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Background: Guidelines on performing cardiopulmonary resuscitation (CPR) have been Access this article online
Website: www.ijccm.org
published from time to time, and formal training programs are conducted based on these
DOI: 10.4103/0972-5229.92070
guidelines.Very few data are available in world literature highlighting the impact of these
Quick Response Code:
trainings on CPR outcome. Aim: The aim of our study was to evaluate the impact of
the American Heart Association (AHA)-certified basic life support (BLS) and advanced
cardiac life support (ACLS) provider course on the outcomes of CPR in our hospital.
Materials and Methods:An AHA-certified BLS and ACLS provider training programme
was conducted in our hospital in the first week of October 2009, in which all doctors in
the code blue team and intensive care units were given training. The retrospective study
was performed over an 18-month period. All in-hospital adult cardiac arrest victims in
the pre-BLS/ACLS training period (January 2009 to September 2009) and the post-BLS/
ACLS training period (October 2009 to June 2010) were included in the study. We
compared the outcomes of CPR between these two study periods. Results: There were
a total of 627 in-hospital cardiac arrests, 284 during the pre-BLS/ACLS training period
and 343 during the post-BLS/ACLS training period. In the pre-BLS/ACLS training period,
52 patients (18.3%) had return of spontaneous circulation, compared with 97 patients
(28.3%) in the post-BLS/ACLS training period (P < 0.005). Survival to hospital discharge
was also significantly higher in the post-BLS/ACLS training period (67 patients, 69.1%)
than in the pre-BLS/ACLS training period (12 patients, 23.1%) (P < 0.0001). Conclusion:
Formal certified BLS and ACLS training of healthcare professionals leads to definitive
improvement in the outcome of CPR.
Keywords: Cardiopulmonary resuscitation, basic life support, advanced cardiac life support
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Indian Journal of Critical Care Medicine October-December 2011 Vol 15 Issue 4
in India. All healthcare professionals are provided in- the outcomes of CPR. The outcomes of interest were
hospital BLS training. They initiate CPR whenever there is immediate survival after CPR and survival to hospital
a cardiac arrest in the hospital and continue till the arrival discharge. Immediate survival was defined as the return
of the code blue team. The hospital has a designated code of spontaneous circulation (ROSC) for more than 20 min.
blue team that responds to all in-hospital cardiac arrest
alarms, announced through the public announcement Statistical analysis
system. The code blue team consists of an anesthesiology The relevant data was entered in the excel sheet and
registrar, a medicine registrar, on-duty resident medical was analysed using Epi Info software. Chi square test
officer, attending staff nurse and nursing supervisor of was used to compare the immediate survival rates
the shift. The hospital policy is to always initiate CPR in (ROSC) and survival to hospital discharge rates in the
a cardiac arrest victim. Do not resuscitate (DNR) policy pre-BLS/ACLS training period and post-BLS/ACLS
is not legal in India. A code blue running sheet is filled training period. For all statistical analysis, P <0.05 was
by a record keeper during the course of CPR. considered to be significant.
Intervention
Results
Before the intervention, the code blue team followed
AHA guidelines for CPR, but no formal training had A total of 627 adult patients suffering in-hospital
been conducted. With the aim of improving CPR skills, cardiac arrest for the first time over the study period
an AHA-certified 3-day BLS and ACLS provider course were included in the study. CPR was attempted in 284
was conducted in our hospital in the first week of patients during the pre-BLS/ACLS training period and
October 2009. The course included lectures and hands- in 343 patients in the post-BLS/ACLS training period.
on training of periarrest case scenarios, which were Demographic data is as shown in Table 1. There was no
followed by a written test and skill assessments. All the significant association between either the age or sex with
anesthesiologists and doctors working in the emergency the outcomes in the study.
and intensive care units participated in the course and
got certified. Of the 284 cardiac arrest victims during the pre-BLS/
ACLS training period, 52 patients (18.3%) had ROSC,
Study design while during the post-BLS/ACLS training period, 97
After getting approval from the hospital ethics patients (28.3%) of 343 patients had ROSC. On statistical
committee, we designed a retrospective study to analysis, this was considered to be a significant difference
evaluate the effectiveness of the above intervention on in the immediate survival rate (P = 0.003) [Table 2].
the outcome of CPR in in-hospital cardiac arrest victims.
