Preparedness for Paediatric CPR amongst Doctors in Cape Town
By
Dr Nabeela Amien
Mb, ChB, Family Medicine Registrar AMNNAB001
This study is in partial fulfilment of the requirements for the degree Masters of Family Medicine in the Faculty of Health Sciences at the University of Cape Town
Supervisors: Dr Graham Bresick, Dr Katya Evans
University
of Cape
Town
The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source.
The thesis is to be used for private study or non- commercial research purposes only.
Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.
University
of Cape
Town
DECLARATION
I, Dr Nabeela Amien, hereby declare that the work on which this thesis is based is my original work (except where acknowledgements indicate otherwise) and that neither the whole work nor any part of it has been, is being, or is to be submitted for another degree in this or any other university. I
authorise the University to reproduce for the purpose of research either the whole or any portion of the contents in any manner whatsoever. I further declare the following:
1. I know that plagiarism is a serious form of academic dishonesty.
2. I have read the document about avoiding plagiarism, am familiar with its contents and have avoided all forms of plagiarism mentioned there.
3. Where I have used the words of others, I have indicated this by the use of quotation marks.
4. I have referenced all quotations and properly acknowledged other ideas borrowed from others.
5. I have not and shall not allow others to plagiarise my work.
6. I declare that this is my own work.
7. I am attaching the summary of the Turnitin match overview.
Signature: ……… Date: ………16/10/2020…………
AKNOWLEDGMENTS
I would like to thank my supervisor’s Dr Graham Bresick and Dr Katya Evans for dedicating their time to helping me complete this study, and for their patience and encouragement. Without their invaluable guidance completing this would not have been possible.
I would also like to thank my parents for always being there for me throughout my life. Finally, thank you Ahmed Moosa for being my pillar of support and biggest cheerleader.
TABLE OF CONTENTS
List of Tables and Figures 6
Abbreviations 7
Part A: LITERATURE REVIEW
Introduction and Objectives of literature review 9
Literature search strategy 10
Summary of literature 12
Identification of gaps for further research 20
References 21
Part B: MANUSCRIPT IN ARTICLE FORMAT (SAFP)
Title and abstract 25
Main text of article
Introduction 26
Research Methods and Design 32
Results 35
Discussion 41
Conclusion 45
Recommendations/Further research 45
Acknowledgments, competing interests and funding 46
References 47
Part C: ADDENDA
Relevant journal instructions to Authors 50
Questionnaire / data capture instrument 51
Consent forms and participant information sheets 56
Research Protocol 59
HREC approval letter 68
LIST OF TABLES AND FIGURES
Page Number
Table A: Grade of doctor as well as geographic location 37
Figure A: Distribution of life support courses done or not done by type of course
38
Table B: Distribution of APLS and PALS courses done or not done by doctor category
38
Table C: Knowledge scores by level of doctor category 39
Table D: Knowledge scores by doctor’ confidence level 40
Table E: Knowledge score by doctors’ experience performing paediatric CPR
40
Table F: Availability of equipment required during paediatric CPR from the primary healthcare doctors’ perspective
42
ABBREVIATIONS
pCPR: Paediatric Cardiorespiratory Resuscitation
PHC Primary health care
SES Socioeconomic status
CHC: Community Health Centre
CDC: Community Day Centre
ILCOR: International Liaison Committee on Resuscitation
APLS: Advanced Paediatric Life Support
PALS: Paediatric Advanced Life Support
NLS: Neonatal Life Support
PHPLS: Pre-Hospital Paediatric Life Support BLS: Basic Life Support
DIPEC Diploma in Emergency Care
IHRM-F The Ideal Hospital Realisation and Maintenance Framework
PHCF Primary Healthcare Facility
Part A: LITERATURE REVIEW
INTRODUCTION
Paediatric Cardiopulmonary Resuscitation (pCPR) is the principal medical intervention used to reduce the high mortality associated with paediatric cardiorespiratory arrest (1-4). In paediatric
cardiorespiratory arrest, pCPR can be a life-saving measure in such events. When pCPR is performed correctly, patient outcomes are better (5, 6). Given that paediatric cardiorespiratory arrest has a high mortality, it is imperative that doctors are always prepared to perform pCPR correctly and timeously using a structured evidence-based approach.
The motivation for this study was driven by the author’s realisation during clinical exposure to pCPR of a lack of confidence in their ability to perform it effectively. The initial literature search into this topic identified three areas required to assess preparation for pCPR, namely doctors’ knowledge of how to perform pCPR, their confidence levels and their knowledge of the availability of the required equipment in their health care facility. The author hypothesised that low levels of these three
components could be a widespread problem and could lead to the implementation of measures that improve doctors’ pCPR competency, thereby preventing unnecessary morbidity and mortality.
The study aimed to assess the preparedness for paediatric CPR of medical doctors working in state primary healthcare facilities in the Cape Metropole with regards to knowledge, confidence, and equipment availability.
OBJECTIVES OF LITERATURE REVIEW
To evaluate and appraise the literature available on preparedness for pCPR amongst medical doctors working in primary healthcare (PHC) facilities. Knowledge, confidence and equipment will be analysed to evaluate preparedness.
LITERATURE SEARCH STRATEGY
A search was performed using the Pubmed Database from 01 September 2019 until the 03 September 2019. A broad search was done that was then followed by a more specific search strategy and this is shown below:
1. “Preparedness for paediatric cardiopulmonary resuscitation” AND “Medical doctors” AND
“primary healthcare” AND “South Africa” OR “Cape Town”.
