Authors: Aggou M. RN, MSc, Fyntanidou B. MD, PhD, Grosomanidis V. MD, PhD, BesiCh. MD, Chandros A. MSc,Valkanidou D. MD, Fortounis K. MD, Bamidis P. PhD
The aim of this study was to evaluate resuscitation skills and knowledge of the nursing staff of University Hospital “AHEPA”, who have previously successfully participated in a validated training CPR/AED course, held in ourhospital.In our study 60 professionally active nurses were involved. After completion of a predesigned questionnaire, they were expected to respond to a simulated cardiac arrest-CA scenario in an area where automated external defibrillation-AED was available. The questionnaire consisted of several questions regarding demographic data, participant’s personal opinion on the resuscitation training program, CPR performance and nurse’s attitudes when facing a CA. Participants were evaluated according to the European Resuscitation Council assessment form for basic life support-BLS with the use of AED (consisting of performance in 17 skills).The vast majority of the study population were female nurses (86.7% and 83.3% respectively), 41-50 years old (70%) with more than 21years working experience (53.3%). All of them have participated in a validated CPR/AED course held in our hospital and 58.3% more than once. All of them stated that they would be willing to initiate CPR efforts, although half of them (56.7%) have never actually performed CPR. 58.3% of the study participants think that they still retain resuscitation skills and knowledge and all of them believe that the resuscitation training program was effective. CPR performance and AED use in the simulated scenarios were evaluated as adequate in 55-85% and 65-98% respectively. In general, the overall success rate in skills related to AED use, were better compared to CPR skills.
CPR/AED skills are not performed very often in daily clinical practice and therefore these resuscitation skills degrade to a significant extend after training. According to our study results, AED skills retention seems to be better compared to CPR skills retention.
Cardiac arrest (CA) is the leading cause of sudden cardiac death. It is responsible for 60% of deaths associated with ischemic heart disease and in 40% of the cases; CA is the first symptom1-8. CA is the cessation of the pumping function of the heart, which is confirmed by lack of response and absence of carotid pulse and normal breathing9-12.
Cardiopulmonary Resuscitation (CPR) is the only treatment option in CA and involves chest compressions, airway opening maneuvers and artificial ventilation13,14. Basic Life Support has been replaced by the term CPR with the use of Automated External Defibrillation (CPR/AED), which refers to CA recognition/confirmation and performance of CPR without any kind of equipment besides AED15.
CA outcome depends mainly on immediate recognition of CA, immediate initiation of chest compressions, early defibrillation and post resuscitation care11,16,17. Despite the great medical advances since CPR was formally endorsed in the 1960s, CA outcome remains low (5-10%), because most of the CAs occur outside of the hospital setting.
Bystanders CPR, before arrival of expert help, contributes to better survival rates especially in cases of CA with a shockable rhythm (ventricular fibrillation and pulseless ventricular tachycardia)10. In those cases, rate of successful defibrillation increases, if CA victims receive bystander CPR18,19.Nowadays, bystanders CPR rates are low, even in modern societies and communities with well organized prehospital care systems20.
In-hospital CA is not a sudden event but in most cases the result of a slow and progressive deterioration, which was either not recognized or not treated on time13. In-hospital CA rates vary widely across hospitals (1-5 CAs per 1000 admissions) and the outcome depends on parameters related to patient’s medical history and reasons for hospital admission21,22. It has been documented by several literature studies that health care providers (physicians and nurses) are not capable to perform CPR successfully in cases of in-hospital CAs23-26.
Scientific societies, working in the field of resuscitation (European Resuscitation Council in Europe), are aiming to establish a universal treatment algorithm for CA and a uniform education and training system to teach CPR13,20. The International Liaison Committee on Resuscitation (ILCOR) is playing a fundamental role in the process leading to the publication of evidence based CPR guidelines.
According to the Greek law, training in CPR is mandatory for all health care providers (RF: 15576-219/22-2-2007).
The goal of education in CPR is to provide to the participants-especially health care providers-the appropriate knowledge and skills, so that they are adequately prepared to manage collapsed patients until advanced medical help arrives13.
Resuscitation skills degrade to a significant degree after some months of training. Contributing factors to this are related to the participants, the instructors and training program27-31.
It is of high importance to take into consideration, that CPR/AED skills might never be performed in daily clinical praxis and therefore frequent refresher and recertification courses could be very useful.
