The significance of pre-existing knowledge of the latest guidelines for cardiopulmonary resuscitation in successful basic life support education of Belgrade sixth year medical students

Introduction. The latest Guidelines for cardiopulmonary resuscitation (CPR) were published in 2010. The aim of the implementation of basic life support (BLS) guidelines is the introduction of uniform criteria within the domain of cardiac arrest diagnostics and treatment both for lay rescuers and first line lifesavers without formal medical education as well as for medical personnel who happen to be in the role of the event witness but without medical equipment and outside of their working place. Objective. The goal of this study was to investigate the significance of pre-existing knowledge of the latest 2010 Guidelines for CPR for achieving successful training in BLS among 6th year students of the Belgrade School of Medicine. Methods. In a five-month prospective study of 6th year medical students doing a clinical internship at the Belgrade Emergency Medical Services (EMS) were in a peer training on the application of BLS. At the beginning and at the end of the training program, the students had to pass entrance (E) and final (F) tests composed of 25 identical questions. Using the E test, the students’ knowledge of the latest CPR Guidelines was tested; they were classified into groups with pre-existing knowledge (group I) and groups without pre-existing knowledge (group II). By comparing data from E and F tests we analyzed the influence of training on the improvement of pre-existing knowledge or gaining new knowledge in BLS and first aid. Results. A total of 423 students were tested. The analysis of obtained data showed that in group I there was a statistically significant difference between correct and incorrect responses to eleven questions on the F and E tests. In group II there was a statistically significant difference between test responses in the E and F tests to 17 questions. In group II, knowledge additionally improved after training so that in the F test, a statistical significance in correct answers was achieved with regard to 8 questions in relation to the E test (p<0.05). There was a statistically significant difference between correct and inaccurate answers in tests F and E with regard to 10 questions. In the entire group of students, a total statistical significance (p<0.05) was achieved in answers to as much as 25 questions. Conclusion. Among 6th year medical students without pre-existing knowledge of the latest 2010 CPR Guidelines, BLS training considerably improved their previously acquired knowledge. Also, students with good pre-existing knowledge, showed a considerably higher level of acquired knowledge after implemented training. A future study with a longer follow-up period to estimate the effect on long-term retention of learning outcomes is needed. SLAÐANA ANÐELIÆ ( ) Belgrade Emergency Medical Services Street Franše d`Eperea 5 11000 Belgrade, Serbia Phone: +381113615015 E-mail: novizivot@ptt.rs DIMITRA KALIMANOVSKA-OŠTRIĆ

The significance of pre-existing knowledge of the latest guidelines for cardiopulmonary resuscitation in successful basic life support education of Belgrade sixth year medical students Introduction Survival after acute cardiac arrest (ACA) is determined by the quality of scientific, evidence-based cardiopulmonary resuscitation (CPR), training quality and financial funds invested in the implementation of the Guidelines.(1) Saving a person in cardiac arrest should be a high-priority task in the healthcare system of any country.According to the Law on Healthcare Insurance ("Sl.Glasnik RS", Official Gazette of the Republic of Serbia, 57/2011), the Law on Road Traffic Safety and the Law on Occupational and Health Safety at Work, each citizen of Serbia is obligated to provide aid to a sick or injured person anywhere and at any time.Knowledge of basic life support (BLS) is a part of each person's healthcare culture.The latest CPR Guidelines were published in 2010.The aim of their implementation is the introduction of uniform criteria in the diagnostics and treatment of ACA.Section 9, Principles of Education in Resuscitation, (2) states that all citizens should gain skills in BLS, regardless of whether they are layperson rescuers or first-line life-savers (firefighters, police officers, swimmer rescuers, security guards, etc.) without formal medical education or medical personnel who happened to be in the role of a bystander witnessing an ACA without medical equipment and outside their working place.(3) In the literature there are reports of successful achievements related to educational curricula for postgraduate medical students, (4) but also in curricula involving undergraduate medical students, school children (5) and teachers.(6) Also, many countries have introduced teaching CPR skills to children aged 10-12 years, (7) as well as using e-learning (video/computer self-instruction) for family members of high-risk patients (at risk of sudden cardiac death).( 8) Up-to-date international studies point out that early bystander CPR is essential for survival after out-of-hospital ACA.
Students can become significant bystander CPR providers if BLS training, according to CPR Guidelines, is implemented as a compulsory part of medical student education.Educated students could strengthen the first three links of the Chain of Survival by a series of interventions that represent early recognition of ACA, calling the EMS, usage of early CPR and early defibrillation.(9) Obligatory training of medical students in resuscitation is important for at least two reasons: as future physicians they should be capable of performing resuscitation on any patient under any situation, and they should also be capable of transferring acquired knowledge to medical personnel with a lower level of qualifications (nurses, ambulance drivers) or laypersons.It has been confirmed that being trained in the application of resuscitation procedures cannot be achieved by reading or listening to theoretical concepts only, but that practical training is of essential significance.The number of participants in the practical curriculum should be limited so as to achieve uniform and qualitative knowledge of the necessary BLS skills.The best results are achieved by training small groups of students (4)(5)(6)(7)(8)

