MEDICAL EDUCATION/CME |
https://doi.org/10.5005/jp-journals-10089-0025 |
Feasibility of Hybrid Training for Basic and Advanced Cardiac Life Support during COVID-19 Pandemic
1Department of Anesthesiology and Intensive Care, Narayana Institute of Cardiac Sciences, Narayana Health, Bengaluru, Karnataka, India
2Critical Care Services, Mazumdar Shaw Medical Centre, Narayana Health, Bengaluru, Karnataka, India
3Emergency Medicine, Mazumdar Shaw Medical Centre, Narayana Health, Bengaluru, Karnataka, India
4,5Critical Care Medicine, Mazumdar Shaw Medical Centre, Narayana Health, Bengaluru, Karnataka, India
6Critical Care Medicine, Narayana Institute of Cardiac Sciences, Narayana Health, Bengaluru, Karnataka, India
7Yashoda Hospitals, Hyderabad, Telangana, India
8Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
9Society of Emergency Medicine for India, Dr. Mehta’s Hospitals, Chetpet Unit, Chennai, Tamil Nadu, India
10Association of Healthcare Providers of India, Bengaluru, Karnataka, India
Corresponding Author: Muralidhar Kanchi, Department of Anesthesiology and Intensive Care, Narayana Institute of Cardiac Sciences, Narayana Health, Bengaluru, Karnataka, India, Phone: +91 9980163108, e-mail: kanchirulestheworld@gmail.com
Received on: 17 August 2022; Accepted on: 22 September 2022; Published on: 31 December 2022
ABSTRACT
Background: The coronavirus disease of 2019 (COVID-19) pandemic in the years 2020 and 2021 disrupted the professional life of healthcare providers in the most unprecedented manner. Notwithstanding this, COVID-19 substantially diminished the platform for the dissemination of knowledge and skills due to restrictions and limited training opportunities. The need for recruitment of healthcare providers to meet the growing demands owing to the pandemic has caused a huge gap in demand and delivery of quality care, especially in basic and advanced cardiac life support skills (BLS/ACLS). In the wake of the pandemic, education, training, seminars, and even medical conferences have found a novel approach to sharing knowledge by utilizing e-learning modules. Technological advancement and studies have proved that e-learning is non-inferior to face-to-face education. However, it would be illogical to conduct certain types of training, such as cardiac life support, fully through online modules since this sort of training demands a considerable amount of time in hands-on sessions. We aimed to investigate the feasibility and effectiveness of training and imparting skills in BLS/ACLS using a combination of online and offline “hybrid technique” education and thereby minimizing exposure to a potentially infectious environment.
Materials and methods: The schedule of the hybrid National Cardiac Life Support (NCLS) was structured as a 2-day training program, the 1st day as an “online” virtual learning module and the 2nd day as “on-site” for hands-on training. All the didactic sessions of NCLS were dealt with online on day 1 using PowerPoint presentations through the Teams Microsoft platform, teaching materials, and ingeniously framed training videos as per standard guidelines. This day 1 session lasted for a total of 5 hours, which was interactive with the active participation of the participants. Day 2 consisted of on-site “hands-on” training with manikins with the best possible COVID-19 precautions. Instructors monitored one-one skill impartment with correct techniques of high-quality cardiopulmonary resuscitation (CPR). The duration of training on day 2 was 7 hours, followed by an assessment. The assessment consisted of two sessions, namely, theory and skill assessments for BLS and ACLS. During the assessment, all the necessary COVID-19 precautions were taken into consideration. To complete the NCLS program successfully, candidates must score a minimum of 80% in the assessment, failing which, the candidates are subjected to remediation or reappearing for the test. Upon successful completion of the training, the candidates are certified in NCLS with a validity of 2 years.
Results: A total of 11 hybrid NCLS training programs were conducted over a period of 18 months with a total of 276 trainees. The overall rating of the hybrid NCLS based on the analysis of feedback, was good/outstanding by 97% of attendees, which was similar to the feedback obtained from the traditional pre-COVID-19 standard NCLS program. To perform meaningful statistical analysis, 11 standard NCLS programs were chosen in a random manner (computer generated), and these programs were compared to 11 hybrid NCLS programs. The pre-COVID-19 standard NCLS classroom training trained 3,078 healthcare providers through 127 courses from its inception (October 2016) till the onset of the COVID-19 pandemic, whereas 276 candidates were trained through 11 hybrid NCLS programs.