2. “Preparedness for paediatric cardiopulmonary resuscitation” AND “Medical doctors” AND
“primary healthcare”
3. “Preparedness for paediatric cardiopulmonary resuscitation”
4. “Paediatric cardiopulmonary resuscitation” AND “knowledge” AND “doctors”
5. “Paediatric cardiopulmonary resuscitation” AND “knowledge” AND “South Africa” Or
“Cape Town” OR “Africa” AND “Doctors”
6. Paediatric cardiopulmonary resuscitation” AND “confidence” AND “doctors”
7. “Paediatric cardiopulmonary resuscitation” AND “confidence” AND “South Africa” Or
“Cape Town” OR “Africa” AND “Doctors”
8. “Paediatric cardiopulmonary resuscitation” AND “knowledge” AND “equipment”
9. “Paediatric cardiopulmonary resuscitation” AND “knowledge” AND “Equipment” AND
“South Africa” Or “Cape Town” OR “Africa” AND “Doctors”
10. “Emergency trolley” AND “paediatric cardiopulmonary resuscitation”
11. “Primary healthcare” AND “South Africa” OR “Cape Town”
The relevant articles were extrapolated from the results by analysing the abstracts. Exclusion factors included articles written in any language other than English. This was followed by a review of each article’s reference list to find other relevant articles. These articles were thenfound using the Primo search function on the UCT Health Sciences library page.
A few common themes were found in the literature, and these will be used as the foundation of the literature review.
1. The South African healthcare system
2. Children and the public South African healthcare system 3. Paediatric CPR
4. Knowledge and paediatric CPR 5. Confidence and paediatric CPR
No instrument on assessing preparedness for pCPR encompassing confidence and equipment availability was found in the literature. Studies that assessed knowledge utilised self-developed questionnaires that were not published and therefore inaccessible. For this reason, a tool was self- developed.
SUMMARY OF LITERATURE
Children and the South African Healthcare System
Children make up close to a third of the population in South Africa, with an average of 1.1 million children born every year and a growth rate of 1.4% (7). Currently, 28.8% of South Africa’s population ranges between the ages of 0-14 years (7, 8). Globally, Children under the age of 15 constitute 25.5%
of the total population (1.99 billion out of a total of 7.80 billion people), which is a quarter of the world population (9). South Africa, therefore, has a higher proportion of children to adults compared to the rest of the world.
Bamford et al (2018) found that 2.36 million children born in South Africa will not survive to their fifth birthday (10). Between 2018 and 2019 the probability of survival to age 5 in South Africa was measured at 96% (8, 10). The infant mortality rate was measured as 27-33 per 1000 live births, with deaths under the age of 5 being measured as 37-40 per 1000 live births (8, 10). By comparison, the current world average of survival to 5 years of age was 97% (10), indicating that South African children have a lower survival rate than the rest of the world.
The major causes for childhood death in South Africa include HIV, pneumonia, diarrhoea, non- communicable diseases and non-natural causes including trauma (10). Studies globally show that not only is trauma one of the leading causes of cardiac arrest in children, but it is associated with poorer outcomes compared to other aetiologies (1, 11). South Africa has a high rate of violent crime (9) with the total murder rate noted to be 35.8 murders per 100 000 people, with 19.3% of those being women and children. In 2017/2018, the South African Police Services recorded an average of 458 assaults per day (9). Furthermore, A review done by the Red Cross War Memorial Children's Hospital in Cape Town noted an upward trend on the number of patients attending their trauma unit with trauma- related injuries (12)
The high trauma rate in South Africa is a direct reflection of the high levels of income inequality in the country (13). While South Africa is classified by the World Bank Group as an upper-middle- income country, in 2010, 53% of its population was found to be living in poverty (13). Consequently, the vast majority of the South African healthcare population attends the overburdened Public
Healthcare System, which provides treatment for 84% of the South African population(14). The World Health Organisation notes a direct link between inequality and poorer health outcomes, including higher infant mortality rates (15).
Studies show that not only is the incidence of sudden cardiac arrest higher in areas of lower
mortality(17). Significant relationships have additionally been found between lower parental education levels and mortality rates post-cardiac arrest, resulting in delays in recognizing and acting on cardiac arrest (17). This is a partly a result of individuals with a lower SES having lower
knowledge and training levels on basic CPR with the result that they have a lower chance of
recognizing its need and commencing it (18). Recognizing and treating cardiac arrest promptly cannot be overemphasized in children as they differ from adults, who have primarily cardiac arrest (1).
Children usually first experience respiratory arrest and later a subsequent cardiac arrest and present with either bradyarrhythmia’s, asystole or pulseless electrical activity. (19). A small proportion of paediatric patients will undergo a primary cardiac arrest with ventricular fibrillation or ventricular tachycardia, and this leaves a small window open for defibrillation in this subgroup (1).
Considering the high ratio of children living in South Africa, the high infant mortality and trauma rates as well as the high level of income inequalities, it can be postulated that South African doctors working in the Public Healthcare System see more cases of paediatric cardiopulmonary arrest. It is therefore essential that these doctors are adequately prepared to perform pCPR.
Paediatric CPR
Cardiac arrest is noted to be present when a child has absent pulses in major arteries,
unresponsiveness, apnoea, and agonal respirations, even with the presence of cardiac contractions generating a pulse pressure, the presence of electrical activity on an ECG, or observed cardiac contractions on an echo (11, 20, 21). Respiratory arrest is defined as“ the absence of respirations”
(22).
A paediatric cardiorespiratory arrest is a rare event (1-4) with high mortality and, if done correctly, CPR improves patient outcomes (5, 6). This includes decreasing the infant morbidity and mortality rate (23). Doctors should, therefore, be able to perform it correctly and in a timeous manner. Due to the urgency surrounding a cardiorespiratory arrest, medical professionals must be equipped with the relevant knowledge and skills to perform pCPR using a structured evidence-based approach.
pCPR is an organised sequence of actions performed to support and maintain the breathing and circulation of an infant, child, or adolescent who has gone into respiratory and/or cardiac arrest to prevent death, neurological injury, or both (23, 24). It can also be done to treat bradycardia (heart rates <60 beats per minute) or poor perfusion even with oxygen or ventilatory support (22).
pCPR is divided into basic and advanced CPR. Basic CPR involves ventilatory efforts as well as chest compressions. Basic manoeuvres to open the airway as well as chest compressions are performed. Airway adjuncts such as mouth-to-mask ventilation devices, oropharyngeal airways, nasopharyngeal airways and face shields may be used (22). Advanced CPR is basic CPR plus advanced airway and circulatory manoeuvres. Advanced airway manoeuvres include bag-mask ventilation, needle cricothyroidotomy and endotracheal intubation, whilst advanced circulatory manoeuvres include the administration of medication or placing the patient on extracorporeal membrane oxygenation(22).