Cardiac arrest was defined by the absence of a detectable Of the 52 patients who survived during the pre-
pulse (pulselessness), by patient’s unresponsiveness or BLS/ACLS training period, only 12 patients (23.1%)
by any arrest rhythm noticed on the monitor.[3] were discharged from the hospital. During the post-
BLS/ACLS training period, 67 patients (69.1%) were
We identified all cases of in-hospital cardiac arrest discharged of the 97 cardiac arrest victims who had
in adults (>14 years of age) that occurred over an 18
months period between January 2009 to June 2010. Data Table 1: Demographic data
regarding each cardiac arrest were collected from the Pre-ACLS training Post-ACLS training
code blue running sheets. We compared the code blue period period
data from January 2009 to September 2009, i.e. pre-ACLS Mean age (years) 58.8 ± 8.2 55.1 ± 6.9
training period, with post-ACLS training period from Sex distribution
October 2009 to June 2010. Males 162 (57 %) 188 (54.8 %)
Females 122 (43 %) 155 (45.2 %)
ACLS, Advanced cardiac life support
The patients on whom CPR was started outside the
hospital or on arrival in the emergency ward were not
included in the study. When a patient suffered several Table 2: Outcomes of cardiopulmonary resuscitation
cardiac arrests in the hospital, only the first episode was Pre-ACLS Post-ACLS P-value
included in the analysis for avoiding falsely elevated rate training period training period
of successful CPR, or falsely diminished rate of survival Total number 284 343
of code blues
to hospital discharge. ROSC n = 52 (18.3%) n = 97 (28.3%) 0.003 (<0.005)
S→D n = 12 (23.07%) n = 67 (69.07%) <0.0001
Data entry consisted of patient demographic data and ROSC, Return of spontaneous circulation; S → D, Survival to hospital discharge
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Indian Journal of Critical Care Medicine October-December 2011 Vol 15 Issue 4
ROSC. The survival to hospital discharge rate in the post- study clearly shows an improved rate of immediate
BLS/ACLS training period was statistically significant survival after the formal BLS/ACLS training (P <
(P < 0.0001) when compared with the pre-BLS/ACLS 0.005). A Brazilian study by Moretti et al. also shows
training period [Table 2]. a significant increase in ROSC from 27.1% to 43.4%
even on inclusion of a single ACLS-trained personnel
Discussion in the resuscitation team.[12] Another study by Sanders’
also reported improved resuscitation success in a rural
In-hospital cardiac arrest is an emergency situation
community hospital after an ACLS provider course.[13]
that requires teamwork and the appropriate sequential
A study by Borimnejad et al. also showed that initial
actions to rescue the patients. [4] The outcome of
survival after CPR improved significantly with the CPR-
cardiac arrest and CPR is dependent on critical
trained emergency team (18.4–30%).[6]
interventions, particularly early defibrillation, effective
chest compressions and assisted ventilation.[5] Over the
Although a previous study by Olasveengen reported a
last 50 years, after the introduction of modern CPR,
weak trend with survival to discharge rates improving
there have been major developments and changes in the
only from 11% to 13% after implementation of the
performance of resuscitation.[6] But, despite considerable
modified 2005 CPR guidelines, the study by Moretti
efforts to improve the treatment of cardiac arrest, most
et al. reported a statistically significant increase in
reported survival outcome figures are poor.[5] Even in
survival to discharge in patients resuscitated by the
the hospitalised patients, the rate of successful CPR has
CPR team having an ACLS-trained personnel versus the
been reported by some studies to be as low as 2–6%,
team having no ACLS personnel (20.6% vs. 31.7%). [6,14]
although most studies report successful CPR outcome
Our study also reports markedly improved survival
in the range of 13–59%.[6,7]
to hospital discharge rates (23.1% vs. 69.1%) after
formal BLS/ACLS training (P < 0.0001). The survival
The lack of resuscitation skills of nurses and doctors in
to discharge rates during the pre-BLS/ACLS period of
basic and advanced life support has been identified as
our study are almost comparable to that reported in the
a contributing factor to poor outcome in cardiac arrest
literature (11.7–32.2%), but the significant increase in
victims.[8] In an effort to improve cardiac arrest outcomes,
survival to discharge rates after the BLS/ACLS training
recent investigations have focussed on the timing and
to 69% highlights that formal training of code blue
quality of CPR. Several guidelines on performing CPR
team members enormously improved the skills of CPR
have been published and certified training courses based
and their level of competence in resuscitation.[1,3,12,15-17]
on these guidelines have become a standard in medical
This also shows that the quality of CPR performed
professionals’ training in many parts of the world.[1] The
might be better after ACLS training. This highlights the
aim of these courses is to provide information and hands-
importance of certified hands-on training program on
on practice in the management of periarrest situations
the outcome of resuscitation.
in accordance with the latest guidelines.
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Indian Journal of Critical Care Medicine October-December 2011 Vol 15 Issue 4
conclude that formal certified BLS and ACLS training In-hospital resuscitation: Association between ACLS training and
survival to discharge. Resuscitation 2000;47:83-7.
courses with hands-on practice and their periodic
10. Hajbaghery MA, Mousavi G, Akbari H. Factors influencing survival
renewal are crucial in improving the outcomes of CPR. after in-hospital cardiopulmonary resuscitation. Resuscitation
2005;66:317-21.
11. Rajaram R, Rajagopalan RE, Pai M, Mahendran S. Survival after
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