Methods
From February 1st to June 30th 2012 a prospective study was conducted involving 6th year medical students that spent a four-day clinical internship at the Belgrade Emergency Medical Services (EMS).During this period, the students first attended a two-day curriculum involving theory and practice, according to a specially designed plan and program, at the Centre for Education (Appendix 1).The aim of the theoretical curriculum was to educate students in the latest 2010 BLS Guidelines and first aid measures for adults.Practical training was carried out in small groups of 4-6 students.After a demonstration, in order to obtain skills, the students took part in workshop training in the presence of demonstrators utilizing dummy simulation of ACA (Little Anne™ CPR Manikin, Laerdal Corporation, Rorarco GmbH, Vienna, Austria), training defibrillator (Laerdal Forerunner Trainer™, Laerdal Corporation, Rorarco GmbH, Vienna Austria), medical equipment and auxiliary sanitary material according to an exactly determined time-table.The curriculum involved BLS (sternal compression and artificial ventilation, management of airways obstruction, coma position), usage of an automatic external defibrillator (AED) and first aid measures (hemostasis, bandaging, immobilization).After completing the practical curriculum, the students participated in two-days of EMS team field activities.As the fourth team member, each student participated in the care of severely injured and critically ill patients, thus contributing to a shortened duration of intervention.The need for continuing medical education was explained as well as the renewal of pre-existing knowledge of practical skills at least every fifth year (after the publication of the latest CPR Guidelines), regardless of the healthcare institution that will employ them.Thus, students were motivated to select, as their future professional choice, employment in a modern EMS such as the Belgrade EMS.As an integral part of the curriculum, at the beginning and at the end of the clinical internship, the students were required to solve a test composed of 25 questions (Appendix 2).The test consisted of multiple choice questions or a short written add-on to the required text.It was composed of 25 questions, each rated one point.The maximal number of points was 25.Two tests were categorized as: entrance -E test and final -F test.In the E test, each student was required to state whether he was acquainted with the 2010 Guidelines for CPR or not; on this basis the students were divided into groups with pre-existing knowledge (I) or groups without pre-existing knowledge (II).The F test contained identical questions as the E test, but it also demonstrated the level of students' acquired knowledge after completing the theoretical and practical curricula.By comparing the results of tests E and F, we analyzed the influence of theoretical lectures and practical training, as a part of a clinical internship, on the improvement of pre-existing knowledge or new knowledge acquisition within the area of CPR and first aid.Analysis of both student groups in relation to
One hundred and thirty-seven (32.4%) students had pre-existing knowledge.
Of the total number of students, 423 solved both E and F test, while 14 did neither the E nor F test (4 without E test and 10 without F test), and were thus not included in the final statistical data analysis (figure 1).We analyzed each question in tests E and F for both groups (I and II) (table 1).
Results showing correct and incorrect answers for all questions are presented in relation to the total number of students in the group solving the tests.
The difference between correct responses to questions is presented for both students groups.At the bottom of the tables, the mean number of students with correct/incorrect answers to E and F test questions is presented.At the end, the mean number and percentage of students who had a larger number of correct answers to all questions on the F test in comparison to the E test was determined.The obtained result was the predictor of the mean increase for students after the completed theoretical and practical curriculum.

Results analysis
Table 1 summarizes results for all students who solved questions in the E and F tests (for both groups in total and E/F tests differences).The following were set apart: questions answered correctly Filling-out the E test before the beginning of the course informs us of the student's pre-existing knowledge, and the F test shows the level of acquired knowledge and adopted BLS skills.By comparing these two tests, the efficacy of the course can be evaluated.Soar et al. (16) consider that, with the objective to evaluate the course efficacy, it is preferable to make a test consisting of 20 instead of 10 questions.Our test with 25 questions is quite a reliable indicator of the course quality.During the training only one student stated that he could not apply first aid to the ill or injured person because of the presence of blood, vomit and secretions which triggered feelings of negative sensations (fainting).In a New Zealand study (17) as well, several students with a negative attitude towards training in skills for a first line saver stated that they did not want to apply BLS measures to unknown persons.It is possible that in our student the media or a negative life experience created a barrier in his BLS skills training, which also the explanation is given in reports by other authors.At the state level, it is necessary to find a 'modus operandi' in securing financial funds from the healthcare system for investment into passing "reanimation standards for clinical practice and training in BLS" like those in the Resuscitation Council (United Kington) (18) and standardization of education curriculum in BLS for medical students.

