European Journal of Cardiovascular Medicine

Cardio-Pulmonary Resuscitation (CPR), is a set of procedures and interventions performed during an event of cardiac arrest, to provide circulation and oxygenation to the body.^[1] It is an emergency procedure that combines chest compressions often with artificial ventilation and used in a person who suffers from sudden cardiac arrest.^[2] CPR adheres to a well-defined set of protocols, with guidance provided by authoritative bodies such as the Indian Academy of Pediatrics, Advance Life Support (ALS) group and the American Heart Association (AHA). These protocols highlight the importance of precise chest compression techniques, emphasizing both the frequency and depth of compressions, as well as the optimal compression-to-ventilation ratio. Additionally, the recommendation of use of an Automated External Defibrillator (AED) further enhances the efficacy of CPR in restoring normal heart function during emergency situations.^[3]

Bystander CPR remains the most crucial component in saving the lives of OHCA victims.[4] Extensive research consistently demonstrates that bystander CPR significantly enhances the chances of survival for OHCA victims, often doubling or tripling survival rates and substantially reducing pre-hospital mortality rates [5-7] But unfortunately only 2% people in the world know the correct method of giving CPR [8,9] Moreover, individuals lacking prior CPR training or basic knowledge exhibit hesitancy in initiating CPR compared to those who have received training.[10] This hesitancy stems from a lack of confidence, coupled with inadequate awareness among other contributing factors. [11, 12]

 Also, inadequate or incorrect knowledge can prove to be disastrous in such situations. Effective CPR is based on adherence to guidelines set forth by organizations such as the American Heart Association (AHA) and the Indian Academy of Pediatrics Advance Life Support (IAPIALS) Group. They recommend 100-120 compressions per minute, with a depth of at least five centimetres, allowing adequate time for chest recoil between compressions, and a compression-to-ventilation ratio of 30:2. Furthermore, it is vital to rotate between chest compressions and ventilation every two minutes to sustain efficacy and minimize fatigue among rescuers. Compliance with these standards ensures CPR is administered with the highest degree of effectiveness, maximizing the chances of successful resuscitation^[13] In previous studies it has been observed that 59 – 65 % of the rhythms found to be causing sudden cardiac arrest are accounted by ventricular fibrillation.^[14,15] Use of an automated external de-fibrillator (AED) within 3-5 minutes of collapse increases the survival rate to 49-75%.^[16]  With a basic training, anyone can use an AED to save the life of a victim of OHCA.^[17]

 Thus, prioritizing medical as well as paramedical students for CPR training is essential, given their future roles as healthcare professionals. By instilling these life-saving skills we can significantly enhance the readiness of future healthcare professionals to provide immediate assistance during critical incidents such as OHCA.

This study aims to examine the impact of targeted training interventions on both knowledge acquisition and confidence levels of students pursuing Physiotherapy regarding administration of bystander CPR and AED utilization.

This educational intervention study was carried out across government and private physiotherapy colleges in south Gujarat over a period of four months. The participants comprised students enrolled in the third and fourth years of Bachelors of Physiotherapy programs, as well as those pursuing Masters of Physiotherapy at SPB Physiotherapy College, Government Physiotherapy College, Lokhat Sarvajanik Physiotherapy College, and United Physiotherapy Association of Surat.  The total sample size of the study was 1000 students.

As a part of the academic curriculum of paramedical staff, the students are required to undergo a training in administering cardio – pulmonary resuscitation (CPR) and the use of an Automatic External De-fibrillator (AED). To facilitate this training, certified instructors specializing in Basic and Advanced Life Support (BLS/ALS) were invited to lead hands-on training sessions for physiotherapy students.

 Informed consent was obtained from all participating students, and they were also allowed to refuse participation at any point of time. A baseline assessment of the knowledge and confidence of the students regarding CPR and the use of an AED was conducted before the training session. This was achieved by a pre-tested, self-administered multiple choice questionnaire consisting of 22 questions in a google form circulated among all the students participating in the study. The questions asked to the students were designed to assess the confidence and level of knowledge of the students regarding CPR.

The trainees were then divided in groups of 20.  They were provided with a hands-on training by certified BLS / ALS instructors (or trainers) on the subject of CPR and the use of an AED. The training sessions were one hour long followed by hand-on practice sessions. The sessions included a power point presentation on the subject followed by the demonstration of administering CPR and using AED over mannequins. The students were then asked to administer CPR and use AED themselves, as a part of the hands-on training session. This was followed by question-and-answer session giving the trainees an opportunity to clear any doubts. The trainees were also given a certificate of participation for the workshop. After the training session, the students were asked to fill the post-test questionnaire consisting of the same 22 multiple choice questions through google form. This questionnaire was also pre-tested and self-administered which assessed their knowledge and confidence of the subject of administering CPR and the use of AED after receiving the training. Both pre and post-test questionnaires took 12-20 minutes to complete.  

