Basic Life Support Knowledge of Medical Students: A Single ... · Central cellenc ccess Al-Werdani et al. (2018) Email: [email protected] Arch Emerg Med Crit Care 3(2): 1044

CentralBringing Excellence in Open Access

Archives of Emergency Medicine and Critical Care

Cite this article: Al-Werdani MM, Mokhtar AM, Ebead AK, El-Sherbeny E, El-Gilany AH (2018) Basic Life Support Knowledge of Medical Students: A Single Faculty Study in Egypt. Arch Emerg Med Crit Care 3(2): 1044.

*Corresponding authorMariam Mostafa Al-Werdani, Mansoura School of medicine, Mansoura University, AlGomhoria St., Mansoura, Al Daqahlia, Egypt, Tel: +201019044121, Email:

Submitted: 23 September 2018

Accepted: 12 November 2018

Published: 13 November 2018

ISSN: 2476-2016

Copyright© 2018 Al-Werdani et al.

OPEN ACCESS

Keywords•Basic life support; Cardiopulmonary resuscitation;

Medical education; First aid

Research Article

Basic Life Support Knowledge of Medical Students: A Single Faculty Study in EgyptMariam Mostafa Al-Werdani1*, Abdalrhman Mostafa Mokhtar1, Ahmed Khaled Ebead1, Enas El-Sherbeny2, Abdel-Hady El-Gilany2

1Mansoura School of Medicine, Mansoura University, Egypt.2Department of Public Health, Mansoura School of Medicine, Egypt

Abstract

Aim of the study: To measure the levels of Basic Life Support (BLS) knowledge in medical students, Mansoura University, Egypt.

Methods: Our cross-sectional study was carried out in Mansoura School of Medicine, Mansoura University, Egypt. Only Egyptian medical students from the subject-based learning system were allowed to participate. Using a self-reported questionnaire, we measured the number of students with good BLS knowledge, attending BLS courses, self-perceived ability to handle emergency situations, previous exposure to emergency situations, and the number of students wanting to learn more about BLS as a part of their curriculum.

Results: With a response rate of 85%, only 5% of the participants scored 50% or more in the questionnaire. Using a cut-off point of 8 (added 1 SD to the mean BLS knowledge score), clinical students were 2.2 times (95% CI: 1.5 -3.1) more likely to achieve good BLS knowledge scores than preclinical students. Attending BLS courses, self-perceived ability to manage emergency situations, and being male were all independent predictors of good BLS knowledge scores, with adjusted Odd’s ratios of 1.7 (95% CI: 1.2-2.4), 2 (95% CI: 1.2-3.3), and 1.8 (95% CI: 1.3-2.6) respectively. Ninety-six percent of the study participants wanted to learn more about BLS as a part of their curriculum.

Conclusions: Ninety-five percent of the students achieved poor BLS knowledge scores. Revisiting the BLS teaching strategies in the subject based system is strongly encouraged. We advise medical students to take BLS courses to raise their knowledge levels.

ABBREVIATIONSBLS: Basic Life Support; PS: Preclinical Students; CS: Clinical

Students

INTRODUCTION Basic life support (BLS) is a set of skills that are essential to

the general public, as they significantly raise the survival rate of emergency patients, especially those suffering from cardiac arrest, stroke and foreign body airway obstruction [1]. This is due to their efficiency in increasing survival following out of hospital cardiac arrest until expert medical help arrives [2,3].

In the East Mediterranean Region (EMR), ischemic heart disease is the leading cause of death causing 20.3% of total mortalities in the EMR, while deaths from road traffic accidents attribute to 3.1% of total mortality (across all age groups in both sexes), further emphasizing the importance of BLS in saving those lives [4,5]. Immediate Cardiopulmonary Resuscitation (CPR) is highly recommended and considered as the most useful preventive measure against cerebral injury after sudden cardiac arrest [6], so the recent guidelines of the European Resuscitation Council (ERC) highlight the critical role of bystander CPR in increasing survival rate of patients with sudden cardiac arrest

[7], which makes BLS knowledge and training essential for the public, not just for the medical personnel who are expected to perform BLS skills perfectly. Unfortunately, the literature shows prevalent poor BLS knowledge among medical students and junior doctors [8–14], which indicates a defect in BLS teaching in the current medical education systems.

