|Year : 2016 | Volume
| Issue : 1 | Page : 10-16
|Does community emergency care initiative improve the knowledge and skill of healthcare workers and laypersons in basic emergency care in India?
Sanjeev Bhoi1, Nirmal Thakur2, Pankaj Verma1, Chhavi Sawhney3, Sameer Vankar1, Deepak Agrawal4, Tejprakash Sinha1
1 Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 JPN Apex Trauma Centre, All India Institute of Medical Sciences, Community Emergency Care Initiative, All India Institute of Medical Sciences, New Delhi, India
3 Department of Anaesthesia, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
4 Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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|Date of Submission||10-Jul-2015|
|Date of Acceptance||19-Aug-2015|
|Date of Web Publication||13-Jan-2016|
| Abstract|| |
Background: Due to lack of training in emergency care, basic emergency care in India is still in its infancy. We designed All India Institute of Medical Sciences basic emergency care course (AIIMS BECC) to address the issue. Aim: To improve the knowledge and skill of healthcare workers and laypersons in basic emergency care and to identify impact of the course. Materials and Methods: Prospective study conducted over a period of 4 years. The target groups were medical and nonmedical personnel. Provider AIIMS BECC is of 1 day duration including lectures on cardio-pulmonary resuscitation, choking, and special scenarios. Course was disseminated via lectures, audio-visual aids, and mannequin training. For analysis, the participants were categorized on the basis of their education and profession. A pre- and a post-course evaluation were done and individual scores were given out of 20 and compared among all the groups and P value was calculated. Results: A total of 1283 subjects were trained. 99.81% became providers and 2.0% were trained as instructors. There was a significant improvement in knowledge among all the participants irrespective of their education level including medicos/nonmedicos. However, participants who had higher education (graduates and postgraduates) and/or belonged to medical field had better knowledge gain as compared to those who had low level of education (≤12th standard) and were nonmedicos. Conclusion: BECC is an excellent community initiative to improve knowledge and skill of healthcare and laypersons in providing basic emergency care.
Keywords: Basic emergency care course, cardio-pulmonary resuscitation, knowledge and skill
|How to cite this article:|
Bhoi S, Thakur N, Verma P, Sawhney C, Vankar S, Agrawal D, Sinha T. 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
|How to cite this URL:|
Bhoi S, Thakur N, Verma P, Sawhney C, Vankar S, Agrawal D, Sinha T. 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 [serial online] 2016 [cited 2020 Apr 1];9:10-6. Available from: http://www.onlinejets.org/text.asp?2016/9/1/10/173870
| Introduction|| |
The Republic of India is the seventh largest country in the world and is home to nearly 1.2 billion people. With 28 states and 7 union territories spread over a vast geographic area with varying economic resources and infrastructure, India is among world's most populous democracy. Trauma, natural, as well as man-made disasters are common causes of fatalities. Twenty percent of emergencies are trauma-related in prehospital setting adding up to existing burden of other emergencies. The WHO has estimated road crashes, cardiac, as well as stroke as major causes of death by 2020. Thirty percent of acutely ill patients die before reaching the hospital in India and more than 80% of injured patients do not reach the hospital within golden hour. Fear of injuring the victim, fear of poor performance and liability, reluctance to perform mouth to mouth cardio-pulmonary resuscitation (CPR) for out of hospital cardiac arrest, early evacuation of a trauma victim, and stoppage of bleeding are the keys to good outcome. Current status of emergency care is lot to be desired at all tier of heath care system. There is a need for specialty of emergency medicine and emergency nursing, which is still in its infancy in India. Prehospital care is not up to the mark, as it acts only as a transport vehicle. In the absence of training standards, the unskilled persons attempt life-saving tasks.
No basic emergency care training protocols and poor prehospital care leads to adverse outcomes. Considering the deficiencies and affordability in resource-constraint setting, the authors created a program named All India Institute of Medical Sciences (AIIMS) basic emergency care course (BECC) which addresses the issue of basic emergency care skills for healthcare and nonhealthcare personals. Authors studied whether this initiative improves the knowledge and skill of healthcare workers and laypersons in basic emergency care in India.
| Materials and Methods|| |
It was a prospective study over a period of 3½ years (13-12-2009-24-05-2013) conducted all over the country. Community emergency care initiative program was disseminated by creating AIIMS BECC. This structured course was created considering the important causes of deaths in India as per national crime report bureau. The contents of the course were CPR, choking, and special scenarios such as trauma, electrocution, drowning, hypothermia, and pregnancy [Appendix 1] [Additional file 1]. To assess the validity, we did a pilot study on police personal and found a good improvement in the knowledge about basic emergency care and CPR.