Conclusion: A standard and structured cardiac arrest resuscitation training program which is tailor-made to the Indian scenario by incorporating evidence obtained from universal/local research shall undoubtedly uplift the quality of resuscitation during the pandemic. Most importantly, training with precautions against infection is a paramount consideration during a pandemic. If online learning technology can play a role here, it is incumbent upon all of us to explore its full potential.
How to cite this article: Kanchi M, kumar CCV, Wilben V, et al. Feasibility of Hybrid Training for Basic and Advanced Cardiac Life Support during COVID-19 Pandemic. J Acute Care 2022;1(2):104-109.
Source of support: Nil
Conflict of interest: Dr Muralidhar Kanchi, Dr Vimal Bharadwaj, Dr Ratan Guptha and Srinath TS are editorial board members, and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his/her research group.
Keywords: Cardiac life support, Cardiopulmonary resuscitation, Hybrid training, Lifesaving skills, Online training, Resuscitation, Training during pandemic.
INTRODUCTION
The COVID-19 pandemic has undoubtedly disrupted the well-established, traditional structure of medical education in the year 2020. As of the beginning of 2021, the COVID-19 pandemic continued to persist. Several countries have responded with proactive measures to counter the second wave of the pandemic by imposing curfews or complete lockdown measures to limit viral transmission. One of the fields that the pandemic has substantially affected is the education/imparting skills of medical professionals.
It is highly desirable that all the health care providers across the country are trained in the recognition of cardiac arrest and its initial management. It is a proven fact that immediate recognition of cardiac arrest and prompt institution of CPR leads to improved outcomes for the patient.1 Studies suggest that if a cardiac arrest is not intervened with early CPR and/or defibrillation, for every single minute delay, the rate of survival decreases by 7%.2 Unlike the West, the majority of the bystanders in the nation are not trained in recognizing a cardiac arrest event and are unable to provide prompt CPR. Hence the “first” or the “fast responders” in the country and in many other countries may be the emergency paramedics/nurses and doctors who man the ambulance/community health centers. These personnel are capable of early recognition of cardiac arrest and rapid institution of CPR following a “chain-of-survival,” which is essential for a successful outcome.2,3
The staff attrition and crisis faced by healthcare institutions during the COVID-19 pandemic were devastating. In India, private hospitals of Karnataka state alone at a given time faced shortages of 30% of doctors and 50% of nurses.4 To combat the COVID-19 situation, healthcare facilities faced an acute demand for health care professionals in large numbers. Most of the hospitals increased their bed capacity to accommodate an increasing number of patients, though a significant number of health care professionals were infected by the virus and hence were either quarantined or admitted to hospitals. Resource crisis forced hospitals to recruit relatively inexperienced junior doctors, nurses, retired professionals, interns, and other health care professionals for clinical care. To strengthen the fight against COVID-19, the Government of India appointed nearly 265,000 health professionals on a contractual basis in the states.5 A recently published Indian study concludes that the knowledge level regarding cardiac arrest resuscitative measures was found to be poor.6 Hence, there was an urgent need to train all physicians and health care personnel in the ideal/correct method of CPR and follow an algorithmic approach to emergency and cardiovascular care, especially during the pandemic season. The established guidelines pertaining to the subject are updated periodically based on the current evidence and published. Hence, updating the knowledge and skill to impart evidence-based cardiac arrest management is of paramount importance. There are several CPR training programs in this part of the world pertaining to emergency and cardiovascular care for healthcare providers. It appears to be less reachable to the various levels of healthcare professionals due to several barriers. A few of these barriers are: (1) cost of the training program, (2) accessibility, (3) language, (4) duration of the course, and last but not least (5) COVID-19 pandemic-induced restriction of crowd gatherings for classroom training, travel limitations, fear of infection, etc.