The manner of performing pCPR differs in newborn babies, infants and adolescents, and it is important to know the difference between them. A neonate is defined as an infant within the first 28 days of life, whereas an infant encompasses the neonatal period up until 1 year. A child is between the ages of 1-12 years, whilst an adolescent is between 13-21 years of age. Adolescent CPR is the same as adult CPR (22).
It is important to note that prior to 1995 there were no formal guidelines for the uniform reporting and case definitions of pCPR. This resulted in separate studies employing a wide variety of different case definitions and reporting measures when researching paediatric CPR. These included different definitions for age cut-offs as well as for survival and neurological outcomes measured (1). This makes it difficult to correctly analyse and compare data, a problem which is compounded by the paucity of literature on CPR for paediatric patients with most studies being retrospective instead of prospective.
CPR is performed in both the out-of-hospital and in-hospital environments (25). Out-of-hospital pCPR is performed by Emergency Medical Services personnel or by lay members of the public, whilst in-patient pCPR in South Africa is usually performed by doctors and/or nursing staff (22).
Some hospitals also utilise dedicated resuscitation teams, who have received additional training (22).
Children will either be present in one of three places within the hospital: the emergency centre, intensive care unit (ICU) and the paediatric ward (26). The emergency centre serves as the first point of contact for paediatric patients arriving at the facility in cardiorespiratory arrest(26). Children admitted to the ICU have a higher chance of developing cardiorespiratory arrest compared to children in the paediatric ward and/or emergency centre (27).
pCPR is also performed in primary healthcare facilities, but there is limited evidence available on the incidence of cardiac arrest in these facilities (28). Primary healthcare facilities in South Africa include
home-based care (29). Most primary healthcare facilities are placed within the communities they serve and can, therefore, be the first point of call during medical emergencies (30).
CPR skills have a positive impact on the return of spontaneous circulation and neurological outcomes and therefore this knowledge should be propagated and disseminated in the form of teaching (31).
There is a proven link between knowledge of the cardiopulmonary resuscitation guidelines and the likelihood of being able to follow and perform the guidelines correctly (1, 27, 32-34).
An understanding of how to perform paediatric CPR is consequently an essential precursor to adequate and effective CPR. This will be discussed in the next section.
Knowledge and Paediatric CPR
The International Liaison Committee on Resuscitation (ILCOR), which includes the Resuscitation Council of Southern Africa, is responsible for reviewing the clinical guides and protocols that have been established globally. These guidelines are further developed into CPR protocols and knowledge is then propagated in the form of courses(35). These courses are taught worldwide (20). CPR was initially developed for adults, and these principles were subsequently used to develop pCPR guidelines (1).
CPR is often taught in the form of paid CPR resuscitation courses and includes Advanced Paediatric Life Support (APLS), Neonatal Life Support (NHL), Paediatric Advanced Life Support (PALS), Pre- Hospital Paediatric Life Support (PHPLS) as well as Basic Life Support (BLS) (35).
Most CPR courses are presented similarly by using a systematic structure or algorithm. Students are sent the course work prior to the course and are tested on the knowledge at the beginning and end of the course (35). These causes are available via numerous companies in South Africa and can be attended throughout various parts of the country during the year (36). Courses are usually self-funded or can be paid by the healthcare workers employer (37).
Studies show that the provision of more training results in a significant increase in resuscitated patients surviving to discharge and having improved neurological outcomes (3, 5, 6, 38, 39). A large systematic review also concluded that the courses have a positive impact on decreasing mortality and morbidity among patients who suffered cardiorespiratory arrest (6). However, this study mainly focused on adults, with only 3 of the 17 studies examined being paediatric in nature.
A 5-year retrospective outcomes study done at the Royal Children's Hospital in the United Kingdom extracted data of paediatric CPR done while progressively increasing the amount of advanced cardiopulmonary resuscitation training. The study likewise noted that there was a significant
improvement in patient outcomes associated with increased training (5), with higher levels of ROSC achieved as well as improved neurological outcomes.
It is documented in the literature that medical professionals either do not do the courses or they do not attend a refresher course (38, 40) and many doctors do not take the effort to update their knowledge (41). A large proportion of doctors stated that they did not need to attend a CPR course as they had sufficient CPR skills (42).
Numerous barriers to healthcare workers attending pCPR courses are discussed in the literature with Financial reasons noted predominantly (43). Courses also require time off work or for healthcare workers to give up their free time, and many are under no obligation to perform the courses to stay employed (35, 44). Other barriers include healthcare workers being unaware of the dates that courses were being held as well as the fact that courses were viewed as being too long (43). Availability of more frequent courses is also impeded by the availability or lack thereof of instructors (35). Still, while there are barriers to medical professionals being able to attend pCPR courses, studies have shown that many doctors would prefer more training (3, 27).
It is important to note that there is a paucity of data on barriers to pCPR courses in South Africa, with no literature found. Two international studies were found, both conducted in high-income countries, albeit that the first study was done in a low socioeconomic area.
Poor-quality basic advanced life support has been demonstrated among healthcare workers (26, 45).
Multiple studies demonstrate that doctors working in clinical settings where pCPR may be required lack the knowledge levels required to perform it effectively(4, 40, 41, 46-48). One study found that 76% of physicians failed to restore spontaneous circulation in a simulated patient who should have had a good prognosis. This translates to poor patient outcomes with a low chance of survival to discharge or poor neurological outcomes (4). There is a multitude of contributing factors that have been postulated for this. These include the fact that a large proportion of doctors only manage cardiac arrest on average twice a year as well as the fact that courses to improve their knowledge were not attended regularly(41). A paediatric cardiorespiratory arrest is rare, noted to occur in approximately 1 in 500 admissions (1-3, 49). In a large hospital, this equates to 1-2 incidences per year. Doctors who perform paediatric CPR more often have been shown to have improved knowledge and skills in performing paediatric CPR (45). Doctors who had more exposure to CPR cases have also performed better in CPR questionnaires compared to those who didn't (29).
