Lippert F, Rasmussen LS. Engaging a whole community in resuscitation. Resuscitation 2012;83:1067-71.  Back to cited text no. 7
    
8.
Lee JH, Cho Y, Kang KH, Cho GC, Song KJ, Lee CH, et al. The effect of the duration of basic life support training on the learners' cardiopulmonary and automated external defibrillator skills. Biomed Res Int 2016;2016:2420568.  Back to cited text no. 8
    
9.
Bhoi S, Thakur N, Verma P, Sawhney C, Vankar S, Agrawal D, et al. Does community emergency care initiative improve the knowledge and skill of healthcare workers and laypersons in basic emergency care in India? J Emerg Trauma Shock 2016;9:10-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Rodgers DL, Bhanji F, McKee BR. Written evaluation is not a predictor for skills performance in an advanced cardiovascular life support course. Resuscitation 2010;81:453-6.  Back to cited text no. 10
    
11.
Papalexopoulou K, Chalkias A, Dontas I, Pliatsika P, Giannakakos C, Papapanagiotou P, et al. Education and age affect skill acquisition and retention in lay rescuers after a European Resuscitation Council CPR/AED Course. Heart Lung 2014;43:66-71.  Back to cited text no. 11
    
12.
Sandroni C, Gonnella GL, de Waure C, Cavallaro F, La Torre G, Antonelli M, et al. Which factors predict candidate outcome in advanced life support courses? A preliminary observational study. Intensive Care Med 2010;36:1521-5.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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