Moreover, the purpose of education is to result in a permanent behavior modification of health care providers, as far as CA management is concerned. Effectiveness of training courses is determined by many parameters, such as the total number of health care providers that participate in such courses, acquisition and retention of skills and mainly by improved outcomes after CA.
The aim of this study was to evaluate resuscitation skills and knowledge of the nursing staff of University Hospital “AHEPA” who participated in the validated training CPR/AED courses, held in our hospital.
Material and Methods
Sixty professionally active nurses-regardless of age, gender, level of education, previous work experience and hierarchical level-who had previously successfully completed a validated CPR/AED course were enrolled in this study. Participation in the study was voluntary. Reasons for recruiting nursing staff in this study included:
- to produce a homogenous sample
- nurses are the first responders to collapsed patients
- basic life support (BLS) is designed especially for first responders
Nursing staff is expected to recognize CA, to initiate CPR, to call for help, to activate the advanced life support (ALS) team or any other rapid response or medical emergency team (depending on the local protocol), to defibrillate (when indicated) with the use of AED and to continue resuscitation efforts until expert help arrives. Furthermore, nurses are responsible to check the emergency cart daily, to go through the check list and to maintain proper supplies of medical drugs and equipment32,33.
Resuscitation knowledge and skills of the participants were evaluated by:
- a questionnaire specifically designed for this study (Table 1)
- an assessment form for BLS/CPR and BLS with the use of AED, recommended by the European Resuscitation Council (ERC) (Table 2).
|1. Gender||10. Do you think that you still retain CPR knowledge and skills|
|· Female||· Yes|
|· Male||· No|
|2. Age (years)||· To some extent|
|· 20- 30||11. Have you ever performed CPR during your nursing shift|
|· 31 – 40||· Yes|
|· 41-50||· No|
|· >50||12. Which are the steps you have to follow in case of a CA in your working area|
|3. Previous Working experience (years)||· Call for help – Initiate CPR – Bring AED|
|· 0-5||· Initiate CPR- Call for help- Bring AED|
|· 6-10||· Cal for help and wait until help arrives|
|· >20||13. Who are you calling for help in case of a CA|
|4. Level of education||· Doctor on duty in my department|
|· University||· Anesthesiologist on duty|
|· Technological Education Institute||· Both of them|
|· Vocational Training Institute||· I do not know|
|5. Professional position||14. Which is your hospital emergency number|
|· Chief nursing officer||· Number|
|· Nurse Manager||· I do not remember|
|· Nurse Assistant Manager||· I do not know|
|· Nurse||· Wrong number|
|6. Department||15. Is there a defibrillator in your working area|
|· Internal medicine||· Manual|
|· Cardiology||· AED|
|· Intensive Care Unit||· Both|
|· Emergency Department||· There is not|
|· Outpatient Department||· I do not know|
|· Operation theatre||16. Is there an emergency cart in your working area|
|· Anesthesiology Department||· Yes|
|· Other||· No|
|7. How many times did you participate in a validated training CPR/AED course||· I do not known|
|· Once||17. Would you perform CPR if it was indicated|
|· Twice||· Yes|
|· More than twice||· No|
|· Never||· I do not known|
|8. The course was organized by||18. Do you think the current CPR training program is effective|
|· University Hospital AHEPA||· Yes|
|· National Centre of Emergency Care||· No|
|· Nursing School||· I do not know|
|· Other||19. Would you like to participate again in such a validated CPR training course|
|9. When did you participate in the course||· Yes|
|· 6 months ago||· No|
|· 6 months-1 year ago||20. How often do you think one should repeat the CPR training course|
|· 1 – 2 years ago||· Every year|
|· 2 – 3 years ago||· Every two years|
|· >3 years ago||· Other|
Table 2:CPR and AED evaluation form and participants success rates.