With the incidence of pCPR being fewer than in adults, it does bring to light a concern that retention of knowledge and skills may be challenging for healthcare practitioners due to less exposure (2) and may thus indicate a need for regular attendance of training courses. This will be discussed next.
Knowledge wanes with time (25, 26, 47, 50). There is a well-documented body of literature proving that medical professionals are only able to retain the knowledge of CPR guidelines for short amounts of time. This is linear with time and occurs as early as 3-6 months post-training (26, 36-38). Findings showed that doctors who had done a paediatric life support course less than 2 years prior fared better on a pCPR questionnaire than doctors who had done a course more than 2 years prior (46). A 33.3%
decrease from post-training test scores was noted and results deteriorated as time progressed (46, 47).
This deterioration ultimately results in a decrease in the quality of CPR (34) and poorer patient outcomes (45).
It has been also been shown that apart from a poorer performance at CPR as time progresses after skills training, there has also been a documented increase in errors (48). This leads to an interesting question as to whether other measures should be developed to optimise the way that CPR is
performed in facilities instead of relying solely on doctors' abilities to retain knowledge. It is
recommended that CPR training should be done every 7 to 24 months at a minimum (27). In light of the above, it is clear that adequate knowledge of pCPR can be deemed a good measure of
preparedness to perform it.
There is no correlation in the literature between the general medical experience of the health professional and CPR knowledge and performance (25, 27, 37). Junior residents performing pCPR were shown to have the worst patient outcomes (27), with many doctors displaying “dangerous deficiencies” in their knowledge of basic CPR guidelines (45). This data applies to paediatricians as well, who have shown poor retention of knowledge and skills in paediatric basic life support (46).
Confidence and CPR
Confidence is defined as ‘A feeling of self-assurance arising from an appreciation of one's own abilities or qualities” (21) and is “a stable personality trait that may or may not be founded in reality’
(2). Confidence levels among doctors concerning pCPR can be defined as their belief in their ability to perform effective CPR on paediatric patients.
High confidence levels have been theorised to be associated with doctors having improved knowledge and skills to perform pCPR as these doctors would have increased knowledge from attending courses, or would have had regular exposure to performing pCPR (47).
Some studies show that doctors in general are overconfident in their pCPR abilities (41). Others note that doctors have low self-confidence concerning to pCPR knowledge and have indicated that they would like more training (17). The studies, however, note that doctors do not accurately assess their self-confidence levels, thereby over or underestimating their abilities. There is no consensus in the literature correlating self-confidence with better knowledge of CPR (26). It has however been shown that increasing CPR refresher training improves doctors’ confidence levels (35, 42).
AlSohime et al performed a national survey looking at factors that influence confidence during CPR.
The study found a positive correlation between confidence levels and the seniority level of the doctor.
Also, doctors who attended a pCPR course before the survey had notably higher confidence levels to perform it (51). This study also shows the value and importance of knowledge and years of clinical practice enhancing confidence levels with regard to performing pCPR. There is bias in the study, however, as only 30% of doctors to whom the study was sent completed the survey. There is a risk that the doctors who completed the survey had a natural interest in pCPR and would therefore show disproportionately higher confidence levels with regard to it(47, 51)
While the studies have not shown any clear correlation between confidence levels and preparedness for pCPR, no literature has broken down confidence in pCPR into different aspect such as anxiety levels, specific CPR courses and experience levels across broader groups of doctors. Therefore, a more in-depth understanding of how self-confidence works in relation to pCPR is necessary.
Equipment for CPR and its relationship to preparedness
Healthcare facilities can be assessed and compared on the processes that they follow when performing CPR (22). To evaluate facilities on these processes and their preparedness to perform CPR, the chain of survival needs to be analysed. This includes recognising the need for CPR, CPR being commenced and managed correctly, with the correct advanced manoeuvres being done using the correct and appropriate equipment (22).
Equipment availability is an important precursor in being able to perform CPR adequately. Without the appropriate equipment available, in working order, and easily accessible, CPR may fail (22).
Furthermore, all healthcare staff should be familiar with the equipment as well as its location(52).
The Ideal Hospital Realisation and Maintenance Framework (IHRM-F) provides an adequate guideline on equipment required to perform CPR adequately, as well as guidelines on how the equipment should be checked and stored (53).
All essential equipment and medication needed to adequately and effectively perform paediatric resuscitation needs to be available on an emergency trolley or in close proximity to it (54). The following equipment should be available: paediatric endotracheal tubes of various sizes, curved stylet, infant laryngoscope with spare bulb and batteries, infant and paediatric bag-valve-masks, oxygen cylinder, infant facemasks, paediatric nasopharyngeal airways, paediatric oropharyngeal airways, umbilical vein catheters, intraosseous needles, heat source, low-reading thermometer, electric/wall suction apparatus, defibrillator, paediatric resuscitation algorithms clearly visible, gloves (small, medium and large – at least one pair of each size), adrenaline injection 1mg/ml, dextrose 50%
intravenous solution, sodium chloride 0.9% 1L (53).
Latent conditions and cognitive factors, such as doctors not knowing what equipment is available in their facility as well as where the equipment can be found, can lead to adverse events during paediatric CPR and ultimately, an adverse outcome for the patient (55). Therefore, the training of healthcare workers on the equipment available and its location is an essential part of CPR training (52). There are currently no studies looking at the knowledge that doctors have regarding equipment availability.
Knowledge amongst doctors on the availability of equipment is therefore integral to the chain of survival and will be assessed as part of the study to assess preparedness to perform CPR.
IDENTIFICATION OF GAPS FOR FURTHER RESEARCH
Most of the aforementioned research on paediatric CPR has been done in urban areas and not much is known about how often it is performed in rural areas, low-income, lower-middle-income and upper- middle-income countries. These statistics may, therefore, differ significantly in South Africa. This paucity of studies in rural, low-income and upper-middle-income countries could impact South African medical professionals as the aetiologies of cardiac arrest may differ to that of first world countries, and likewise, the outcomes would differ. This could impact the efficacy of CPR protocols that were developed based on systematic reviews from high-income countries.
