Download Attitudes of Doctors Working in Abant Izzet Baysal

Original Article
Turk J Anaesthesiol Reanim 2016; 44: 142-8
DOI: 10.5152/TJAR.2016.04875
Attitudes of Doctors Working in Abant Izzet Baysal University
Health Research and Application Center on Cardiopulmonary
Resuscitation
Hamit Yoldaş1, Hasan Kocoğlu1, Hakan Bayır1, İsa Yıldız1, Akcan Akkaya1, Abdullah Demirhan1, Ümit Yaşar Tekelioğlu2
1
Abstract
2
Department of Anaesthesiology and Reanimation, Abant İzzet Baysal University School of Medicine, Bolu, Turkey
Department of Anaesthesiology and Reanimation, Pamukkale University School of Medicine, Denizli, Turkey
Objective: We aimed to evaluate the attitudes of doctors about cardiopulmonary resuscitation (CPR) in this research.
Methods: Overall, 234 doctors who were working in Abant İzzet Baysal University Health Research and Application Center and who
accepted to participate in this research were included. Research data were obtained by a questionnaire containing questions about demographic characteristics of doctors and their knowledge about CPR. Questionnaires were applied between 27.02.2012 and 04.06.2012. The
chi-square test was used for categorical variables. A value of p<0.05 was considered statistically significant.
Results: It was determined that 90% of the participants included in the study applied and/or observed CPR, and 62% of participants
did not attend any CPR course. In addition, 64.1% of the doctors were found to be aware of guidelines prepared every 5 years. Although
65.2% of the doctors who attended a course previously gave a correct answer for the question about the number of cardiac compressions
during adult CPR, 47.6% of the doctors who did not attend a course gave the correct answer (p=0.014). Additionally, 71.9% of participants who attended a course previously and 51.7% of participants who did not replied correctly to the question ‘What should be done
immediately after defibrillation during CPR?’ And also the results for the question about how many joules is necessary to begin defibrillation with a monophasic defibrillator were statistically significant according to the attendance for a CPR course (p<0.005).
Conclusion: In this study, we have identified the lack of knowledge of the doctors about resuscitation.
Keywords: Cardiopulmonary arrest, cardiopulmonary resuscitation, questionnaire
Introduction
C
ardiopulmonary arrest (CPA) is a sudden stop in spontaneous respiration and blood circulation. Resuscitation can
be defined as the effort made to re-gain spontaneous heartbeat, respiration and cardiac functions. Heart diseases
cause 90% of sudden deaths, and non-heart diseases cause 10%. At the moment of arrest in these patients, a ventricular fibrillation (VF) rhythm can be commonly observed. Accordingly, the time between arrest and defibrillation affects
the success of resuscitation to a great extent. There is a vital relationship between the heart, lungs and brain. Hence, when
the function of one of these three organs stops, the functions of the other two organs also stop after a short time (1, 2). Even
if the heart continues its pumping action for a few minutes after the respiration of the patient stops, the blood entering the
brain contains insufficient oxygen. Consequently, death occurs because of a lack of oxygen in the brain tissue (1). Performing urgent and effective cardiopulmonary resuscitation (CPR) is of vital importance for patients with cardiac arrest (3, 4).
Cardiopulmonary resuscitation is a symptomatic treatment method that aims to maintain the functions of vital organs until the
heart begins to function again. The whole process that is performed in cardiac arrest treatment is called CPR (5). Because information on the approach to CPR is continuously improving, health staff who encounter arrest cases more commonly must be
given education at regular intervals and must be informed about new improvements. Only those who receive effective education
have high success levels after education and can perform effective and accurate CPR after improvements (4, 6-9).
The duties and responsibilities of doctors are important for the first intervention in cardiac arrest. This study aimed to reveal
the attitudes of doctors about the recognition of cardiac arrest and starting and maintaining CPR, to evaluate their knowledge on recent improvements and to contribute to educational programs with the obtained data.