|Ensure safety of rescuer, victim and bystanders||Demonstrates looking for potential dangers
|Check response||Demonstrates gently shaking and shouting to establish responsiveness|
|Call for help||Demonstrates calling for help
|Open airway||Demonstrates head tilt and chin lift
|Assess breathing||Demonstrates looking, listening and feeling for normal breathing for no more than 10 sec whilst maintaining head tilt / chin lift|
|Get help||Describes how to phone for emergency services
|Chest compressions||Demonstrates effective chest compressions (Rate 100-120, depth 5-6cm, Hand position – centre of the chest. Minimises interruption in chest compressions|
|Rescue breaths||Demonstrates rescue breaths sufficient to cause the chest to rise and fall|
|Compression: ventilation ratio||Demonstrates ratio of 30 compressions to 2 ventilations
|Assess victim||Demonstrates safe and effective initial assessment of collapsed victim according to CPR guidelines|
|Demonstrates switching AED on|
|Demonstrates attaching pads in acceptable position|
|Stand clear||Allows rhythm analysis whilst making sure that nobody touches the victim (including visual sweep and verbal instruction)|
|Deliver shock||Demonstrates rapid and safe delivery of a shock (including visual sweep and verbal instruction to stand clear)|
|Follow AED instructions
|Demonstrates listening to and executing AED instructions|
|CPR||Minimises interruption to chest compressions|
Participation in the study was optional and the questionnaire was anonymous. In order to protect anonymity, no consent was obtained by the participants of the study. However, completion of the questionnaire was considered as consenting to be enrolled in the study.
The questionnaire consisted of 20 questions: 10 on demographic data, 5 about attitude during CA and the last 5 about participants’ opinion on the resuscitation training they received.
Initially, participants filled out the questionnaire and thereafter they were expected to respond to a simulated CA scenario of a collapsed patient in an area, where AED was available.
Data were recorded in predesigned forms and thereafter they were transferred in pre-formatted EXCEL worksheets. SPSS 21 was used for the statistical analysis (IBM SPSS statistics 21).
Data recorded, were presented in frequency and percentage tables, as suggested by SPSS for quality parameters. Chi square test was used to evaluate correlation between independent (questions 1 to 9) and dependent (questions 10 to 20) variables and moreover CPR/AED skills. Statisticalsignificancewassetata p value less than 0.05.
According to the study protocol all of the participants were professionally active nurses. The vast majority of the study population were women (83.3%), 41-50 years old (70%) with more than 21years working experience (53.3%) and they had graduated from a Technological Educational Institute (58,3%). Demographic data are presented in detail in table 3.
|DEMOGRAPHIC DATA||Frequency||Percentage (%)|
|· 20- 30||1||1,7|
|· 31 – 40||15||25|
|3. Previous Working experience (years)|
|4. Level of education|
|· Technological Education Institute||35||58,3|
|· Vocational Training Institute||23||38,3|
|5. Professional position|
|· Chief nursing officer||0||0|
|· Nurse Manager||3||5|
|· Nurse Assistant Manager||5||8,2|
|· Internal medicine||6||10|
|· Intensive Care Unit||8||13,3|
|· Emergency Department||7||11,7|
|· Outpatient Department||12||20|
|· Operation theatre||9||15|
|· Anesthesiology Department||2||3,3|
Study participants have previously successfully completed a validated CPR/AED ERC course held in AHEPA University hospital as part of their educational program in resuscitation. More than half of them have participated more than once in such a course (43.3% twice and 15% more than twice). Time elapsed since completion of the CPR/AED course was more than 3 years for 48.3%, 2-3 years for 15% and 1-2 years for 23% of the study participants. The rest of the frequency and percentage values related to resuscitation training are presented in table 4.
In case of an in-hospital CA, almost all of the participants responded that they would call immediately for help and then they would initiate CPR. Generally, they tend to call both the doctor on duty in their department and the anesthesiologist on duty. 30% of the participants did not remember the hospital emergency number or they remembered the wrong phone number.
58,3% of the study participants think that they still retain resuscitation skills and knowledge. All of them stated that they would be willing to initiate CPR efforts, although only 43% of the nurses have actually performed CPR during their nursing shift.
CPR performance and AED use in the simulated scenarios were evaluated as adequate in more than 50% and more than 60% respectively (table 4).