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Part B: MANUSCRIPT IN ARTICLE FORMAT
Title:
Preparedness for paediatric cardiopulmonary resuscitation in medical doctors working in primary healthcare facilities in Cape Town, South Africa
Abstract:
Background: CPR is the principal medical intervention used to reduce the high mortality associated with cardiorespiratory arrest. There is a paucity of literature on the preparedness for paediatric CPR (pCPR) amongst doctors in Cape Town. The study aimed to assess the preparedness for pCPR of doctors working in Western Cape Provincial Government primary healthcare facilities (PHCFs) in Cape Town with regard to knowledge, confidence and doctors’ knowledge of equipment availability.
Methods: A cross-sectional descriptive-analytic study using a self-developed questionnaire to collect quantitative data from a sample of 206 doctors working in Cape Town PHCFs.
Results: 173 doctors (84% response rate) completed the questionnaire. The majority (81.8%) had not done a pCPR course (Paediatric Advanced Life Support or Advanced Paediatric Life Support). 88.3%
had done Basic Life Support; 28% >2 years ago. The average pCPR knowledge score was 61%
(SD=20.3, range 8.3-100%). Doctors doing their community service and internship had significantly higher knowledge scores compared to Grade 3 medical officers (p = .001 and .010 respectively). 11%
had performed pCPR >10 times in the past year; 20% had never performed pCPR, and 35% did not feel confident performing pCPR. More than 35% of doctors were uncertain about the availability of equipment in their facility.
Conclusion: Doctors working in Cape Town PHCFs are poorly prepared to perform pCPR. Doctors’
knowledge of pCPR and availability of equipment is inadequate and confidence in their ability to perform pCPR is low. Formal pCPR training and education on equipment location and availability is recommended.
INTRODUCTION
A paediatric cardiorespiratory arrest is a rare event (1) with high mortality. In cardiorespiratory arrest, Cardiopulmonary Resuscitation (CPR), can be an important life-saving measure. When paediatric CPR (pCPR) is performed correctly, patient outcomes are better (2). Given that paediatric cardiorespiratory arrest has a high mortality, doctors must be prepared to perform pCPR correctly and timeously using a structured evidence-based approach. Three critical aspects are associated with performing effective pCPR, namely doctors’ knowledge of how to perform pCPR; their confidence levels; and their knowledge of the availability of the required equipment in their facility.
South Africa has a higher proportion of children to adults compared to the rest of the world, with an average of 1.1 million children born every year and a growth rate of 1.4% (3). 2.36 million children born in South Africa will not survive to their fifth birthday (4). The probability of survival to age 5 in South Africa is currently measured at 96% and the infant mortality rate has been measured as 27-33 per 1000 live births, with deaths under the age of 5 being measured as 37-40 per 1000 live births (4).
By comparison, the current world average of survival to 5 years of age is 97% (4), indicating that South African children have a lower survival rate than the rest of the world.
South Africa has a high rate of violent crime (5) with the total murder rate noted to be 35.8 murders per 100 000 people, with 19.3% of those being women and children. Studies globally show that not only is trauma one of the leading causes of cardiac arrest in children, but it is associated with poorer outcomes compared to other aetiologies (6).
The high trauma rate in South Africa is a direct reflection of the high levels of income inequality in the country (7). While South Africa is classified by the World Bank Group as an upper-middle- income country, in 2010, 53% of its population was found to be living in poverty (7). Consequently, the vast majority of the South African healthcare population attends the overburdened Public
Healthcare System, which provides treatment for 84% of the South African population(8). The World Health Organisation notes a direct link between inequality and poorer health outcomes, including higher infant mortality rates (9).
Studies show that not only is the incidence of sudden cardiac arrest higher in areas of lower socioeconomic status (SES)(10), but lower SES contributes to higher levels of morbidity and mortality (11). Significant relationships have additionally been found between lower parental education levels and mortality rates post-cardiac arrest, resulting in delays in recognizing and acting on cardiac arrest (12). Recognizing and treating cardiac arrest promptly cannot be overemphasized in children as a small proportion of paediatric patients will undergo a primary cardiac arrest with
ventricular fibrillation or ventricular tachycardia, and this leaves a small window open for defibrillation in this subgroup (13).
Considering the high ratio of children living in South Africa, the high infant mortality and trauma rates as well as the high level of income inequalities, it can be postulated that South African doctors working in the Public Healthcare System see more cases of paediatric cardiopulmonary arrest. It is therefore essential that these doctors are adequately prepared to perform pCPR.
pCPR is an organized sequence of actions performed to support and maintain the breathing and circulation of an infant, child, or adolescent who has gone into respiratory and/or cardiac arrest to prevent death, neurological injury, or both (14, 15).
CPR skills have a positive impact on the return of spontaneous circulation and neurological outcomes and this knowledge should be propagated and disseminated in the form of teaching (16). There is a proven link between knowledge of the cardiopulmonary resuscitation guidelines and the likelihood of being able to follow and perform the guidelines correctly (17-19). An understanding of how to perform paediatric CPR is consequently an essential precursor to adequate and effective CPR.
Knowledge and Paediatric CPR
CPR is often taught in the form of paid CPR resuscitation courses and includes Advanced Paediatric Life Support (APLS), Neonatal Life Support (NHL), Paediatric Advanced Life Support (PALS), Pre- Hospital Paediatric Life Support (PHPLS) as well as Basic Life Support (BLS) (19). Studies show that the provision of more training results in a significant increase in resuscitated patients surviving to discharge and having improved neurological outcomes (2, 20).
It is documented in the literature that medical professionals either do not do the courses or they do not attend a refresher course (20, 21) and many doctors do not take the effort to update their knowledge (22).
Numerous barriers to healthcare workers attending pCPR courses are discussed in the literature with Financial reasons noted predominantly (23). Courses also require time off work or for healthcare workers to give up their free time, and many are under no obligation to perform the courses to stay employed (19, 24). Other barriers include healthcare workers being unaware of the dates that courses were being held as well as the fact that courses were viewed as being too long (23). Availability of more frequent courses is also impeded by the availability or lack thereof of instructors (19). Still, while there are barriers to medical professionals being able to attend pCPR courses, studies have shown that many doctors would prefer more training (1, 18).