As a part of COVID-19 precautionary measures, the government imposed various measures which resulted in crucial medical training being impossible, such as BLS and ACLS. For a considerable duration during the pandemic, all the training pertaining to BLS and ACLS came to a halt. This has made an unmet demand and necessity for a standard structured training program in cardiac life support that follows evidenced-based guidelines adaptable to the Indian scenario. With the above background and to meet the demand for BLS/ACLS training, bloomed the theme of a hybrid training program on essential emergency and cardiovascular skills for health care professionals. Several levels of meetings were held with the expert panel of NCLS to formulate a hybrid NCLS program. The objectives of hybrid NCLS included the following with the best possible COVID-19 precautionary measures during training (Fig. 1) (1) recognition and management of precardiac arrest conditions such as choking/upper airway obstruction, cardiac arrhythmias, acute coronary syndrome (ACS), stroke and postcardiac arrest management; (2) recognition of early warning signs of early clinical deterioration; (3) skills in basic and advanced life support, airway management, basics of mechanical ventilation, defibrillation, and cardioversion; (4) special emphasis was made to enable trainees with effective communication, documentation; and (5) team dynamics session designed in such a way that a team of doctors and nurses works in a coordinated and effective manner putting all the qualities of team dynamics.
Fig. 1: Instructions to the trainees for the on-site hands-on session on the 2nd day
MATERIALS AND METHODS
The first NCLS was launched at Narayana Health, Bengaluru, India, on 5th October 2016.7 On 20th January 2017, the Association of Health Care Providers India (AHPI) and Narayana Hrudayalaya hospital aligned with the Society for Emergency Medicine India (SEMI) for NCLS. In the year 2017, the NCLS was endorsed by the Indian College of Anaesthesiology and the National Board of Examination. Subsequently, NCLS was endorsed by the Indian College of Cardiology (ICC) in 2017 and by the Simulation Society in 2019. NCLS was later accredited by the West Bengal University of Health Sciences.8 From the very first program, Karnataka Medical Council granted three credit points for each of the NCLS programs.9 Through 127 programs in various parts of the nation, 3,078 candidates, including doctors, nurses, and paramedics, were trained in various institutions till March 2020. From March to December 2020, no training programs were conducted as there was a ban on group meetings and conferences. The exponential decrease in the quality of resuscitation can be directly proportionate to the level of resuscitation training. A mass of newly appointed healthcare providers who are not efficient in resuscitation at the highest quality. Considering this fact, the concept of “hybrid NCLS” was originated.
The hybrid NCLS training program encompasses basic and advanced life support training. BLS training instructed health care professionals in early CPR, which includes steps of performing CPR, relieving choking, and using an automated external defibrillator (AED). ACLS training facilitates participants to improve their skills in treating victims of cardiac arrest or other cardiopulmonary emergencies. NCLS focuses on the importance of high-performance team dynamics, communication, systems of care, recognition and intervention of cardiopulmonary arrest, immediate postcardiac arrest, recognition and management of acute arrhythmia, stroke, and ACS. Through instruction and active participation in case-based scenarios, learners enhance their skills in the differential diagnosis and treatment of both prearrest, arrest, and postarrest conditions. Any health care provider who had the privilege/license to administer intravenous drugs from the State/National Health Council and had a valid clinical practice license under the state/equivalent council was considered eligible for NCLS. Each of the candidates received the course schedule and study material at least 7 days prior to the day of the course. The study material was designed by the expert panel of NCLS, which comprised the essentials for emergency and cardiovascular care modulated as per the Indian scenario. Prior to each hybrid NCLS program, an online session was conducted to discuss the essential algorithms with the candidates for better understanding (Fig. 2). The schedule of the hybrid NCLS was structured as a 2-day training program; the first day was an “online” virtual learning module (Table 1) and the 2nd day for “on-site” for hands-on training. All the didactic sessions of NCLS were dealt with online on day 1 using PowerPoint presentations through the Teams Microsoft platform, teaching materials, and ingeniously framed training videos as per standard guidelines. This day 1 session lasted for a total of 5 hours, which was interactive with the