Table 4:Frequency and percentage values related to resuscitation training of the study
|How many times did you participate in a validated training CPR/AED course||Frequency||Percentage (%)|
|· More than twice||9||15|
|The course was organized by|
|· University Hospital AHEPA||58||96,7|
|· National Centre of Emergency Care||1||1,7|
|· Nursing School||0||0|
|When did you participate in the course|
|· 6 months ago||6||10|
|· 6 months-1 year ago||2||3,3|
|· 1 – 2 years ago||14||23,3|
|· 2 – 3 years ago||9||15|
|· >3 years ago||29||48,3|
|Do you think that you still retain CPR knowledge and skills|
|· To some extent||25||41,7|
|Have you ever performed CPR during your nursing shift|
|Which are the steps you have to follow in case of a CA in your working area|
|· Call for help – Initiate CPR – Bring AED||42||70|
|· Initiate CPR- Call for help- Bring AED||17||28,3|
|· Cal for help and wait until help arrives||1||1,7|
|Who are you calling for help in case of a CA|
|· Doctor on duty in my department||6||10|
|· Anesthesiologist on duty||22||36,7|
|· Both of them||32||53,3|
|· I do not know||0||0|
|Which is your hospital emergency number|
|· I do not remember||8||13,3|
|· I do not know||1||1,7|
|· Wrong number||9||15|
|Is there a defibrillator in your working area|
|· There is not||2||3,3|
|· I do not know||0||0|
|Is there an emergency cart in your working area|
|· I do not known||0||0|
|Would you perform CPR if it was indicated|
|· I do not known||1||1,7|
|Do you think the current CPR training program is effective|
|· I do not know||1,7||1,7|
|Would you like to participate again in such a validated CPR training course|
|How often do you think one should repeat the CPR training course|
|· Every year||26||43,3|
|· Every two years||30||50|
25% (15 out of 60) of the participants performed successfully all 10 skills related to CPR, whereas 6.6% (4 out of 60) did not achieve any skill. As far as the use of AED is concerned the corresponding percentages were 41.7% (25 out of 60) and 1.7% (1 out of 60) and in total (both CPR performance and AED use) 18.3% and 1.7% respectively (table 5).
Table 5:CPR and AED skills success rates of participants.
Furthermore, much more nurses compared to nurse managers and assistant managers, consider that their resuscitation training program is effective and women want to be recertified in a higher rate than men.Data correlation revealed that nurses with a working experience of 6-10years and those working in the ED or in the ICU have performed CPR during their working shift far more often compared to the rest of the nursing staff.
Managers and assistant managers were more successful than nurses in performance of “Check response”, “Breathing efforts” and “AED activation” skills.
“Stand clear” skill was performed more frequently by participants over 50 years of age and shock was delivered more often by nurses working in the ICU or in the ED.
Training in resuscitation is one of the most important factors influencing outcome after CA1,20,34. Since the 1960s, when modern CPR was formally endorsed35,36, training in resuscitation for health care professionals and public has gained increasing attention1,20 . Therefore, the International Committee on Resuscitation (ILCOR) has already published recommendations related to education and training in CPR14,28. Moreover, one of the ERC working groups are responsible for establishing guidelines for education and one chapter in the latest ERC CPR guidelines is about principles of education in resuscitation.13
Today, it is well known and documented, that CPR performed by bystanders can improve outcome after CA39-41. In addition to this, in-hospital CA is not usually a sudden unpredictable event but the result of a slow and progressive deterioration13,43. Therefore, early recognition of the deteriorating patient and prevention of CA are key elements in the chain of survival13,37,44.
After completion of a questionnaire, specifically designed for this study, participants were expected to respond to a simulated CA scenario of a collapsed patient in an area, where AED was available. Manikins and AED devices were similar to the ones used in the validated CPR/AED courses.
Demographic data analysis revealed that the vast majority of the study population was women (83.3%), which was an expected result, since most of the nurses working in the University Hospital “AHEPA” are women.
Almost all of the participants were between 30-50years old (31-40years 25% and 41-50years 70%). This result is attributed to several premature retirements (due to the new pension measures) and to “hiring freeze” (due to the financial crisis and the memorandum). This also explains the fact that most of the nurses (53.3%) have been working for more than 20years.
Most of the participants have graduated from a Technological Educational Institute (58.5%), whereas 38.3% have graduated from a Vocational Training Institute and very few have graduated from University. These percentages reflect the academic degrees of the professionally active nurses working in the University Hospital “AHEPA”.
According to the available data, nurses were the vast majority of the participants included in our study (86.5%) as opposed to nurse managers and assistant managers. Nurse predominance reflects clinical reality since standard nursing staff consists of many nurses and only a few managers and assistant managers.