Statistical Analysis

The data was collected through linked spreadsheets and transferred to Microsoft Excel 2019 and was analysed using Medcalc 19.6.4. software. The normality of the data distribution was assessed using the Shapiro-Wilk test. Descriptive statistics were then computed and reported as percentages. Total participant scores before and after the training session were expressed as median values with inter-quartile ranges and the Wilcoxon signed-rank test was applied.

To evaluate the paired before and after scores, both Chi-square and McNemar’s tests were employed to determine if a significant change occurred in the proportion of knowledge before and after the training session

The research examined both pre and post-intervention data of 1000 physiotherapy students across three colleges in South Gujarat and the United Physiotherapy Association. Among these students, 40.9% were in their third year of Bachelor of Physiotherapy (BPT), 47.4% were in their fourth year of BPT, and 11.7% were pursuing a Master of Physiotherapy degree. Shapiro-Wilk test demonstrated a non-normal distribution of the before and after test scores (p-value < 0.001)

Before the training, only 30.2% of students were confident in their CPR skills, with 60.8% expressing intermediate confidence, and 9% lacking confidence. However, after the training, an additional 565 trainees, previously lacking confidence or showing only intermediate confidence, became confident in administering CPR. This surge increased the total proportion of confident trainees to 86.7%. Post-training, only 11.7% had intermediate confidence, and a mere 1.6% lacked confidence. (Figure 1)  

Figure 3 presents the overall median scores achieved by physiotherapy students in both the pre and post-tests. The median score in the pretest was 16, with a range between 12 and 18, while in the post-test, it increased to 21, with a narrower range of 21 to 22.

Applying the Wilcoxon Signed-Rank test revealed a substantial disparity between the pre-test and post-test scores (Z = 26.6, p < .001, r = 0.9), indicating a significant improvement in scores following the intervention.

Across the majority of variables examined related to CPR, it was observed that there was a notable enhancement in scores among trainees following the training session (p < 0.05). However, the analysis revealed that for the first two questions regarding the feasibility of training the general public in CPR, there was no significant improvement observed (p = 0.242). Table 1 displays the correct answers provided by students in both the pre and post-tests, with a chi-square test applied to assess knowledge gain. (Table 1)

Table 1: Correct answers given by the trainees in the pre and post-test regarding knowledge about CPR.

The McNemar test analysed paired data, classifying responses into 'correct' and 'incorrect' categories (Table 2). Results showed a significant enhancement in baseline knowledge post-training (McNemar p < 0.001). Moreover, 16.4% of initially unconfident students now felt prepared to administer CPR (Q1 to Q4). There was also a notable improvement in CPR protocol knowledge (Q5 to Q14), with a McNemar p-value < 0.001.

Maximum gain in knowledge was seen in correct sequence of BLS with a staggering improvement of 56.9%, and all the 569 students who got this question wrong in pretest, answered it correctly in the post test (Table 2). Similar pattern was observed in the questions concerning time to check breathing (36.1%) and pulse, compression to breath ratio (12.9%), CPR in non-responsive & non-breathing victim (18.4%) where all the students who got those questions wrong in the pretest answered it right in the post-test demonstrating the impact of the training. Around half (46.5%) students correctly identified the essential characteristics of a high-quality CPR in the post test (Table 2).

A significant improvement in knowledge regarding AED was noted among the participants (McNemar p-value <0.001). After the training, 65.1% individuals correctly identified the protocol after administering shock through AED, 29.2% students got the methods to use AED in victim with hairy chest right 30% correctly understood the use of AED in children in the post test (Table 2)

A portion of the training focused on educating participants about "choking." Following the training, all participants demonstrated an understanding of what constitutes choking. Additionally, 21% of participants correctly identified the proper method for administering the Heimlich manoeuvre and12.1% of participants accurately recognized the appropriate steps to be taken when assisting a choking victim in the post-test, despite having previously marked them incorrectly in the pre-test. This indicates a notable improvement in knowledge and competency regarding choking management after the training session (Table 2).