142
Address for Correspondence: Dr. Hamit Yoldaş, E-mail: [email protected]
©Copyright 2016 by Turkish Anaesthesiology and Intensive Care Society - Available online at www.jtaics.orgından ulaşılabilir.
Received : 21.05.2015
Accepted : 19.11.2015
Yoldaş et al. Attitudes of Doctors on Cardiopulmonary Resuscitation
Methods
This descriptive study was conducted to evaluate the attitudes
of doctors about CPR. The research was conducted on doctors
working at the Abant İzzet Baysal University Health Research
and Practice Centre after receiving approval from the Ethics
Committee for Clinical Research in Abant İzzet Baysal University on 20 February 2012 (no: 2012/31). Research data were
collected through a questionnaire designed in accordance with
the literature. The questionnaire form consisted of 30 questions
about the doctors’ demographic features and general knowledge
of CPR (Appendix 1). The responses to the questionnaire were
evaluated as correct and incorrect. The questionnaire forms
were administered to 234 doctors who worked at the Abant
İzzet Baysal University Health Research and Practice Centre
and who agreed to participate in the study between 27 February
2012 and 04 June 2012 after their written informed consent
was obtained. Before the survey, the aim of the research was explained to the participants. Doctors who were in rotation at the
time of the questionnaire administration (between 27 February
2012 and 04 June 2012) and who declined to participate in the
study were excluded.
Statistical analysis
When evaluating the findings of the study, Statistical Package
for the Social Sciences (SPSS Inc., Chicago, IL, USA) for
Windows 15.0 software was used for statistical analyses. The
chi-square test was employed for categorical variables. Data
were presented as the number of individuals and percentage
in tables. A value of p<0.05 was accepted as significant.
Of the participants, the percentage of doctors who performed
CPR was 77.4% (n: 181) and the percentage of doctors who
watched CPR was 128% (n: 30). According to the results of
the questionnaire, 70.3% (n: 83) of the lecturers and 84.5%
(n: 98) of the research assistants had performed CPR previously. This difference was statistically significant (p: 0.018)
(Table 1).
The study revealed that 38.0% of doctors (n: 89) attended a
CPR course previously and 62% (n: 145) did not attend one.
In total, 77.4% of doctors (n: 181) wanted to attend a CPR
course; however, 22.6% (n: 53) did not want to attend. Of
the participants, 35.6% (n: 42) of lecturers and 36.2% (n:
42) of research assistants knew about the 2010 Resuscitation
Guidelines, and the difference between them was not statistically significant (p: 0.922).
Of the doctors, 64.1% (n: 150) put the chain of survival in
the correct order; however, 35.5% (n: 83) put it in incorrect
order. In total, 71.9% (n: 64) of doctors who had attended
a CPR course previously and 59.3% of doctors (n: 86) who
had not attended a course gave correct answers to the same
question. This result was found to be statistically significant
(p: 0.039) (Table 2).
Results
Table 1. Rates of cardiopulmonary resuscitation in
participants
Yes (performed)a
A total of 234 doctors (118 lecturers and 116 research assistants) who worked at Abant İzzet Baysal University Health
Research and Practice Centre participated in the study. The
questionnaire forms were given to 20 doctors (8.5%) from
the Basic Sciences, 127 doctors (54.3%) from the Internal
Sciences and 87 doctors (37.2%) from the Surgical Sciences.
Lecturer (n, %)
Research assistant
(n, %)
83 (70.33)
98 (84.50)
No (not performed) 21 (17.79)
9 (7.75) p=0.018*
Only watched
14 (11.86)
9 (7.75)
Total
118 (100)
116 (100)
b
*Statistically significant (p value is between a and b), chi-square test
Table 2. Comparison of responses given to some questions according to attendance of a cardiopulmonary resuscitation course
Doctors that attended course (n, %)
Doctors that did not attend course (n, %)
Which is the correct order of the chain of survival in adult cardiac arrest treatment?
