Evaluating the retention of skills in postgraduate physician students following a theoretical-practical course in Advanced Cardiovascular Life Support

Introduction

Deaths related with cardiovascular disease occur at earlier ages in developing countries. In Latin America and the Caribbean, men are at risk of premature death as a result of this disease, although in recent years the rate has increased in women¹. People who are victims of cardiovascular disease face difficulties due to the disability of the disease, which affects their families and the economy. According to the World Health Organization, the mortality rate in the Americas in 2016 with regard to ischemic heart diseases, cerebrovascular diseases and diabetes mellitus was 63.1, 35.2 and 33.5, respectively, out of 1000,000¹. Between the years 2010 and 2013, ischemic heart diseases were the leading cause of death in the Americas (10.99%), followed by cerebrovascular diseases (6.70%) and diabetes mellitus (5.49%)². Just in Ecuador, the number of deaths from heart disease in 2010 was 11992 (51.68% in men and 48.32% in women)³.

Mortality from arterial hypertension, cerebrovascular disease and diabetes mellitus has increased in general⁴; therefore, it has been found that adequate knowledge in cardiopulmonary resuscitation (CPR) is essential in order to reduce mortality caused by these conditions. The early onset of CPR and defibrillation are important and necessary for the reduction of morbidity-mortality in patients with cardiorespiratory arrest. For every minute CPR is delayed, the probability of survival decreases by up to 10%. For this reason, guidelines recommend routine CPR training for health care providers to improve their performance and patient results^5,6.

In the present study, the retention capacity of the Advanced Cardiovascular Life Support (ACLS) course was evaluated in postgraduate students of Critical Areas of the Pontificia Universidad Católica del Ecuador.

Methods

Results

The characteristics of the participants are detailed in Underlying data¹¹. There were statistically significant differences in the test scores between the subject groups for the first theoretical test immediately after the ACLS course. It was observed that these differences were between the Emergencies and Disasters and Anesthesiology groups (p< 0.05), as well as between the Critical Medicine and the Anesthesiology groups (p = 0.027). No statistical difference was seen between the Emergencies and Disasters and Critical Medicine groups. Likewise, for the second theoretical test score (30 days after the ACLS course), a statistical difference was seen between the Emergencies and Disasters and Anesthesiology groups (p < 0.05), and the Critical Medicine and Anesthesiology groups (p= 0.020), but not between the Emergencies and Disasters and Critical Medicine groups (p= 0.539).

There was no statistically significant differences in the first practical examination between the groups when evaluating their practical skills acquired immediately after the intervention of ACLS (p = 0.066). However, in the second practical examination assessed after 30 days of the initial intervention, statistically significant differences were identified. When conducting the post-hoc test through Scheffe, it was observed that there were differences in the level of practical skills between the Emergencies and Disasters and Anesthesiology groups (p= 0.04), as well as between the Critical Medicine and Anesthesiology groups (p= 0.013). A statistically significant difference was not observed between the Emergencies and Disasters and Critical Medicine groups (p= 0.994).

For all students for the theoretical examination, there was a decrease in the result (Table 1) between the test carried out immediately after the intervention (mean = 83.43) and 30 days after the intervention (mean= 76.21) (p< 0.05). In the practical examination, a statistically significant decrease was found in the result between the test carried out immediately after the intervention (mean = 93.81) and 30 days after the intervention (mean = 75.71) (p< 0.05).

Finally, a covariance analysis (ANCOVA) was performed for the results of the theoretical and practical examinations after 30 days of the intervention on ACLS, in order to investigate whether the relationship between the variables found is maintained when controlling the effect (introducing them as covariates) (Underlying data⁷).

Significant variables for scores in the theoretical test after 30 days were: age and sex of the participant, stress, year of the postgraduate course, validity of the certificate in ACLS, number of times that the person used the information from the ACLS course during clinical practice, if they were instructors of ACLS, and regularity of the studies. No statistically significant differences were found in relation to rest during the previous night in the results of written examination. Unlike the results of the theoretical examination, no statistically significant differences were found in the participant's post-shift status in the 30-day practical evaluation.

Discussion

There are international organizations, such as the American Heart Association, which have developed cardiopulmonary resuscitation treatment programs; at Pontificia Universidad Católica del Ecuador, it is considered essential in undergraduate with Basic Life Support (BLS) program and postgraduate (BLS and ACLS Advanced Cardiovascular Life Support) training. However, these are no courses carried out in health centers where these students receive their daily training, instead these are organized by scientific companies.