Multiple studies demonstrate that doctors working in clinical settings where pCPR may be required lack the knowledge levels required to perform it effectively (21, 22, 25, 26). There is a multitude of contributing factors that have been postulated for this. These include the fact that a large proportion of doctors only manage cardiac arrest on average twice a year as well as the fact that courses to improve their knowledge were not attended regularly(22). A paediatric cardiorespiratory arrest is rare, noted to occur in approximately 1 in 500 admissions(1, 13, 27). In a large hospital, this equates to 1-2
incidences per year. Doctors who perform paediatric CPR more often have been shown to have improved knowledge and skills in performing paediatric CPR (28). Doctors who had more exposure to CPR cases have also performed better in CPR questionnaires compared to those who didn't (29).
With the incidence of pCPR being fewer than in adults, it does bring to light a concern that retention of knowledge and skills may be challenging for healthcare practitioners due to less exposure and may thus indicate a need for regular attendance of training courses.
Knowledge wanes with time (26, 29-31). There is a well-documented body of literature proving that medical professionals are only able to retain the knowledge of CPR guidelines for short amounts of time. This is linear with time and occurs as early as 3-6 months post-training (26, 36-38). Findings showed that doctors who had done a paediatric life support course less than 2 years prior fared better on a pCPR questionnaire than doctors who had done a course more than 2 years prior (25). This deterioration ultimately results in a decrease in the quality of CPR (32) and poorer patient outcomes (28).
It has also been shown that apart from a poorer performance at CPR as time progresses after skills training, there has also been a documented increase in errors. It is recommended that CPR training should be done every 7 to 24 months at a minimum (27). In light of the above, it is clear that adequate knowledge of pCPR can be deemed a good measure of preparedness to perform it.
There is no correlation in the literature between the general medical experience of the health professional and CPR knowledge and performance (25, 27, 37).
Confidence and CPR
Confidence is defined as ‘A feeling of self-assurance arising from an appreciation of one's own abilities or qualities” (33) Confidence levels among doctors concerning pCPR can be defined as their belief in their ability to perform effective CPR on paediatric patients.
High confidence levels have been theorised to be associated with doctors having improved knowledge and skills to perform pCPR as these doctors would have increased knowledge from attending courses, or would have had regular exposure to performing pCPR (26).
Some studies show that doctors in general are overconfident in their pCPR abilities (41). Others note that doctors have low self-confidence with regard to pCPR knowledge and have indicated that they would like more training (17). The studies, however, note that doctors do not accurately assess their self-confidence levels, thereby over or underestimating their abilities. There is no consensus in the literature correlating self-confidence with better knowledge of CPR (26).
AlSohime et al performed a national survey looking at factors that influence confidence during CPR.
The study found a positive correlation between confidence levels and the seniority level of the doctor.
Also, doctors who attended a pCPR course before the survey had notably higher confidence levels to perform it (34). This study also shows the value and importance of knowledge and years of clinical practice enhancing confidence levels with regard to performing pCPR.
While the studies have not shown any clear correlation between confidence levels and preparedness for pCPR, no literature has broken down confidence in pCPR into different aspect such as anxiety levels, specific CPR courses and experience levels across broader groups of doctors. Therefore, a more in-depth understanding of how self-confidence works in relation to pCPR is necessary.
Equipment for CPR and its relationship to preparedness
Healthcare facilities can be assessed and compared on the processes that they follow when performing pCPR (35). To evaluate facilities on these processes and their preparedness to perform pCPR, the chain of survival needs to be analysed. This includes recognising the need for pCPR, pCPR being commenced and managed correctly, with the correct advanced manoeuvres being done using the correct and appropriate equipment (35).
Equipment availability is an important precursor in being able to perform pCPR adequately. Without the appropriate equipment available, in working order, and easily accessible, pCPR may fail (35).
Furthermore, all healthcare staff should be familiar with the equipment as well as its location(36).
The Ideal Hospital Realization and Maintenance Framework (IHRM-F) provides an adequate guideline on equipment required to perform pCPR adequately, as well as guidelines on how the equipment should be checked and stored (37).
Latent conditions and cognitive factors, such as doctors not knowing what equipment is available in their facility as well as where the equipment can be found, can lead to adverse events during pCPR and ultimately, an adverse outcome for the patient (38). Therefore, the training of healthcare workers
on the equipment available and its location is an essential part of pCPR training (36). There are currently no studies looking at the knowledge that doctors have regarding equipment availability.
Knowledge amongst doctors on the availability of equipment is therefore integral to the chain of survival and has been assessed as part of the study to assess preparedness to perform pCPR.
The aim of this study was to assess the preparedness for pCPR of medical doctors working in Department of Health Community Health Centres (CHC) and Community Day Centres (CDC) in the Cape Metropole of the Western Cape. Preparedness is defined as sufficient knowledge and confidence to perform pCPR competently and knowledge of the availability of the necessary equipment.
The objectives are as follows:
1. To assess the knowledge of pCPR amongst doctors working in CHC’s, CDC’s including family medicine registrars.
2. To assess the confidence of doctors in initiating CPR in Paediatric patients.
3. To assess the availability of equipment required during pCPR from the primary healthcare doctors’ perspective.
RESEARCH METHODS AND DESIGN
Study design: This is a cross-sectional, descriptive-analytic study using a questionnaire (Quantitative data collective method).
Setting: The study was done at CHC’s and CDCs situated within the 4 district health substructures in the Cape Town Metropole. The facilities included in the study are:
1. Metro Substructure 1 (Northern/Tygerberg): Bellville CDC, Bishop Lavis CDC, Bothasig CDC, Delft CHC, Elsies River CHC, Goodwood CDC, Kraaifontein CHC, Ravensmead CDC,
Ruyterwacht CDC
2. Metro Substructure 2 (Western/Southern): District 6 CDC, Du Noon CHC, Greenpoint CDC, Kensington CDC, Maitland CDC, Retreat CHC, Vanguard CHC.