Correct 64 (71.9)
86 (59.3)
Incorrect
24 (27)
59 (40.7)
p=0.039*
According to the 2010 Resuscitation Guidelines, what is the correct number of cardiac compressions per minute while performing adult CPR?
Correct 58 (65.2)
69 (47.6)
Incorrect
31 (34.8)
73 (50.3)
p=0.014*
What should be done immediately after defibrillation during CPR? Correct 64 (71.9)
75 (51.7)
Incorrect
25 (28.1)
69 (47.6)
*Statistically significant (p<0.05), chi-square test. CPR: cardiopulmonary resuscitation
p=0.003*
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Turk J Anaesthesiol Reanim 2016; 44: 142-8
Table 3. Responses given to the question ‘What is your first
intervention if you do not feel a pulse in a patient developing
loss of consciousness while being followed in the hospital?’
Number (n)
(%)
Resuscitation team is called
77
32.9
Patient is defibrillated
5
2.1
143
61.1
Oxygen is given
8
3.4
No response
1
0.4
Cardiac massage is started
Discussion
Table 4. Responses given to the question ‘Which choice
describes an automated external defibrillator correctly?’
Number (n) (%)
It has been developed for defibrillation
in a case of arrest witnessed by an
ordinary person. 120
51.3
It has been developed for nurses who
have taken advanced life support courses
to be able to perform defibrillation rapidly. 54
23.1
It has been developed for increasing
the survival rate in arrest cases in airplanes.
It is used by pilots.
13
5.6
It has been developed for ambulance
staff to be able to perform defibrillation
even if they work without a doctor. 46
19.7
The rate of participants who gave the answer ‘I call the resuscitation team’ to the question ‘What is your first intervention if you do not feel a pulse in a patient developing loss
of consciousness while being followed in the hospital?’ was
32.9% (n: 77). 61.1% (n: 143) of participants chose the answer ‘Cardiac massage is started’ (Table 3). For the question
‘Which choice describes an automated external defibrillator
(AED) correctly?’, 51.3% of the doctors (n: 120) gave the
correct answer (Table 4).
For the question ‘What is the rate of chest compressions
per minute in adult CPR according to the 2010 Resuscitation Guidelines?’, 65.2% of the participants who attended a
course answered correctly, while the rate for the doctors who
did not take a course was 47.6%. This result was found to be
statistically significant (p: 0.014) (Table 2). To the question
‘What should be done immediately after defibrillation during
CPR?’, 71.9% (n: 64) of the doctors who had attended a
CPR course and 51.7% (n: 75) of the doctors who had not
taken a course gave the correct answer. This difference was
statistically significant (p: 0.003) (Table 2).
144
positions of the participants, and no statistically significant
difference was observed. However, the difference between
the rate of correct answers given by the participants who had
attended a course and who had not attended a course was
statistically significant (p<0.005).
The answers given to the question about how many joules
are necessary to begin defibrillation with a monophasic defibrillator in adult patients were compared considering the
In the USA, the population of which is approximately 300
million, approximately a million people die every year of cardiovascular diseases, which constitute about half of the causes
of mortality. The rate of mortality due to coronary artery disease is 350,000 per year, and most of these are sudden deaths
(10).
Approximately 2/3 of sudden deaths due to coronary artery
disease occur outside the hospital, generally within the first
two hours after the beginning of symptoms (11).
Based on research results from other countries, because distinct data on the conditions in Turkey are not available, it
can be said that good and rapid emergency care systems, immediate early CPR and early defibrillation are important. In
developed countries, health staff are required to learn early
CPR as well as doctors (12, 13).
Anyone can encounter a CPA case at any place, at any time.
It is a conscientious and legal responsibility that doctors and
allied health personnel, who have a high likelihood of encountering CPA, must start CPR immediately.
