Dismal situation of cardio pulmonary resuscitation knowledge and skills among junior doctors in twin cities of Pakistan

Objective: To assess the knowledge, attitude, and practice of cardio pulmonary resuscitation (CPR) among junior doctors in 13 tertiary care hospitals of Rawalpindi and Islamabad. Methods: A total of 317 junior doctors from 13 tertiary care hospitals in Rawalpindi and Islamabad in Pakistan were included in this cross-sectional study. Data were collected using a 37-item interviewer-administered structured questionnaire by the researchers. Informed consent and ethical approval were secured. Doctors’ knowledge, attitude, and practice regarding CPR were presented and compared across the demographic variables (age, gender, CPR training etc.). Data analysis was done using SPSS V 23 at an alpha level of 5%. Results: Response rate for this study was 87.08%. Abbreviations of BLS, AED, and EMS were known by 94.3%, 36.0%, and 41.0% doctors respectively. No doctor had complete knowledge of CPR. Less than half of the participants knew the proper compression depths. Overall knowledge regarding CPR steps was poor. Out of 31 CPR knowledge, attitude, and practice related questions 21 correct answers were given by two doctors which was the highest score. The mean KAP score was 14.18 ± 0.15. Conclusion: Awareness regarding CPR is essential for all doctors. Many authorities in developed countries are giving CPR training to the general population whereas in Pakistan, many of the doctors never had CPR training. The current study showed the clear majority wants hands-on CPR training. Hospital authorities may find this as an opportunity to improve the knowledge and skills of health workers.


INTRODUCTION
Cardiovascular diseases (CVDs) are the number one cause of death globally. 1 According to the World Health Organization, about 17.3 million people died from Cardiovascular Diseases (CVDs) in 2008. This represented 30% of all the global deaths. 2 Threequarters of all deaths from myocardial infarction occur after cardiac arrest in the community. 3 This proportion is even higher in people under 55 years of age, in whom 91% of cardiac arrest deaths occur out of the hospital. 3 In these conditions, early Cardio Pulmonary Resuscitation (CPR) and early defibrillation might be useful to improve the survival and neurologic outcomes. 4 Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental

Original Article
Dismal situation of cardio pulmonary resuscitation knowledge and skills among junior doctors in twin cities of Pakistan aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (AED). 5 All healthcare professionals are expected to have current knowledge of Basic Life Support (BLS) guidelines to revive unresponsive and cardiac arrest patients. 6 In the present study, we aimed to assess the knowledge, attitude, and practice about BLS among the doctors of 13 tertiary care hospitals in Rawalpindi and Islamabad, Pakistan.

METHODS
Junior doctors from 13 tertiary care hospitals of Rawalpindi and Islamabad, Pakistan were included in this study as the respondents. The doctors who have been working for less than four years in a hospital were considered as junior doctors. The sample size was calculated using widely used formulae z 2 *p(1-p)/e 2 . 1 Since the prevalence rate was unknown, 50% prevalence was considered. At an alpha level of 5%, the required sample size was 384. In order to include the required samples, the researchers visited these hospitals during the morning, evening and night shifts to recruit as many junior doctors as possible. During the study duration, 364 junior doctors were inducted in the study out which 317 returned the questionnaire with a response rate of 87.08%. The data was collected from April 2018 to October 2018 through a 37 items questionnaire related to demographic characteristics, knowledge, attitude, and practice of CPR among junior doctors. The questionnaire validation was done by two epidemiology professors. Researchers interviewed all the included doctors face to face with the questionnaire. Purpose of the current study was clearly explained to the interviewees. Informed consent was taken from each participant. Ethical approval was secured from Institutional Review Board of Poonch Medical College, Rawalakot, Azad Kashmir, Pakistan. Statistical Analysis: Frequencies and percentages were used to present the demographic characteristics and CPR knowledge, attitude, and practice related questions and responses. The mean ± SD number of correct responses to all CPR related questions were presented. The mean number of correct answers were compared between genders, doctor having CPR training (yes/ no), and doctors attended CPR course (yes/ no) by Mann Whitney U test. The mean number of correct responses were compared across the age groups, time since graduation and time since last CPR training by Kruskal Wallis H test.
The analysis was performed in 95% confidence interval using the Statistical Package for Social Science (SPSS), version 23.0 (IBM, Armonk, NY, USA).

RESULTS
Among the 317 total respondents, 171 (53.9%) were male and 258 (81.4%) were from age group 23 to 25 years. More than half had (54.6%) valid CPR training certificate. ( Table-I) The majority, 299 (94.3%) knew the abbreviation of 'BLS'. Ninety-eight percent respondents thought BLS training is necessary for the doctors. More than half (53.0%) knew the correct compression to ventilation ration which is 30:2. Responses to the 13 CPR knowledge related questions, seven CPR attitude related questions and 11 CPR practice related questions were presented in Table-I, Table-II, and Table-III respectively. Mean number of correct answers for all 31 CPR questions for all respondents was 14.18 ± 0.15 with a minimum of seven correct answers and a maximum of 21 correct answers.
The mean number of correct answers for all CPR related questions was not statistically significantly different across the demographics. (p values > 0.05) ( Table-V).

DISCUSSION
No doctor could give 100 percent the current answer according to our study. The highest percentage of correct answer given by a doctor was 68%. This study finding goes in line with a previous Indian study which included doctors, other health workers, and medical students. 8 Knowledge regarding infant and children CPR in comparison with the adult CPR was shown to be poorer in this study (Table-II). This might be due to the overall prevalence of children cardiac arrest cases being lower than the adult cardiac arrest cases. 9 Only 54.6% of doctors had valid CPR certificate in 13 tertiary care hospitals in Pakistan, whereas a study revealed 99% of the medical students received CPR training in UK. 10 Interestingly, a fewer percentage of doctors would perform mouth to mouth breathing on the opposite gender (39.7%) compared to the same gender (59.3%) ( Table-III). Gender based barriers still exist in the health care provision in Pakistan. 11 The clear majority wanted to get handson BLS training and suggested BLS training to be included in the medical curriculum. This study encourages medical educationists to look at this matter. Because, trained doctors show better CPR related knowledge, attitude, and practice than the untrained doctors. 12,13 This study showed the duration of medical practice improves knowledge, attitude, and practice score of CPR although not at a statistically significant level (Table-V). Similar and comparable findings were shown by a Malaysian study. 14 Limitation of the study: The study was crosssectional in nature therefore causality cannot be established. Data were only collected from the tertiary hospitals, which may not represent all the doctors of the country. Only the doctors were included in this study whereas CPR knowledge is essential for all the health workers. Awareness regarding ACLS protocol was not studied.

CONCLUSION
It is unacceptable to work in a hospital as a doctor without knowing how to perform a basic lifesaving procedure like CPR. The current study raises question about how to improve the knowledge, attitude and, practice among the doctors who never had CPR training. Despite showing an overall poor knowledge most of the participants wanted to perfect the CPR steps. Hospitals should provide enough resources to ensure all its health workers learn and relearn BLS protocols.

Recommendation:
This study recommends further studies to assess BLS and ACLS awareness among  all health workers of the country. This study also encourages the hospitals to provide mandatory CPR training to the health workers at free of cost.