3. Metro Substructure 3 (Klipfontein/ Mitchell’s Plain): Cross-Roads CDC, Dr Abduragman CDC, Gugulethu CHC, Hanover Park CHC, Heideveld CDC, Inzame Zabantu CHC, Mitchell’s Plain CHC, Nyanga CDC
4. Metro Substructure 4 (Khayelitsha/Eastern): Khayelitsha CHC, Kleinvlei CHC, Mfuleni CDC, Michael Mapongwana CHC, Nolungile CHC, Nomzamo CDC
The following facilities declined the request for research to be conducted: Symphony Way CDC, Reed Street CDC, Grassy Park CDC, Hout Bay CDC
Approval to conduct research was not obtained by the Western Cape Department of Health for the following facilities: Morningstar CDC, Parow CDC, Wynberg CDC, Gustrouw/Rusthof CHC and Macassar CHC.
Study population and sampling strategy: The study population included 173 out of 206 doctors working in CHC’s and CDC’s in the Cape Metropole. The doctors who participated were grouped according to the role that they fulfil within their healthcare facility and comprise of interns, community service doctors, medical officers, family medicine registrars and consultants. The
calculated sample size required to be statistically significant is 134 doctors, with a confidence interval of 95% and a margin of error of 5%. An attempt was made to capture all doctors working in the primary healthcare facilities at the time of data collection. Each facility was attended multiple times in order to capture each doctor.
Inclusion criteria:
- Currently employed to provide clinical service at a CHC or CDC at the time of the survey completion.
Exclusion criteria:
- Doctors working in private hospitals and local military hospitals.
- District level hospitals are excluded from this study.
- The City of Cape Town primary healthcare facilities have been excluded from the study as it does not form part of the Cape Metropole.
- Certified Nurse Practitioners (CNP’S) will not be included in the study due to the fact that all of the facilities included in the study have doctors working in them at all times and in the case of a patient needing CPR the doctor will lead the CPR team.
Definitions of the study population
1. Intern: A general practitioner in training who has completed medical school and has a medical degree but does not yet have a licence to practice medicine unsupervised.
1. Community service Medical officer: A general practitioner who has completed internship but still needs to work one or two years in a state-run facility before being allowed to practice as a doctor independently.
2. Medical officer grade 1: A general practitioner who is registered as an independent
practitioner (has completed internship and community service) and has been working for the state for less than 5 years.
3. Medical officer grade 2: A general practitioner who is registered as an independent practitioner (has completed internship and community service) and has been working for a minimum of 5 years.
4. Medical officer grade 3: A general practitioner who is registered as an independent practitioner (has completed internship and community service) and has been working for a minimum of 10 years.
5. Family Physician: A medical officer who has completed a vocational training programme which the relevant faculty of medicine or health sciences prescribed as part of the course in family medicine of that faculty.
6. Family medicine registrar: A medical officer training to become a family physician.
Instrument development: The questionnaire was self-developed by the researcher as no suitable instrument measuring the 3 main variables in this study were found in the literature. It contained 2 sections: Section A appertained to characteristics of the participants, including confidence levels, whilst Section B dealt with knowledge on pCPR. The knowledge questions were derived from the Resuscitation of Southern Africa CPR algorithms. The questionnaire was piloted by 5 doctors (2 emergency medicine physicians, 2 medical officers and one community service doctor working in a state-funded emergency room at Mitchells Plain District Hospital) to assess for errors or faults and then uploaded to LimeSurvey, which is a statistical survey web app. LimeSurvey was utilised as it was the web app approved for use by the University of Cape Town due to its secure database.
Data collection: Once approval had been received to conduct research per facility, the clinical managers of the respective facilities were contacted, and a time was arranged for the researcher to travel to the site and collect the data. Participants were recruited by the researcher travelling to the study sites and requesting the participation of the on-site doctors. Participants were introduced to the study verbally and by means of the information sheet and subsequently signed a consent form. The doctors were then given a tablet/phone with the questionnaire on it which was completed under the supervision of the researcher. All results were uploaded to the LimeSurvey site in real-time and were transferred to Microsoft Excel for analysis. Multiple visits were necessary per facility to ensure that as many doctors as possible were included in the study.
Data analysis: A biostatistician was consulted to analyse the results. In scoring confidence levels amongst doctors the “quite” and “extremely confident” categories were combined, while the
“slightly” and “not confident” categories were combined. The same method was applied to the anxiousness categories. For assessing knowledge of paediatric CPR amongst doctors each question was coded as right or wrong and then summed, divided by 12 and then multiplied by 100 to get a percentage knowledge score. Furthermore, in order to assess overall knowledge scores a one-way anova table was used in order to compare more than 2 groups. A Bonferroni corrected p-value was used in order to adjust the level of significance in order to be stricter so that the researcher did not interpret there being a difference when there was none. The same statistical analyses methods were used in assessing knowledge scores by doctor’s confidence levels. To analyse knowledge scores by doctor’s experience level in performing CPR, courses were dichotomised. Independent sample t-tests compared knowledge scores of doctors who had or had not done each course.
Ethical considerations: Ethics approval to conduct the study was granted by the UCT Human Research Ethics Committee (HREC REF: 660/2019). Permission and access to conduct the study in the Cape metropolitan area were obtained from the metropolitan director followed by the substructure director and then the managers of the primary healthcare facilities. Permission was also obtained from
RESULTS: Data Analysis and Interpretation
The following section will comprise a discussion on the interpretation and summary of the results.
Characteristics of respondents
173 out of 206 doctors working in Community Health Centres and Community Day centres in the Cape Metropole participated in the survey, a response rate of 83%. 11 results were removed due to incomplete data. 162 completed surveys were analysed. 25% were Medical Officers Grade 1, and 30% were Medical Officers Grades 2 and 3. Community Service Doctors made up 15% of the sample and Interns made up 14%. Consultants and Registrars each made up 8% of the sample (see Table A) All 4 substructures in the Cape Metropole had similar participant numbers.
