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In 1992, a survey undertaken by Buss et al showed a poor level of resuscitation knowledge among all grades of paediatricians.1 Since this study was published, standardised resuscitation teaching has become commonplace in the UK, with the introduction, in 1992, of advanced paediatric life support (APLS) and pediatric advanced life support (PALS) courses. These courses are recommended for all paediatricians in training as well as doctors in other specialties who look after children.2 3We repeated the original survey to determine whether trainee paediatricians in 1999 have a better level of resuscitation knowledge compared to their 1992 counterparts.
Our survey closely simulated the 1992 study in terms of design of study, numbers of doctors targeted, and geographical region. We undertook a telephone survey of the most senior resident paediatrician on two separate days in 47 hospitals accepting acute paediatric emergencies across four separate regions: Wales, the South West, Wessex, and the West Midlands. The 94 individuals ranged from senior house officer to senior registrar grade. Each respondent was asked their grade, certification of APLS or PALS course, and eight clinical questions (table 1). The interviewers, DC (specialist registrar in paediatric anaesthesia) and JF (specialist registrar in paediatric intensive care) were both experienced in the resuscitation of critically ill children, and each was allocated two different regions. Acceptable answers were based upon APLS, PALS, advanced trauma life support (ATLS), and European Resuscitation Council (ERC) guidelines4-7 (see table 1). We assigned a score of one mark for each correct answer, giving a possible maximum score of eight. All parts of question 1 needed to be correct to qualify for a mark.
Fisher's exact test was used to compare the percentage of correctly answered individual questions between 1992 and 1999. Individual paediatricians' results and seniority status were not available from 1992 for comparison. Multiple regression was used to investigate the 1999 score totals while adjusting for the registrar status of the respondents. A p value of less than 0.05 was considered significant and all differences are presented with 95% confidence intervals (CI).
A total of 91/94 (97%) paediatricians contacted in 1999 participated in the study. There were more correct answers to all questions in 1999 compared to 1992 (table 2).
Question 1. Paediatricians continue to estimate the tracheal tube size more accurately in the younger child compared to the older
Question 2. Although there was a significant improvement in the knowledge of the correct adrenaline dose, 19% of paediatricians in 1999 still suggested an incorrect dose
Question 3. There was a greater understanding of the importance of prolonged resuscitation in hypothermia
Question 4. There was a better understanding of volume replacement for severe haemorrhage in 1999, with many paediatricians mentioning the importance of patient reassessment
Question 5. Very few doctors in both 1992 and 1999 could quote a formula for fluid replacement in burns
Question 6. The use of the intraosseous site for gaining vascular access has increased greatly since 1992, with all 1999 respondents suggesting its use
Question 7. The appropriate use of radiological imaging for major trauma was better understood by 1999 respondents
Question 8. The indication for cricothyroidotomy in patients with severe upper airway obstruction was better understood in 1999 than in 1992.
Comparison between 1992 and the subgroup of the 1999 sample who had not attended a course provided a measure of non-course related changes over time. The non-course attendees in 1999 answered all questions correctly more frequently than the 1992 group. For questions 3, 6, and 7 this difference was significant.
Among the 1999 respondents, all questions except 3 and 6 were answered correctly more frequently by those doctors who had completed a course. The difference was significant for questions 1a, 2, and 8. Those who had attended a course in 1999 had a higher total score compared to those who had not attended (5.43 v 4.55; 95% CI 0.12, 1.66; p = 0.023). A higher proportion of the doctors questioned in 1999 were registrars (63/91; 69%) compared to the 1992 cohort (37/73; 51%). The registrars tended to get higher scores and were also more likely to have been on a course. If registrar status was accounted for, course attendance was no longer significant (difference 0.74; 95% CI −0.02, 1.5; p = 0.0566).
There is much debate as to whether resuscitation courses result in practical improvement in knowledge. In a review of 17 studies of life support courses, 5/8 studies failed to show any significant gain in knowledge, and 8/9 studies failed to show any significant net gain in scores of skills performance between pre and post-course follow up testing.8 Retention of knowledge and skills declines from as early as three months.
Our study shows that, since 1992, paediatric resuscitation knowledge has significantly improved. Comparing the 1992 data with the subgroup of 1999 who had not attended a course shows an overall improvement regardless of APLS/PALS course attendance. The 1999 data show a higher total score among those attending a course, and that paediatricians who had completed a resuscitation course answered some questions (1a, 2, and 8) significantly better. This improvement was less pronounced when registrar status was taken into account and it may be that self selection occurs, whereby the more motivated and experienced paediatrician attends an APLS/PALS course, and these individuals may have better resuscitation knowledge anyway.
We do not know if this improved knowledge results in improved outcome. However, Roberts and colleagues9 have shown a substantial decline in hospital deaths for children admitted with severe injury between 1989 and 1995 and suggested that this may be a result of better initial assessment and resuscitation in hospital.
From this study, we cannot prove conclusively that the introduction of paediatric resuscitation courses in the UK has been responsible for the improvement in knowledge. There is also no guarantee that knowledge of resuscitation guidelines translates into improved patient outcomes, although there has been a coincident reduction in the in-hospital mortality following trauma during the study period.
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