In Egypt, Mansoura School of Medicine has two teaching systems: subject-based and problem based, with the subject-based being the main one. It consists of three Pre-clinical years (students are taught academic subjects), 3 clinical years (clinical subjects), and one year of internship. BLS teaching is distributed throughout the clinical years not as a separate subject but as part of other departments’ curricula i.e. Pediatrics, Toxicology and Internal medicine. Students are also introduced to some minor aspects of BLS in their preclinical years.

To the best of the authors’ knowledge, there are scarce data about BLS knowledge of medical students in Egypt. This prompted us to study the BLS knowledge of Egyptian medical students and its associated factors, comparing the knowledge of Clinical students (CS) to their preclinical peers (Preclinical Students: PS).


Al-Werdani et al. (2018)Email: [email protected]

Arch Emerg Med Crit Care 3(2): 1044 (2018) 2/7

METHODSLocation and duration: This study was conducted among

medical students of Mansoura University, Mansoura, Al Dakahlia, Egypt from December 2017 to February 2018.

Study design: a cross sectional study followed by a comparative study.

Sample size and inclusion criteria: According to the department of students’ affairs, the total number of students in Mansoura medical school in 2016 was 6783 students: 3481 in the preclinical years and 3302 in the clinical years. The sample size was calculated using epi info program assuming that the expected frequency of BLS knowledge is 50% the least required sample size was 364 this was multiplied by two to compensate for the design effect of the cluster sampling method. The students were selected through stratified cluster sampling with proportional allocation. Participants had to be Egyptian students studying at the subject-based system.We recruited students from the subject based system due to the following:

1. The other system’s students were inaccessible to us. (main reason)

2. Students from the Problem Based System (PBL) receive quality education, and a threemonth-emergency medicine course.

3. Subject-based system is the main system in the school.

4. Subject-based system students are more likely to continue working in Egypt.

Data collection: ethical approval was obtained from the Institutional Review Board (IRB) of Mansoura faculty of medicine. During class time, data were collected using an anonymous self-administered structured questionnaire in English. An informed written consent was obtained from all students before participation; the collector informed them about aim of study and that all collected data will be confidentially used for the purpose of this research only. The questionnaire was structured after extensive literature review to collect relevant data. It was used previously to assess BLS knowledge among Indian students [9]. We modified the order of questions to start with theoretical then clinical knowledge. The key answers of the questionnaire were modified based on the opinion of public health and emergency experts. (S1,2)

The structured questionnaire consisted of 3 parts:

- Part onehad questions about the following variables: Taking previous BLS training courses, the students’ self-perceived ability to manage emergency situations and their willingness to learn more about BLS as part of the curriculum.

- Part two consisted of 11 questions to assess BLS theoretical knowledge.Thesecovered the following aspects of BLS:

1- The abbreviation of BLS, AED (Automated External Defibrillator) and EMS (Emergency Medical Service).

2- Sequential steps of BLS (Checking for airway,

breathing, circulation) in unresponsive victims and techniques of removing foreign body in choking emergencies.

3- CPR Techniques in different age groups.

- Part three consisted of 9 questions structured to simulate real life emergency situations.

Statistical analysis: after excluding the incomplete response forms, the data were analyzed on 664 responders with a response rate of 85%. The results were analyzed using key answers based on the recent guidelines of the ERC [15].

The data were statistically analyzed using Statistical Package for Social Sciences program (SPSS v24) – IBM company, New York, United States. Each question was scored (0, 1) with 1 for a correct answer and 0 for an incorrect answer. We used a cut off value (mean BLS knowledge +1 SD =8) to divide the students into 2 groups of good and poor BLS knowledge. We decided to use 8 as a cut-off point to facilitate better comparisons across the study participants (since the BLS knowledge scores were abysmally low). There was no gold standard approach available to the authors to study BLS knowledge and determine the optimum cut-off point for the questionnaire.