active participation of the participants. Day 2 consisted of on-site “hands-on” training with manikins with COVID-19 precautions to the maximum possible extent. Instructors monitored one-to-one skill impartment with correct techniques of high-quality CPR. The duration of training on day 2 was 7 hours, followed by assessment (Table 1). The assessment consisted of two sessions, namely, theory and skill assessments for BLS and ACLS. During the assessment, all the necessary COVID-19 precautions were taken into consideration (Figs 3 and 4). To complete the NCLS program successfully, candidates must score a minimum of 80% in the assessment, failing which, the candidates are subjected to remediation or reappearing for the test. Upon successful completion of the training, the candidates are certified in NCLS with a validity of 3 years. The certification was affiliated with and endorsed by SEMI, AHPI, ICC, the Indian College of Anesthesiologists, Bangalore Chapter of the Indian Society of Critical Care Medicine, and the Simulation Society. The State Medical Council recognized NCLS with credit hours for NCLS provider course participants. Training certificates were provided within 10 days of successful completion. Feedback in the form of predesigned elements was distributed and collected by the candidates at the conclusion of the program for the betterment of subsequent programs. For every NCLS course, the following requirements were adhered to: (1) the instructor-candidate ratio was maintained at 1:6; (2) the number of candidates per session was limited to 25 participants; mentors needed per session, including the lead mentor, was five; (3) each NCLS course had a lead instructor; (4) a lead instructor was an AHA certified ACLS instructor who has taken part in at least four American Heart Association/in-house training programs in a 2-year time frame; (5) an NCLS instructor was a healthcare provider whose working profile is directly/closely related to emergency medicine/critical care/anesthesiology/full-time academics; (6) an NCLS instructor possessed a valid AHA provider card and had a minimum of a 3-year clinical experience in cardiac arrest resuscitation; (7) curriculum included a precourse and posttraining evaluation; and (8) all new entry NCLS instructors underwent go a monitoring session on selected topics which was chaired by an NCLS expert panel.
| Online components | |
|---|---|
| Topic | Duration |
| Introduction | 10 minutes* |
| Out-of-hospital cardiac arrest management | 30 minutes* |
| AED | 20 minutes* |
| Basic oxygenation and ventilation devices | 30 minutes* |
| BLS—pediatric and infant | 30 minutes* |
| Choking—adult, pediatric, and infant | 20 minutes* |
| BREAK | 15 minutes |
| ACLS and reversible causes of cardiac arrest | 45 minutes* |
| Immediate postcardiac arrest care | 20 minutes* |
| Team dynamics | 15 minutes* |
| ACS | 30 minutes* |
| Stroke | 30 minutes* |
| On-site “hands-on” components | |
| “Hands-on” sessions | Duration |
| “Hands-on” CPR and AED | 60 minutes |
| “Hands-on” BLS on infant | 45 minutes |
| “Hands-on” choking | 40 minutes |
| Theory assessment (BLS) | 30 minutes |
| BREAK | 15 minutes |
| “Hands-on” arrhythmia management | 60 minutes |
| “Hands-on” airway management | 60 minutes |
| “Hands-on” mega code and team dynamics | 90 minutes |
| Test and practical assessment | |
*Includes interaction discussion time
Fig. 2: Screenshot of the “online” session
Fig. 3: Candidates undergoing evaluation. Please note that every second seat was left vacant and face masks were worn by all
Fig. 4: Interactive session on the 2nd day of hybrid NCLS with safe distance and face masks protocol
RESULTS
A total of 11 hybrid NCLS training programs were conducted over a period of 18 months with a total of 276 trainees. The background of trainees were medical graduates (MBBS) undergoing postgraduation, nursing, and paramedical staff. A total of 166 physicians, 87 nurses, and 23 paramedical staff were trained in hybrid NCLS involving 37 instructors. To perform meaningful statistical analysis, 11 standard NCLS programs were chosen in a random manner (computer generated), and these programs were compared to 11 hybrid NCLS programs. The feedback comparison of a standard (on-site) NCLS program and hybrid NCLS programs is depicted in Figure 5. The overall rating of the hybrid NCLS based on the analysis of feedback was good/outstanding by 97% of attendees, which was similar to the feedback obtained from the traditional pre-COVID-19 standard NCLS program (Table 2). The success rate of candidates in the final assessment in attaining the proposed cutoff score (80%) was 89% in hybrid NCLS, which is comparable with 88% for standard classroom NCLS. The pre-COVID-19 standard NCLS classroom training trained 3,078 health care providers through 127 courses since its inception (October 2016) till the onset of the COVID-19 pandemic, and on the contrary, 276 candidates were trained through 11 hybrid NCLS programs.