It has two tier, provider course of 1 day duration and instructor course. The target groups were doctors, nurses, and lay persons (Police constables, Central Reserved Police Force, Border Security Force, National Cadet Crop cadets, and school children) of India. Participants had different education level ranging from primary education to postgraduate level. The course material was sent to the participants 15 days prior to the course. We designed an 8 h course with about 4 h available for mannequin practice. The course components included lectures, mannequin practice, audio-visual, and scenario-based training along with performance testing on one-person and two-person CPR as well as infant CPR. All presentations were delivered using power point projections. Lectures were delivered by trained instructors of BECC. Each batch had 16-24 participants with an instructor to student ratio of 1: 4-1:6. Theoretical knowledge was evaluated by 20 pre- and post-test questions [Appendix 2] [Additional file 2]. The mannequin used was “Little Anne” (Laerdal Medical Corporation, NY, USA). The automated external defibrillator (AED) used was the LIFEPAK ® 500T AED training system (Medtronic Physio-control, USA) with defibrillation pads. Subjects had to score ≥80% to be successful. Remedial was done for those who could not pass the test as well as the skills. Those who scored more than 90% and had good communication skills were eligible for instructor course and termed as instructor potential (IP). These IPs underwent instructor course of 1 day. Successful candidates were termed as instructor candidate (IC). IC has to teach under supervision of a faculty in English and local dialect to become a certified instructor. The subjects evaluated the quality of course on parameters of content, presentation, and usefulness on a Likert scale [Appendix Table 1] [Additional file 3]. After the end of the course, the participants were certified with AIIMS BECC provider status card with a registration number having a validity of 2 years from the date of issue. The instructors were certified with full instructor status.
A total of 1400 participants have done BECC course. Out of them, 1283 participants were included in final analysis due to missing data of some participants. Initially, a code was given to the participants on the basis of their education level and profession [Appendix Table 2] [Additional file 4]. However, for analysis, the participants were assigned three codes depending upon their education level. Those who had studied up to 12th class (low education), graduates, and postgraduates (higher education) were given the code 1, 2, and 3, respectively [Appendix Table 3][Additional file 5]. Participants were also divided into two groups: Medico and nonmedico group, depending on whether they belong to medical field or not. All paramedics, nurses, and doctors irrespective of education level were clubbed together and labeled as medicos and given code B. All the remaining participants were labeled as nonmedicos and given code A [Appendix Table 4] [Additional file 6]. All the participants were given pre- and post-course questionnaire containing 20 questions. Final score were calculated out of 20 points. All the values were given as mean ± standard deviation. Pre- and post-course scores were compared and P value was calculated in all participants and intra- and inter-group comparisons were made.
| Results|| |
The overall precourse score of participants on knowledge about CPR and acute emergency care was 12.7 ± 3.8. Post-BECC course, there was significant improvement in the score (17.9 ± 2.1) as depicted in [Table 1]. There was significant increase in score after undertaking BECC in all the groups irrespective of their education level and profession.
Intergroup comparison revealed that participants who are graduates and postgraduates had more significant gain in knowledge as compared to participants who are less educated, i.e., till class XII. The difference in knowledge gain between graduates and postgraduates participants was not significant [Table 2].
|Table 2: Difference in knowledge gain among various groups and their P value |
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On comparing medico and nonmedico groups, it was found that medicos had better knowledge gain than the nonmedico (P< 0.05).
Out of 1283 participants, 1263 participants gave valid feedback and evaluated the quality of course on the basis of content, presentation, and usefulness. Final code lies in between excellent and good on all the three scales of quality determination on a Likert scale (content 1.11 ± 0.35, presentation 1.18 ± 0.39, and usefulness 1.16 ± 0.46).
Thirty-seven participants scored >90% and identified as IP. They underwent 1 day instructor course, out of them, 25 participants became certified instructors.
| Discussion|| |
It is evident from the results that knowledge and skill of participants improved by our BECC. There was significant knowledge gain at all education level including medicos and nonmedicos. By creating this program, we addressed the need of basic emergency care skills for healthcare and nonhealthcare personnel. There was a significant impact of the course as the variability in education, understanding, profession, and loco-regional factors were taken care of. It is being taught in local dialect such as Hindi, Marathi, and other local languages. The faculty was trained with micro-teaching skills in dialectics as well as taking skill stations. In a study by Meaney et al., the authors compared novel techniques such as increased student: Teacher ratio and feedback mannequins with traditional American Heart Association basic life support (BLS) course. They found that cost-effective training strategies and devices are not inferior to the traditional techniques. They concluded that such courses should be developed in resource-limited settings to train the healthcare professionals.