Multivariate logistic regression analyses were used to identify independent variables associated with good BLS knowledge. Adjust Odds ratio at 95% confidence interval was calculated. Each item of the questionnaire was compared between preclinical and clinical students using Pearson’s chi square test. The total score was then compared across the participant characteristics using the Independent sample t-test. P value less than 0.05 was considered statistically significant.

RESULTS A total of 662 students participated in the study, of

whom383 were PS, and 279 were CS. Only five percent of the students scored more than 50% in the questionnaire. Table (1) describes the percentage of students achieving good knowledge scores in each study group. We encountered some significant gender differences, with a significantly higher percentage of male students achieving good knowledge scores. There was no significant difference between students who have been through emergency situations compared to those who have not.

In addition, a logistic regression was performed to ascertain the effects of Academic year, Sex, BLS training course and Self- perceived ability to manage emergency situation (Table 2). The logistic regression model was statistically significant, χ2 =16.8, p < 0.0005, explaining 21.0% (Nagelkerke R2) of the variance in BLS knowledge, and correctly classified 69.3% of cases. CS were 2.2 times more likely to have good BLS knowledge than PS. Attending BLS training courses, thinking they can manage emergency situations, and being male were independent predictors of good BLS knowledge.

Table (3) shows the 20-item-questionnaire, scanning for significant differences between the answers of PS and CS. Interestingly, PS performed significantly better in questions 3 and 7, which asked about the location of chest compressions in infants and their depth in children over one year while CS




Table 1: Good BLS knowledge and its associated factors % in the Good knowledge column represents the % of students in the Total column with good BLS knowledge while the % in the Total column represents the % of students out of the total number of participants(662).

Variable Total (662) N (%)

Good knowledge (225) N (%) X2 P value

Sex

Male 209 (31.6) 90 (43.1)11.2 0.001

Female 453 (68.4) 135 (29.8)

Attending BLS training course

Yes 246 (37.2) 112 (45.5)23.2 <0.001

No 416 (62.8) 113 (27.2)

Academic year

Preclinical 383 (57.9) 101 (26.4)23.5 <0.001

Clinical 279 (42.1) 124 (44.4)

Exposure to emergency situation

Yes 208 (31.4) 80 (38.5)2.7 0.1

No 454 (68.6) 145 (31.9)

Self-percieved ability to manage emergency situations

Yes 88 (13.3) 46 (52.3)15.1 <0.001

No 574 (86.7) 179 (31.2)

Students wanting to learn more about BLS as a part of their curriculum

Yes 641 (96.8) 215 (33.5)1.7 0.18

No 21 (3.2) 10 (47.6)

Table 2: Multivariate logistic regression of independent predictors of good BLS knowledge.

Predictor β P value AOR (95% CI)

Academic year

Clinical 0.79< 0.001

2.2(1.5 -3.1)

Pre-clinical ---- r

Self-perceived ability to manage emergency situations

Yes 0.70.004

2 (1.2 -3.3)

No ---- r

Sex

Male 0.620.001

1.8(1.3 – 2.6)

Female --- r

BLS training course

Yes 0.540.003

1.7 (1.2 –2.4)

No ---- R

Constant % predicted = 69.3%, Model c2 = 16.8, P = 0.005

Table 3: comparisons between clinical and preclinical students regarding items and total score of BLS knowledge.

Question - no. (%)Preclinical (383) N (%)

Clinical (279) N (%) P value

What Does "BLS" stand for? 243 (63.4) 238 (85.3) <0.001

What is the location for chest compression? 157 (41) 124 (44.4) 0.38

What is the location for chest compression in infant? 102 (26.6) 50 (17.9) 0.009

Depth of compression in adults during CPR. 149 (38.9) 105 (37.6) 0.74

Depth of the compression in children over 1 year during CPR. 48 (12.5) 20 (7.2) 0.03

Depth of compression in infant during CPR. 45 (11.7) 16 (5.7) 0.08




Rate of chest compression in adult and children during CPR. 96 (25.1) 106 (38) <0.001