Courses completed
The majority of doctors (>74.7%) had never done a course on APLS nor PHPLS (88.9%), nor a DIPEC (93.8%). Moreover, 63% of doctors had never done PALS and ATLS. Most doctors in the survey (almost 90%) had been on a course in Basic Life Support. Of the doctors who had completed the BLS course, 28% completed it more than two (2) years prior to this survey (see Figure B and C).
53% of doctors said that the cost of attending a CPR course was a barrier.
Table A. Grade of doctor as well as geographic locations
Grade of Doctor n %
Intern 22 13.6
Community service doctor 24 14.8
MO 1 40 24.7
MO 2 31 19.1
MO 3 18 11.1
Registrar 13 8.0
Consultant 14 8.6
Total 162 100
Substructure n %
Substructure 1 (Northern/Tygerberg) 41 25.3%
Substructure 2 (Western/Southern) 36 22.2%
Substructure 3 (Klipfontein/ Mitchell’s Plain) 39 24.1%
Substructure 4 (Khayelitsha/ Eastern) 38 23.5%
Doctors working across all substructures 8 4.9%
Total 162 100%
Figure A. Distribution of Life Support Courses done when / not done by type of course
Table B. Distribution of APLS and PALS courses done/not done by doctor category
APLS PALS
Done course Not done Done course Not done
Intern 3 (13.6%) 19 (86.3%) 3 (13.6%) 19 (86.3%)
Community service doctor 3 (12.5%) 21 (87.5) 7 (29.2%) 17(70.8%)
Mo Grade 1 3 (7.5%) 37 (92.5%) 14 (35%) 26 (65%)
Mo Grade 2 13 (41.9%) 18 (58.1%) 12 (38.7%) 19 (61.3%)
Mo Grade 3 4 (22.2%) 14 (77.8%) 9 (50%) 9 (50%)
Registrar 7 (53.8%) 6 (46.2%) 7 (53.8%) 6 (46.2%)
Consultant 8 (57.1%) 6 (42.9%) 9 (64.3%) 5 (34.7%)
Performance of CPR in the past year
In the past 12 months, 58% of doctors had performed CPR 1-5 times, 12% (19) performed CPR 6-10 times, 11% (17) had performed CPR more than 10 times and 20% (31) of doctors had never
performed CPR.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Basic Life Support
Advanced Paediatric Life
Support
Paediatric Advanced Life
Support
Advanced Trauma and Life
Support
Pre-hospital Paediatric Life
Support
Diploma in Emergency Medicine Never done <6 months ago 6-12 months ago 12-24 months ago >2 years ago
Knowledge of pCPR
The average knowledge score was 61.7% (SD = 20.3, range 8.3 – 100 %).
Knowledge and category of doctor
A one-way ANOVA (see Table D) revealed that knowledge scores differed significantly by the doctor category (F = 3.83, p = .001). Post-hoc comparisons revealed that Community Service Doctors had significantly higher knowledge compared to MOs Grade 3 (p = .001), as did Interns (p = .010).
Community Service Doctors had the highest knowledge scores, followed by Interns, then Consultants and registrars. MOs Grade 1 and MOs Grade 3 had the lowest knowledge scores.
Table C. Knowledge scores by level of doctor category
N Mean SD 95% CI for mean Min Max
Lower Bound
Upper Bound
Community Service Doctor
24 71.9 17.2 64.6 79.1 33.3 100.0
Consultant 14 59.5 20.4 47.8 71.3 16.7 83.3
Intern 22 68.6 17.0 61.0 76.1 25.0 100.0
MO Grade1 40 63.8 16.2 58.6 68.9 25.0 100.0
MO Grade 2 31 57.3 22.0 49.2 65.3 8.3 91.7
MO Grade 3 18 46.8 23.6 35.0 58.5 8.3 83.3
Registrar 13 58.3 20.4 46.0 70.7 25.0 100.0
Total 162 61.7 20.3 58.5 64.8 8.3 100.0
Knowledge and course attendance
Knowledge scores did not differ depending on whether a doctor had previously done a course or not (all ps > 0.05). However, there was a trend towards doctors who had done basic life support having significantly higher knowledge scores compared to doctors who had never done this course (p = 0.07, knowledge scores 63% vs 54% respectively).
Knowledge and confidence levels
A one-way ANOVA (see Table E) revealed that knowledge scores differed significantly by the doctor's level of confidence (F = 5.12, p = .007). Post-hoc comparisons revealed that doctors who were confident had significantly higher knowledge compared to doctors who were not confident (p =
.003), and doctors who were moderately confident had significantly higher knowledge compared to doctors who were not confident (p = .015). As can be seen from Table E, knowledge scores decreased as confidence decreased.
Table D. Knowledge scores by doctors confidence level
N Mean SD 95% CI for mean Min Max
Lower Bound
Upper Bound
Confident 42 67.1 16.0 62.1 72.1 33.3 100.0
Moderately confident 64 63.9 20.5 58.8 69.0 8.3 100.0
Not Confident 56 55.1 21.4 49.3 60.8 8.3 100.0
Total 162 61.7 20.3 58.5 64.8 8.3 100.0
Knowledge anxiety levels
On the other hand, knowledge scores did not differ by doctors’ level of anxiety (F = 1.07, p = .344).
However, doctors with moderate anxiety had higher knowledge than doctors with no or high anxiety.
Knowledge and experience performing CPR
A one-way ANOVA (see Table F) revealed that knowledge scores differed significantly by doctor's experience performing CPR (F = 4.37, p = .006). Post-hoc comparisons revealed that doctors who had never performed CPR had significantly lower knowledge compared to doctors who had performed CPR more than 10 times (p = .006). Knowledge scores increased as the level of experience performing CPR increased.
Table E. Knowledge scores by doctor’s experience performing CPR
N Mean SD 95% Confidence
Interval for Mean
Min Max
Lower Bound
Upper Bound
None 31 51.3 20.0 44.0 58.7 16.7 83.3
1-5 times 92 62.6 20.1 58.4 66.8 8.3 100.0
6-10 times 19 64.0 19.5 54.7 73.4 25.0 91.7
> 10 times 17 71.1 14.8 63.5 78.7 50.0 100.0
Total 159 61.5 20.1 58.3 64.6 8.3 100.0