The smashing majority of the nursing staff included in our study (96.7%) has participated in validated BLS/AED courses held in our hospital and most of them more than once. Contributing factors to broad acceptance of our hospital’s training program are its longevity in conjunction with the fact that education is offered with no participation fee (as opposed to what is common practice in our city) during working hours (both for the participants and the instructors). Time elapsed since completion of the CPR/AED course was more than 1year for the vast majority of the participants and more than 3years for half of them45. According to ERC Course Rules, certified BLS/AED providers are responsible to recertify within 6 months before expiration of their certificate by completing successfully either a full BLS/AED provider course or the corresponding recertification course46,47.
Nursing staff knows beyond any doubt that in case of a CA they should call immediately for help and initiate CPR. A manual or automated defibrillator is available in every department of our hospital; in some cases even both are available.
53.3% of the nursing staff calls both the physician on duty in their department and the anesthesiologist on duty, whereas only 10% calls just the physician on duty. This reflects the common belief that may actually be a fact that doctors of other specialties are not competent in performing resuscitation. Lack of specific medical emergency teams may cause confusion about whom to call in case of CA. The fact that a significant percentage of the nursing staff did not remember the emergency phone number or remembered the wrong phone number underlines the necessity of a better organization of emergency call centers and communications.
Despite the fact that more than half of the study participants (56.7%) have never performed CPR during their nursing shift, almost all of them (96.7%) stated that they would be willing to initiate CPR in the future, if this would be indicated48. A significant percentage of the nursing staff (58.3%) thinks that they still retain resuscitation skills and knowledge, although many of them have never performed those skills. This data indicates that there is a high possibility that CPR/AED skills will be never performed even by health care providers.
Almost all of the nurses (98.3%) think that resuscitation training via validated ERC courses is very effective and they would like to re-participate in such a course. Half of them believe that resuscitation training should be repeated every year and the other half every 2 years46,47,49.
CPR performance in the simulated scenarios was evaluated as adequate in more than 50%. The highest achievement score was recorded for “check response” skill (85%) and the lowest for “open the airway” skill (48.3%). This difference in achievement scores reflects clinical reality since skills such as “check response” and “call for help” are performed in many other clinical settings besides CA, whereas skills like “open airway” and “assess breathing” are considered to be an anesthesiologist’s responsibility.
As far as the use of AED is concerned, the overall success rates were in general better, and almost 100% of the participants have activated the AED successfully. These findings are in accordance with other studies, where is has been shown that skills related to the use of AED can be retained for a longer period of time. It seems that the easy usage of the AED device in conjunction with the understanding of its significance contribute to the longer retention of the specific skills.
Data analysis revealed that only a small percentage of the participants failed to perform any skill and almost 1/3 of the participants performed successfully less than half of the skills (CPR or AED skills in total).
These findings confirm other literature study results concerning loss of skills over time and indicate the necessity of re-training courses for skills and knowledge retention.
As expected, nurses working in the ED or in the ICU, where CAs actually happen more often, have performed CPR more frequently and were more successful in shock delivery compared to the rest of the nursing staff working in other departments.
Observance of safety rules related to AED use was better among nurses over 51years of age and worse in nurses between 20-30years old. This result reflects the enthusiasm of the younger people and the experience of the elder.
A possible limitation of the study is the relatively small number of study participants compared to the total number of BLS/AED providers and the total number of people working in the University Hospital “AHEPA”, which does not allow generalization of the study results. Moreover, due to the small number of managers and assistant managers included in our study, we cannot draw any safe conclusions from the correlation analysis of the study parameters with the professional position of the nurses.
The findings of this study suggest that resuscitation skills degrade after training to a significant extend. There was no correlation between skill loss and parameters such as age, number or previous BLS/AED courses or time elapsed since training. Overall, participants showed a better retention of AED skills compared to CPR skills. Also, frequent refresher and recertification courses could be useful and promoting simulation training in resuscitation (simulated CA scenarios), could attribute to substantial modification of nurses behavior in case of a real CA.
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Author Disclosures: Authors Aggou M, Fyntanidou B, Grosomanidis V, BesiX, Chandros A, Valkanidou D, Fortounis K, Bamidis P. have no conflicts of interest or financial ties to disclose.
Vasilis Grosomanidis MD, PhD
Assistant Professor Aristotle University of Thessaloniki
Anaesthesia and ICU clinic AHEPA University Hospital
Amisou 12 Thessaloniki
Tel :2310994865, 6974430690
E mail :