In adult, compression ventilation ratio of CPR (If single rescuer). 137 (35.8) 134 (48) 0.002

In pediatric, compression ventilation ratio of CPR (If single rescuer). 80 (20.9) 66 (23.7) 0.4

What does "AED" stand for? 51 (13.3) 28 (10) 0.2

What does "EMS" stand for? 172 (44.9) 162 (58.1) 0.001When you find someone unresponsive in the middle of the road, what will be your first response? (Note: You are alone there). 152 (39.7) 166 (59.5) <0.001

If you confirm somebody is not responding to you even after shaking and shouting at him, what will be your immediate action? 206 (53.8) 180 (64.5) 0.006

How do you give rescue breathing in infants? 86 (22.5) 112 (40.1) <0.001If you and your friend are having food in a canteen and suddenly your friend starts expressing symptoms of choking, what will be your first response? 101 (26.4) 101 (36.2) 0.007

You are witnessing an infant who suddenly started choking while he was playing with the toy, you have confirmed that he is unable to cry (or) cough, what will be your first response. 50 (13.1) 71 (25.4) <0.001

You are witnessing an adult unresponsive victim who has been submerged in fresh water and just removed from it. He has spontaneous breathing, but he is unresponsive. What is the first step?

62 (16.2) 58 (20.8) 0.13

You noticed that your colleague has suddenly developed slurring of speech and weakness of right upper limb. Which one of the following can be done? 91 (23.8) 92 (33) 0.009

A 50-year-old gentleman with retrosternal chest discomfort, profuse sweating and vomiting. What is next? 101 (26.4) 73 (26.2) 0.95

If you do not want to give mouth-to-mouth CPR the following can be done EXCEPT? 168 (43.9) 121 (43.4) 0.9

Mean Score ± S.D. 5.9 ± 2.5 7.25 ± 2.5 < 0.001

%: the percentage of correct answers out of the total number of preclinical/clinical students

performed in questions number 11-20 which were designed to simulate real life situations.

DISCUSSIONTo our disappointment, only 5% of the participants scored

more than 50% in the questionnaire. This goes in line with other studies performed on medical students in the literature, which showed slightly better levels of good knowledge of 17%, and 19% in Pakistan and Netherlands respectively [9,12].

Surprisingly, however, males scored significantly better than their female counterparts. Being male was even considered an independent predictor of BLS knowledge according to our regression model. This goes against previous literature that studied BLS knowledge in medical students or even in junior doctors [11,14]. The gender inequality index (GII) in Egypt, Saudi Arabia, and Pakistan during the time of our and the referenced studies were 0.449 (2017), 0.234 (2017), and 0.575 (2010) [16]. This suggests that the male female differences in BLS knowledge attainment are not explained by gender inequality since Saudi Arabia, with its astonishingly low GII of 0.234, had their females achieve better BLS knowledge scores than males. Pakistan had females achieving higher than males as well, despite their high GII of 0.575. Egypt, being the one in between (GII: 0.449), had higher male BLS scores than females. There are a lot of uncontrolled variables coming with this suggestion however, so more research should be done to delineate the effect of gender inequality on BLS knowledge attainment across countries.

Attending BLS courses significantly increased the number of students with good knowledge scores, our regression model showed that it even works as an independent predictor of BLS knowledge. This is consistent with the literature; a previous

study found an association between good first aid knowledge and taking first aid courses, especially formal ones [14]. Another comparative study showed better BLS knowledge scores among formally trained versus untrained medical students [17]. Some studies, however, showed that there is no significant relation between previous training and good BLS knowledge [8,13]. This difference in results might be due to the confounding effect of the time spent after training without rehearsal. Avisar et al. showed that retention of CPR skills goes down significantly when comparing a 1-year-post-training group to a 2-year-post-training one [18]. That goes to show that the continuous rehearsal of BLS skills is quite important.