Table 2: Difference between baseline and post-intervention knowledge in study participants

Most studies assessing the knowledge and confidence regarding the administration of bystander CPR are done in physicians and medical students as they are trained in CPR skills worldwide, however, there is a lack of knowledge to tackle cardiac arrest in practical situations.^[18]

As paramedical students including physiotherapists are also essential healthcare providers, they need to have the knowledge and confidence of administering CPR. This study was done to provide the same to the budding physiotherapists and observe their gain in understanding of the topic.

The study took place across three physiotherapy colleges in South Gujarat, where students were educated on CPR and the use of AEDs through hands-on training with mannequins. Their comprehension of these topics was evaluated using the same questionnaire in both pre and post-test assessments. The majority of the students were pursuing bachelor's in physiotherapy (88.3%) and the rest were doing Masters in physiotherapy (11.7%).

Before the training, a significant proportion of students lacked confidence or had low confidence in administering CPR (69.8%). However, after completing the training, a remarkable 86.7% of participants reported feeling confident, indicating a highly satisfactory outcome.

The median test score showed a significant improvement from 16 (12,18) in the pretest to 21 (21,22) in the post-test; the maximum score that could be obtained was 22. Similarly, in a study conducted by Tavares LFB et. al. among undergraduate students of health sciences, including physiotherapy students in Sao Paulo, Brazil, there was a notable enhancement in post-test scores compared to pretest scores among the participants.^[19]

The questionnaire assessed fundamental knowledge of CPR, the correct protocol for administering CPR, use of AEDs, and identification and steps to take when someone is choking. Significant improvements were observed in correct responses across all these sections after the test.

During the baseline assessment, participants already demonstrated awareness of individuals eligible for BLS/CPR training (87.6%) and perceived training the general public for these skills as an achievable goal (92.4%). Consequently, these variables did not yield significant differences when the chi-square test was applied.

A study in Seoul, South Korea, led by Sohyune R. Sok et al., evaluated a simulation-based CPR Training Program's impact on clinical nurses. Similar to our study their results showed significant post-training improvements in both knowledge and performance during simulated CPR scenarios. Nurses demonstrated an enhanced understanding of CPR procedures and increased proficiency in delivering CPR interventions. These findings underscore the efficacy of simulation-based training in equipping nurses with vital CPR skills, emphasizing the importance of hands-on learning approaches in healthcare education to enhance patient outcomes and safety.^[20]

Our study revealed a significant improvement in participants who initially answered questions incorrectly in the pre-test, as evidenced by a statistically significant change in the post-test. It proved the success and fruitfulness of training the physiotherapy students in CPR as it made them competent to administer bystander CPR in emergencies. Källestedt, ML.S., Berglund, A., Herlitz, J. et al., examined the impact of CPR and AED training on the self-perceived attitudes of healthcare professionals towards performing resuscitation across various roles in Sweden. Their study encompassed a diverse group, including "other-university educated staff," comprising physiotherapists, occupational therapists, social welfare officers, psychologists, and biomedical analysts, totalling 228 participants. It was observed in their study that the ‘others’ group improved significantly only their secure knowledge of CPR but still felt the need to have things under their control before they administered CPR to any person in need (p-value <0.05). At the end of the training, they still had some self-perceived nervousness, anxiety, and doubts about how to proceed if cardiac arrest occurs in a patient. ^[21]

However, in our study, physiotherapy students felt much more confident about how to proceed with cardiac arrest patients and knew the protocol well by the end of the training. It can be attributed to conducting the session among 20 students at a time, giving them hands-on training on the mannequin, and keeping a doubt-solving session at the end of each session. This method of delivery of training gave the students personal attention, motivated them to learn through practice, and gave a chance to rectify their mistakes and doubts.

The strengths of our study were a large sample size (n=1000) and inclusion of students of most physiotherapy colleges of South Gujarat to achieve that, increased generalisability. Organising the training in a batch of 20 and training being conducted by certified ALS/BLS instructors also contributed to observing statistically significant improvement in knowledge and confidence among the trainees. Such a study has not been conducted exclusively among physiotherapy students which makes it unique.

 It is evident from our study that a simple hands-on training session organised for healthcare staff such as physiotherapists can drastically improve the knowledge and confidence to administer CPR, especially on encountering out-of-hospital cardiac arrests (OCHA), and improve the survival rates of people found in such unfortunate conditions.

Furthermore, we advocate for the extension of similar training initiatives to the broader community to save lives during OHCA events. Government initiatives for spreading awareness among thousands of non-medical personnel and youths to administer CPR properly are also organised at a large scale regularly. Many industries, as part of their Corporate Social Responsibility efforts, and various non-governmental organizations have already undertaken this vital initiative.

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