| Parameters | On-site (2016–2020) | Hybrid (2021–2022) |
|---|---|---|
| Number of programs | 11 | 11 |
| Total no. trained | 322 | 276 |
| Physicians | 197 | 166 |
| Nurses | 111 | 87 |
| Paramedical staff | 14 | 23 |
| No. passed | 284 | 246 |
| No. remediated | 38 | 30 |
| Unsuccessful | 0 | 0 |
| Aggregate of sessions | 5104 | 4005 |
| Evaluation of quality in training based on feedback—numerator indicates no. of responses in that category. Denominator indicates maximum score available (in 18 sessions per course) | ||
| • Poor | 16/5104 | 5/4005 |
| • Fair | 27/5104 | 21/4005 |
| • Satisfactory | 209/5104 | 83/4005 |
| • Good | 1752/5104 | 863/4005 |
| • Outstanding | 2508/5104 | 3033/4005 |
Fig. 5: Feedback comparison of standard (offline) vs hybrid NCLS
DISCUSSION
Since there exists a huge gap in the number of candidates trained and the number of programs conducted as standard classroom NCLS and hybrid NCLS, a direct comparison of the effectiveness of a hybrid program vs a conventional program cannot be ascertained now unless there are a considerable number of hybrid courses. However, there is evidence on the topic that online training is non-inferior to classroom training.10
According to the Brandon-Hall Study, learning through e-learning typically requires 40–60% less employee time than learning the same material in a traditional classroom setting.11 The Research Institute of America found that e-learning increases retention rates by 25–60%, while retention rates of face-to-face training are very low in comparison: 8–10%. This is because, with e-learning, students have more control over the learning process as well as the opportunity to revisit the training as needed.12 e-Learning is good for the environment. Britain’s Open University’s study found that producing and providing e-learning courses consumes an average of 90% less energy and produces 85% fewer CO2 emissions per student than conventional face-to-face courses.13
Furthermore, in recent years, synchronized distance education (SDE) (live) has been widely used for educational purposes by health science students. A recent meta-analysis of randomized clinical trials demonstrated a higher overall satisfaction (standardized mean difference 0.60, 95% confidence interval 0.38–0.83; p < 0.001) for SDE compared with traditional education, showing that SDE was quite acceptable by medical students.14 The 2-day course imparted knowledge of basic and advanced life support techniques in victims of cardiac arrest in both adults and children, identification and management of precardiac arrest conditions such as cardiac arrhythmias, ACS, heart block, etc. Additionally, the participants were trained on techniques to improve chest compression fraction, arrhythmia recognition and management, airway skills, basics of ventilation, defibrillation and cardioversion, resuscitation techniques in special situations such as poisoning, drowning, stroke, ACS, effective communication, and documentation. In addition, indigenous institutional protocols were framed for in-hospital resuscitation and discussed with the participants for resuscitation during the times of pandemic (Flowchart 1).
Flowchart 1: Narayana Hrudayalaya hospital health city code blue protocol during the COVID-19 pandemic
CONCLUSION
A standard and structured cardiac arrest resuscitation training program which incorporates an evidence-based approach and is adaptable to the Indian scenario is of paramount importance in a pandemic. Most importantly, training which integrates with recommended precautions against infection is mandatory during times of pandemics. It is expected that on completion of a hybrid NCLS program, a candidate will gain knowledge and sufficient skills in managing cardiac arrest victims with available resources. The purpose of this article was not intended towards comparing standard resuscitation training and a hybrid approach but was meant to determine the feasibility of hybrid training on BLS and ACLS during a pandemic. If online learning technology can play a role here, it is incumbent upon all health care professionals to explore its full potential.
ORCID
Muralidhar Kanchi https://orcid.org/0000-0003-3347-0204
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