Stating the obvious, there was a significant difference in BLS knowledge scores between CS and PS. This goes in accordance with CS receiving BLS courses as part of their curriculum as well as having better clinical awareness overall. Similarly, previous studies revealed better BLS knowledge among senior medical students [13,19]. PS showed significantly higher scores on questions 4 and 7, which asked about chest compression location and depth in infants, despite not taking any pediatric rounds whatsoever. This could be attributed to self-interests of students or extra-curricular activities related to pediatrics. Moreover, CS scored significantly better in questions 12-20, which were designed to simulate real life situations. This goes to show that CS have developed realistic clinical awareness compared to their preclinical peers.

Our findings showed no significant association between good BLS knowledge and previous exposure to emergency situations. However, self-perceived ability to manage emergency situations was significant in both the association with good BLS knowledge, and the regression model. One possible explanation of this is




the confounding effect of whether the student was prepared or not when facing emergency situations i.e.: If the student was not prepared with good knowledge and skills, the emergency situation may have traumatized the student, which affected his/her self-confidence. This explanation ties in with the findings of a previous study conducted in France that found a positive association between the number of exposure to cardiac arrest events and self-confidence regarding BLS skills [20].

In this study, 96% of students said they need to know more about BLS, and stated their willingness to learn more about it as part of their curriculum. This falls in line with many studies in the literature, including a study conducted on American students where 64.2% thought that BLS should be included in their curriculum [8,14,21].

As for the limitations of this study, we only assessed the theoretical BLS knowledge using a self-reported questionnaire. We did not assess the practical BLS knowledge. Another general limitation of all self-reporting studies is the dependence on self-perception and lack of objectivity. In this study, such variables include self-perceived ability to manage emergency situations, and the previous exposure to emergency situations.� Additionally, this was a single faculty study, so its findings cannot be generalized to other medical schools all over Egypt.

CONCLUSIONOverall, students showed poor levels of BLS knowledge as

seen in only 5% of them scoring over 50% in the questionnaire. This sheds the light on the need to revisit the currently followed teaching strategies in the subject based system. One strategy would be to add emergency department rounds to the curriculum, supported by continuous practice to achieve non-plummeting BLS knowledge and skill levels [22].

ACKNOWLEDGEMENTSThis study was done as a part of the research division activities

of Mansoura Students’ Scientific Association (MSSA), a member in International Federation of Medical Students’ Association - Egypt (IFMSA-Egypt). MSSA supported the study by helping with data collection and entry (providing manpower, and materials).

We thank Dr. Yasmeen Taalab for the useful discussions, and her expert opinion on the questionnaire items as one of the European Resuscitation Council directors in Egypt.

We also thank the following MSSA members for their effort in data collection and their support:

HasnaaKeshk, Mohamed A. Basal, Ahmed Magdy, Mai Sherif,MohamedElbaz, MarwaRaafat, Ahmed El-Shaer, Sarah Misbah, Mustafa Naser, Amany Abdel Naeem, M. Magdi, Esraa Saleh, Amira Ahmed Mowannes, Khaled Mohamed Alaasr, Omnia Ahmed Elmahdy, SamaAmgadEleraki, Mahmoud SamyAgeez, Abdelhamid, EsraaEmadMaghrabia, Shehab Ashraf, AbdelRahmanAmgadEleraki, Louay Nasr, Marwan Elsheikh, Noaman Mohamed NoamanHigazy, Nada MoustafaBedair, Mohamed Ahmed Sharaf El-Din, Mai Ali Mohammed.

REFERENCES1. 2005 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care. Part 1: Introduction. Circulation. 2005; 112(22 SUPPL.).

2. Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. Jama. 2013; 310: 1377-1384.

3. Pollack R, Brown S, Rea T, Aufderheide T, Barbic D,Buick JE, et al.Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests. Circulation. 2018; 137: 2104-2113.

4. World Health Organization. WORLD HEALTH STATISTICS - MONITORING HEALTH FOR THE SDGs. World Heal Organ 2016:1.121.

5. Summary tables of mortality estimates by cause, age and sex, globally and by region, 2000–2016. WHO.

6. Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2017; 376: 1737–1747.