Resuscitation is a procedure that must be performed with full
knowledge. This study aimed to investigate how much doctors knew about resuscitation and about new improvements.
In a study by Akilli et al. (14), the rate of doctors who encountered CPA and performed CPR was found to be 90%.
In our study, it was revealed that 90% of the participants
performed CPR and/or watched it.
Moreover, in our study, the rate of research assistants who
stated that they had performed CPR previously was found
to be higher than that of lecturers. This difference may result from the fact that arrest cases more frequently occurred
during the duties of research assistants.
Our study revealed that research assistants were more enthusiastic about learning CPR than lecturers. Research assistants
answered the question about whether they wanted to attend a
course on CPR with ‘yes’ at a higher rate than lecturers. This
result was attributed to the higher possibility of encountering
a CPA case for research assistants.
In a thesis study performed in 2008 on the attitudes of
nurses towards CPR, it was reported that most participants
(91.4%) chose ‘yes’ for the statement ‘I apply the look, listen and feel method while controlling the respiration of the
patient’ (15). Similarly, in our study, it was found that 92.7%
Yoldaş et al. Attitudes of Doctors on Cardiopulmonary Resuscitation
(n: 217) of doctors used the look, listen and feel method for
controlling the respiration of a patient developing loss of consciousness in hospital.
It was demonstrated that immediate, rapid, strong and uninterrupted chest compression increased the survival rate in
cases of CPA in adults (16). In a study by Bilir et al. (17),
42.5% of doctors correctly answered the question about the
compression:respiration ratio. In the study of Kımaz et al.
(12), the correct compression:ventilation ratio was known by
18.9% of participants. On the other hand, the rate of those
who chose a 5:1 ratio was found to be 80%. Half of the doctors in our study chose the cardiac compression/respiration
ratio of 30:2 in the presence of double rescuers in adult CPR,
which was the correct answer. Other doctors chose 15:2 and
5:1 ratios. This low rate shows that doctors do not follow the
improvements in the European Resuscitation Council guideline that is published every five years, and they do not receive
sufficient education on this subject.
In a study conducted on nurses, the rate of those who knew
the correct number of cardiac compressions per minute was
66%, which was similar to that in our study (15).
The most common cause of sudden death in patients with
acute myocardial infarction is ventricular fibrillation, and
its definite treatment is electrical defibrillation. The success of defibrillation in stopping arrhythmia depends on
early application (18). In ventricular fibrillation cases, the
success rate is 100% if necessary intervention is performed
within the first 30 seconds. However, for every minute that
defibrillation is delayed, the survival chance decreases by 7
to 10%. After 10 minutes, there is no survival chance for
the patient. In our study, the question ‘how many joules
are necessary to begin defibrillation with a monophasic
defibrillator in adult patients?’ was answered correctly by
203% of lecturers and 12.1% of research assistants. It was
found that 28.1% of doctors who attended a CPR course
and 9% of doctors who did not attend a course gave correct answers to the same question. These rates, which are
quite low, show the importance of organizing CPR education programs.
Atropine, which previously was routinely used in Asystole
and Pulseless Electrical Activity, is not recommended in the
2010 Resuscitation Guidelines. 56.4% of the participants answered the question on this topic incorrectly. This shows that
the doctors that participated in the study were not aware of
recent developments in the 2010 Resuscitation Guidelines.
Success in CPR is obtained through good and continuous education. Education is overemphasised in the guidelines. The
goal of education is to help the man in the street, civil defence
experts, health staff in the field, emergency medicine teams
or resuscitation teams to gain the ability to perform CPR at
a clinical level.
The studies that were conducted showed that simple knowledge skills deteriorated within 1 to 6 months following education (19). In the study of Chamberlain et al. (20), it was
reported that education repeated in the 6th month was effective for the protection of knowledge and skills.