Conclusion
Among 6th year medical students without pre-existing knowledge of the latest 2010 Guidelines for CPR, theoretical and practical BLS training considerably improved their performance in the application of their acquired knowledge.Even students who were thought to have pre-existing knowledge showed a considerably higher level of acquired knowledge after the implemented training.A future study with longer follow-up periods to estimate the effect on long-term retention of learning outcomes is needed.Also, factors that contribute to negative students' attitudes towards BLS training require further investigation.
and in a larger number of workshops.(6,7) Objective.To indicate the significance of pre-existing knowledge of the latest 2010 CPR Guidelines for successful BLS training amongst 6th year students of the Belgrade School of Medicine (BMS).

Figure 1 .
Figure 1.Flow of participants through trial.

1 . 2 . 18 .
Number of links in the Chain of Sur-The most important signs for the recognition of cardiac arrest are: a) altered state of consciousness b) widening and narrowing of the pupil c) sudden loss of consciousness, absent breathing, absent carotid pulses 3. Assessment of level of consciousness is done by using the following technique: a) look, listen, feel b) shake and call loudly c) Heimlich maneuver 4. Assessment of an unconscious person breathing should be done by using the following technique: a) shake and call loudly b) Heimlich maneuver c) look, listen, feel d) backward head, chin lift 5. Assessment of an unconscious person breathing should last up to: a) 10 min b) 30 sec c) 10 sec d) 2 min 6.The most adequate position for an untraumatized, unconscious but breathing person is: a) in a comfortable position, cushion under head b) placed on back and on hard surface c) kept in position as found d) flank, coma position 7.The phone number for the Belgrade EMS is: a) 193 b) 991 c) 122 d) 194 8.During resuscitation, the victim should be placed in the following position: a) flank, on side, coma position b) high, half-sitting position c) on the ground, hard surface, in horizontal position on the back d) in position as found 9. Chest compression in resuscitation of adults is performed: a) on the upper third of the sternum b) in the center of the sternum c) below the sternum d) below the left rib vault 10.Relationship between compression and ventilation in adult resuscitaof sternum in adults is performed at the rate of: a) 40-60/min b) 100-140/min c) 100-120/min d) 60-80/min 12.In adult resuscitation pressure on the chest wall toward the spine must be at a depth of: a) 5 -6 cm b) 1 -2 cm c) 10 cm d) 8 -10 cm 13.When is the TRIPLE MANEUVER utilized?a) in trauma to open airway b) diabetic coma c) epileptic seizure 14.Most reliable method for opening the airway is: a) place the victim in sitting position b) pull out the tongue manually c) backward head, lift chin 15.When do we apply the Heimlich maneuver?a) in airway obstruction due to the tongue falling back b) in partial airway obstruction c) in foreign body airway obstruction 16.State three types of artificial ventilation utilized in BLS: a) ________________________ b) ______________________ c) __________________ 17.Duration of air insufflation in artificial ventilationWhich are the indicators for successful CPR? a) pupil width b) body temperature c) capillary refill d) spontaneous circulation and breathing 19.How long does it take for a layperson to implement BLS measures?a) _______________________ b) ________________________ c) _________________ 20.Is it true that breathing stops soon after cardiac arrest?a) YES b) NO 21.Method of temporary hemostasis is: (three correct answers) a) digital compression b) tie off the bleeding vessel c) hyperflexion of extremities d) wound tamponade e) blood vessel suture f) blood vessel bypass 22.According to the site of blood escape, bleeding can be: (two correct answers) a) arterial b) external c) venous d) capillary e) internal 23.According to the type of vessel damage, bleeding can be: (three correct answersbodies (knife, projectile..) and bone fragments, while providing first aid on field: a) must not be extracted b) must be immediately extracted c) may be extracted only if the foreign body is contaminated 25.Vulnus punctum means: a) laceration b) puncture wound c) crush wound d) penetration wound

Percentage of students in the entire group, regardless of pre-existing knowledge, who incorrectly answered every single question in the entrance
(E) and final (F) tests.Graph 3. Analysis of correct and incorrect answers to each question of the entrance (E) and final (F) test in the entire group.

Table 1 .
Numerical and percentual results of correctly and incorrectly solved questions of E and F tests; difference and mean rate.

Table 2 .
Statistical analysis of results.