Life supporting first aid was a term coined by Safar and Bircher for few simple measures which are crucial to make a difference for a patient's immediate survival while waiting for the help. The American College of Emergency Physicians strongly encourages CPR training for the lay public. In recent years, various initiatives to optimize prehospital care have been developed such as organization of mass CPR training events, CPR training of family members of patients suffering from heart disease, mass education, television campaigns, and training of high school students., However, in a country such as India, affordability, language problem, and a demand far exceeding availability are the major issues.
In a study by Gombeski et al., they compared two training courses, one was 8 h long with three sessions and the other was 4 h long, single session, and they found that knowledge and performance scores were significantly higher for trainees from the long course. They further concluded that the length of the training program should be determined on the basis of the community's needs and resources. In India, emergency medical service (EMS) is in its infancy, a longer training course, which gives trainees a greater opportunity to expertise and retaining the skill is more appropriate. Authors have trained doctors, nurses, and lay persons across India, and also recommend a longer (at least 8 h) training module with more hands on practice in view of poor availability of EMS access in our country.
In a meta-analysis by Husain and Eisenberg, the authors concluded that providing the police officers with basic CPR skills and training in the use of AED can increase survival rates for out-of-the hospital cardiac arrests (major link of “early defibrillation” in the “chain of survival”). In a study by Papalexopoulou et al., the authors concluded that education level affects positively and age has an adverse effect on both acquisition and retention of CPR/AED skills. They recommended that the resuscitation courses might be designed according to the candidate's literacy level. However, this may cause discrimination between the participants. Our course content was simple, easy to understand, and the basic minimum required for saving a life was taught. In our study we also found that the education level and profession too had an influence on knowledge gain with better gain in participant with higher education and medical personnel.
In India, prehospital emergency care is not included in the medical curriculum, so most doctors have little knowledge of difficulties associated with the prehospital management of cardiac arrest victims. Allison et al. developed an undergraduate prehospital trauma course and 205 medical students in the 4th year of medical school participated in the course. The feedback from the students and doctors completing the course was positive and they all felt better equipped to deal with the emergency situations. The authors also recommend the inclusion of chapter on basic prehospital emergency care for school children as well as training program for medical curriculum.
Our course mainly stresses on improving the knowledge and skill whereas the respondent's intention to perform CPR on a real victim is predicted by his attitude. In a study by Nielsen et al., they compared the effect of local television broadcast with BLS and AED courses on the attitude of people toward different aspects of resuscitation. They concluded that a targeted media campaign and widespread education can significantly increase the willingness to use an AED and the confidence in providing chest compressions and mouth-to-mouth ventilation rather than a targeted campaign. We also feel that attitude can be changed with the support of media and mass education program along with frequent exposure and CPR training courses such as BECC.
Deterioration in the skill is a major problem, unless refresher training is provided. The CPR guidelines recommend that the refresher training should be done within 12-24 months. In a study by Papalexopoulou et al., the authors re-evaluated the participants 1, 3, and 6 months after initial training. They found that practical performance during the CPR/AED scenario was worse in the 1st month of re-evaluation, but due to repetition of the algorithm, there was an improvement in the performance in subsequent re-evaluations. Regarding written evaluation, the mean scores improved over time. Hence, they suggested that 6 months would be the ideal time for re-evaluation. In another study by Nishiyama et al., the authors compared the CPR quality at 6 months and 1 year after the initial training. The CPR quality at 1 year was better as compared to 6 months, so they suggested that the 6 months evaluation can serve as refreshing training to improve and maintain CPR skills.
One of the major drawbacks of our study is the absence of refresher courses. The authors feel that every training course should be followed by a refresher course after 6 months.
| Conclusion|| |
BECC has been an effective community emergency care initiative in improving the knowledge and skill of healthcare workers and laypersons in basic emergency care in India. Our vision is to expand the pool of BECC certified instructors across the country, so that they can disseminate the knowledge of prehospital care to each and every person across India leading to improvement in the outcome.
, Dr. Kapil Dev Soni, Dr. Naveen Yadav, Dr. Farooq Kamran, Dr. Vijay Sharma, Dr. Shilpa Sharma, Dr. Ashish Bindra, Dr. Sanjeev Lalwani, and Dr. R.K. Ramchandani.
Financial support and sponsorship
All India Institute of Medical Sciences, New Delhi, disseminated the course with the logistic and financial support of National Rural Health Mission and State Government Across India.
Conflicts of interest
There are no conflicts of interest
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Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]
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