In a study by Moser et al. (21), it is recommended that a
brief repetition should be performed every 3 to 6 months
and education should be repeated once a year. Indeed, in
the 2010 guidelines, it is recommended that doctors should
be educated more frequently than every six months (22). In
another study, Dane et al. (23) compared the interventions
performed by nurses who were and were not given CPR education. While 37.5% of patients who received early CPR
from educated nurses remained alive, only 10.3% of patients
who received CPR from uneducated nurses survived.
Conclusion
As a result of the evaluation of data obtained from this study,
which was conducted with the aim of evaluating the knowledge levels of doctors about resuscitation and determining
whether they were aware of new developments, it has been
detected that doctors working in hospital lack knowledge
about resuscitation, and this lack is at a level that can be overcome. We suggest that in-service training programs, courses,
seminars and symposiums should be organised in order to
resolve this lack of knowledge and to update the knowledge
of doctors who are effective in the improvement and maintenance of public health.
Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Abant Izzet Baysal
University School of Medicine (2012/31).
Informed Consent: Written informed consent was obtained from
doctors who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – H.Y., H.K.; Design – H.Y.,
H.B.; Supervision – A.A.; Resources – A.D.; Materials – Ü.Y.T.;
Data Collection and/or Processing – İ.Y., H.B.; Analysis and/or
Interpretation – H.Y., H.K., A.A.; Literature Search – İ.Y., H.B.;
Writing Manuscript – H.Y., H.B.; Critical Review – H.K., Ü.Y.T. ;
Other – A.A., A.D.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
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Yoldaş et al. Attitudes of Doctors on Cardiopulmonary Resuscitation
Appendix 1. Questionnaire form
1- Your age?
a) 25–30 years
b) 30–40 years
c) 40–45 years
2- How long have you been working as a doctor?
a) Less than 1 year b) 1–5 years c) 6–10 years 3- What is your department in the hospital?
a) Basic sciences
b) Internal sciences
c) Surgical sciences
d) Above 45 years
d) More than 10 years
4- What is your position in the hospital?
a) Lecturer
b) Research assistant
5- Have you ever performed cardiopulmonary resuscitation (CPR)?
a) Yes
b) No
c) Watched
6- Have you ever attended any course on CPR?
a) Yes
b) No
7- If a course or an in-service training program on CPR is organised, do you want to attend it?
a) Yes
b) No
8- Do you know about the 2010 Resuscitation Guidelines?
a) Yes
b) No
9- Which one is not a member of the International Liaison Committee on Resuscitation (ILCOR), which designed the 2010
Resuscitation Guidelines?
a) American Society of Anaesthesiologists (ASA)
b) European Resuscitation Council (ERC)
c) American Heart Association (AHA)
d) Heart and Stroke Foundation of Canada (HSFC)
10- Which is the correct order of the chain of survival in adult cardiac arrest treatment?
a) Early CPR, early help, early defibrillation, early advanced life support
b Early help, early CPR, early defibrillation, early advanced life support
c) Early help, early CPR, early advanced life support, early defibrillation
d) Early advanced life support, early defibrillation, early help, early CPR
11- Which is the correct order of the resuscitation steps?
a) Basic Life Support, Advanced Life Support, Long-Term Life Support
b) Advanced Life Support, Long-Term Life Support, Basic Life Support
c) Compression, Ventilation, Defibrillation
d) Monitorisation, Intubation, Cardiac Massage
12- Which must be controlled first in the evaluation of a patient or an injured person?
a) Consciousness
b) Respiration
c) Circulation
e) Patency of the airway
13- Which one is not included in the algorithm of Basic Life Support?
a) Calling for help
b) Opening the airway
c) Performing cardiac massage
d) Applying adrenalin
14- Which method is used for controlling the respiration of an unconscious patient?
a) Look-listen-feel
b) Jaw-thrust c) Heimlich manoeuvre d) Recovery
15- Which manoeuvre is used to provide patency of the airway in an unconscious patient without head-neck trauma?