The present study is the first study, to the best of our knowledge, carried out in Ecuador that compares the retention of theoretical and practical knowledge of postgraduate students in Critical Areas courses, including Emergencies and Disasters, Anesthesiology and Critical Medicine. These students are the ones who have the highest possibility of facing situations that require advanced cardiovascular care.

The findings of this study are consistent with previous literature that has shown that the knowledge and practical skills of health providers have been reduced before the recommended training interval (2 years). The average in which this reduction is observed is between 6 months to 1 year^10,12; however, there are not many previous studies that indicate the behavior between 1 to 6 months.

In the present study, the participants' theoretical evaluations showed an average of 83.43% immediately after the intervention, and 76.21% in the 30-day post intervention evaluation. The practical examination showed an average of 93.81% immediately after, and 75.71% at 30 days; therefore, it is concluded that practical skills have more declination than theoretical knowledge, which agrees with the literature, which indicate that practical skills are more affected over the time^12–16, and also that the results of theoretical examinations are not good predictors of practical evaluation results¹⁷. In this study, the most impaired practical skills were: treatment according to the rhythm of arrest, ensure scene, perform aftercare and adequate recognition of arrest rhythms. These findings suggest that appropriate intervals and re-training strategies should be differentiated between knowledge and skills, with reinforcement of the latter.

Comparing the three postgraduate groups in Critical Areas, it was found that the Emergency and Disaster and Critical Medicine groups did not have statistically significant differences in the knowledge of both written and practical evaluations within 30 days of the intervention. However, it was observed that there is a difference between the Anesthesiology group with the other two groups (p < 0.05). Similar results were observed in the study carried out by Botha et al. (2012) in which the participants of Emergency Medicine had a better overall performance in the evaluations with respect to the participants of Anesthesiology, taking into account that they both belong to Critical Areas¹⁸. The reason for having less retention in this group can be explained by several factors, including the low incidence of patients with cardiorespiratory arrest in operating rooms, where anesthesiologists perform their daily work. In a study conducted by An et al. (2011) in Pittsburgh, USA, 23 cases of intraoperative cardiac arrest of a total of 218274 patients were found, resulting in a prevalence of 1.1 cases for 10000¹⁹. Hence, the application of the Adult Cardiac Arrest Algorithm-2015 Update of the American Heart Association for Advanced Cardiovascular Life Support (ACLS) will be very infrequent and will not be enough to maintain knowledge and skills. Conversely in Department of Emergencies and Intensive Care Unit, 42% of all hospital cardiac arrests are recorded in these departments according to a study conducted in Uganda²⁰; in another study carried out in the USA 59% of these events were reported in these departments²¹.

In conducting covariance analysis in this study, a statistically significant relationship was found between time of the last training course of ACLS with satisfactory results in theoretical and practical evaluations, which means that the more recent the intervention, the better results there will be. This agrees with the results of a study conducted by Jensen et al. (2009), which found that declination of knowledge in ACLS was lower when courses were conducted at 0 and 6 months, with evaluations at 6 months and 12 months, with average scores of 73, 85 and 82%, respectively²².

In relation to the years of clinical practice, it was observed in the present study that this factor influenced the evaluation results (p< 0.05). In the study carried out by Yang et al. (2012), it is mentioned that the participants who had at least half a year of clinical practice, obtained better results than those that had less time¹³.

On the contrary, there was statistically significant difference between the results and level of stress a student had. This contrasts with the study of Júnior et al. (2002), which shows that stress significantly affects the performance of the participant, and sleep time did not affect the results²³.

The study has several limitations. Since the qualification of the evaluations do not affect the student's final performance in the post-graduate degree, the written examination grade may not reflect the participant's knowledge. Since the research was held at Pontificia Universidad Católica of Ecuador, it is difficult to generalize the study, taking into account that in this institution it is compulsory for graduate students to perform training in ACLS; however, in most universities in Ecuador, these are not conducted, so the level of previous knowledge will vary depending on the situation.

Conclusions

Cardiovascular diseases are included in the first 10 causes of mortality in Ecuador, which means it is necessary to perform training in the management of cardiorespiratory arrest.

Knowledge gained from courses in ACLS of post-graduate studies in Emergencies and Disasters, Anesthesiology and Critical Medicine deteriorate after 30 days in advanced cardiovascular life support. It should be emphasized that practical skills are the most affected compared with theoretical skills.

The results of this research indicate that it is necessary to carry out courses more frequently, in order to keep knowledge and skills at a level that guarantees that adequate care to patients is provided, reducing potential risk of death or disability.

Data availability