7. Perkins GD, Soar J, Monsieurs KG, Nolan J. Guidelines 2017 update : response to, In mountain and rural areas all CPR providers should perform chest compressions and rescue breaths for patients in cardiac arrest: Pharmacotherapy during cardiac arrest-When evidence-based data failed to be implemente. Resuscitation 2018; 0.

8. Joseph N, Kumar GS, Babu YPR, Nelliyanil M, Bhaskaran U. Knowledge of First Aid Skills Among Students of a Medical College in Mangalore City of South India. Ann Med Health Sci Res. 2014; 4: 162–166.

9. Chandrasekaran S, Kumar S, Bhat S, Saravanakumar, Shabbir M, Chandrasekaran V. Awareness of basic life support among medical, dental, nursing students and doctors. Indian J Anaesth. 2010; 54: 121.

10. Reddy S, Doshi D, Reddy P, Kulkarni S, Reddy S. Awareness of Basic Life Support Among Staff and Students in a Dental School. J Contemp Dent Pract J Contemp Dent Pr 2013;1414:511–517.

11. Al-Shamiri HM, Al-Maweri SA, Shugaa-Addin B, Alaizari NA, Hunaish A. Awareness of basic life support among Saudi dental students and interns. Eur J Dent 2017;11: 521–525.

12. Tan ECTH, Severien I, Metz JCM, Berden HJJM, Biert J. First aid and basic life support of junior doctors: A prospective study in Nijmegen, the Netherlands. Med Teach 2006;28:189–192.

13. Mejia CR, Quezada-Osoria C, Moras-Ventocilla C, Quinto-Porras K, Ascencios-Oyarce C. Nivel de conocimientos sobre emergencias m??dicas en estudiantes de medicina de universidades peruanas. Rev Peru Med Exp Salud Publica 2011;28:202–209.

14. Khan A, Shaikh S, Shuaib F, Sattar A, Samani SA, Shabbir Q, et al. Knowledge attitude and practices of undergraduate students regarding first aid measures. J Pak Med Assoc 2010;60:68–72.

15. Perkins GD, Handley AJ, Koster RW, Castrén M, Smyth MA, Olasveengen T,et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015 Oct 1;95:81-99.

16. Human Development Reports (1990-2017) by the United Nations Development Programme.

17. Abbas A, Bukhari SI, Ahmad F. Knowledge of first aid and basic life support amongst medical students: a comparison between trained and un-trained students. J Pak Med Assoc 2011;61:613–616.

18. Avisar L, Shiyovich A, Aharonson-Daniel L, Nesher L. Cardiopulmonary resuscitation skills retention and self-confidence of preclinical medical students. Isr Med Assoc J 2013;15:622–627.

19. Weller J, Robinson B, Larsen P, Caldwell C. Simulation-based training

https://www.ncbi.nlm.nih.gov/pubmed/24084923




















https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727740/






to improve acute care skills in medical undergraduates. N Z Med J 2004;117:U1119.

20. Freund Y, Duchateau F-X, Baker EC, Goulet H, Carreira S, Schmidt M, et al. Self-perception of knowledge and confidence in performing basic life support among medical students. Eur J Emerg Med 2013;20:193–196.

21. Pillow MT, Stader D, Nguyen M, Cao D, McArthur R, Hoxhaj S. Perceptions of basic, advanced, and pediatric life support training in a united states medical school. J Emerg Med 2014;46:695–700.

22. Jurgens CY, Goodlin S, Dolansky M, Ahmed A, Fonarow GC, Boxer R, et al. Heart Failure Management in Skilled Nursing Facilities: A Scientific Statement from the American Heart Association and the Heart Failure Society of America. vol. 8. 2015.











Al-Werdani MM, Mokhtar AM, Ebead AK, El-Sherbeny E, El-Gilany AH (2018) Basic Life Support Knowledge of Medical Students: A Single Faculty Study in Egypt. Arch Emerg Med Crit Care 3(2): 1044.

Cite this article

Documents

Basic Life Support Knowledge of Medical Students: A Single ... · Central cellenc ccess Al-Werdani et al. (2018) Email: [email protected] Arch Emerg Med Crit Care 3(2): 1044