a) Lifting the chin forward and up
b) Turning the head to the side
c) Cleaning inside the mouth
d) Tilting the head backward and lifting the chin forward and up
16- You are the first person who reaches a patient after trauma. You notice that patient does not have respiration. Which step must
not be performed?
a) Start artificial respiration
b) Provide patency of the airway c) Ask for help
d) Place the patient in the recovery position
17- Which position must be given to a patient to whom CPR will be performed?
a) Supine position on hard and flat surface b) Supine position on soft surface
c) Prone position on hard and flat surface d) Prone position on soft surface
147
Turk J Anaesthesiol Reanim 2016; 44: 142-8
Appendix 1. Questionnaire form (Continious)
18- Which choice describes an automated external defibrillator (AED) correctly?
a) It has been developed for defibrillation in a case of arrest witnessed by an ordinary person who has taken a Basic Life Support course.
b) It has been developed for nurses who have been given advanced life support courses to be able to perform defibrillation rapidly,
especially in areas of hospitals that are far away from the emergency unit.
c) It has been developed for increasing survival rates in arrest cases in airplanes. It is used by pilots.
d) It has been developed for ambulance staff to be able to perform defibrillation even if they work without a doctor.
19- What is your first intervention if you do not feel a pulse in a patient developing loss of consciousness while being followed in the hospital?
a) Resuscitation team is called
b) Patient is defibrillated
c) Cardiac massage is started
d) Oxygen is given
20- Which compression/respiration ratio is correct in the presence of double rescuers in adult CPR?
a) Compression/respiration ratio 15/2
b) Compression/respiration ratio 100/2
c) Compression/respiration ratio 5/1
d) Compression/respiration ratio 30/2
21- What is the rate of chest compressions per minute in adult CPR according to the 2010 Resuscitation Guidelines?
a) 50
b) 75
c) 100
d) 150
22- Which is the correct place for performing cardiac compression?
a) 1/3 lower part of the sternum, by bending the arm from the elbows
b) 1/3 lower part of the sternum, by not bending the arm from the elbows
c) 1/2 lower part of the sternum, by bending the shoulder from the elbows
d) 1/2 lower part of the sternum, by not bending the arm from the elbows
23- Which step is not performed for a patient who has a regular rhythm, but no heartbeat by listening?
a) Cardiac massage is performed
b) Airway is controlled
c) Oxygen is given
d) Defibrillation is performed
24- Which rhythm causes sudden cardiac death most commonly?
a) Ventricular asystole b) Ventricular tachycardia c) Ventricular fibrillation d) Idiopathic arrhythmia
25- What must be done immediately after defibrillation during CPR?
a) Rhythm must be controlled
b) Cardiac massage must be continued
c) Blood gas must be taken
d) Pulse must be controlled
26- In which of these situations is defibrillation performed?
a) Atrium fibrillation b) Electrical activity without pulse
c) Ventricular tachycardia without pulse
d) Atrial flutter
27- How many joules are necessary to begin defibrillation with a monophasic defibrillator in adult patients?
a) 150 j
b) 200 j
c) 300 j
d) 360 j
28- Which drug is not given in asystole and electrical activity without pulse?
a) Adrenalin
b) Atropine
c) Dopamine
d) Sodium bicarbonate
29- When is adrenalin given in refractory ventricular fibrillation?
a) After 1st shock
b) After 2nd shock
c) After 3rd shock
d) After 4th shock
30- Which of these is the method and dose of adrenalin application?
a) 1 mg IV 3–5 per minute b) 1/2 mg IV 3–5 per minute
c) 1 mg PO 3–5 per minute d) 1/2 mg PO 3–5 per minute
10) b
5)
9) d
4)
8)
3)
7)
2)
6)
1)
Answer Key:
15) d
14) a
13) d
12) a
11) a
20) d
19) a
18) a
17) a
16) d
25) b
24) c
23) d
22) b
21) c
30) a
29) c
28) b
27) d
26) c
148