ANALYSIS OF COMPETENCES IN NEONATAL RESUSCITATION OF PEDIATRICIANS AND STUDENTS OF MEDICINE, HOW TO by International Educational Scientific Research Journal

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PhD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. (*Corresponding Author) PhD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 3 MD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 4 MD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 5 MD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 6 MD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 7 PhD. Pediatric Department, Faculty of Medicine, Valladolid, Spain, 47000. 2

ABSTRACT Introduction: In 2001, the Spanish group for "Cardiopulmonary Resuscitation" (CPR) was created. Since that time, multiple courses have been made. The objectives of these courses were obtaining new skills in: neonatal resuscitation, stabilization and transport of critically ill children and training courses for CPR training courses. In our hospital, an annual training course in advanced neonatal CPR is made. Up to 5 to 10% of the newborns will require some assistance to begin breathing at birth. Therefore, every practitioner who attends newborns must have the skills that can be required. Objectives: our goal was to analyse the knowledge in CPR from the pediatricians (medical doctors and the pediatric residents) in the two hospitals of our city. Moreover, we also analysed the knowledge from the students in Medical School after the passed course in Pediatrics. We proposed to establish a periodic training so as to keep an optimal ability in resuscitation skills. Material and methods: we obtained a representative sample made from Medical doctors (MD) and pediatric residents belonging to the hospitals in our city, as well as the students in the last year. Multiple-choice questions (MCQ) (20 questions) and a Modified Evaluation Questionnaire (MEQ) (20 questions) were applied. Collected variables were: mark obtained in the test, study group (medical doctors, paediatric resident, year of residence and medical student), previous CPR courseand time after the last real neonatal resuscitation. Results: We obtained 81 completed questionnaires: MD, 29 (78%), pediatrics resident, 23 (72%) and students, 31 (20%). The median scores (interquartile range) were: Pediatricians: 8 (7-8.75), Residents: 7 (6.5-7.75) and Students: 4.19 (3.72-5.12), with significant differences when comparing each of the groups. In the group of residents, we found statistically significant differences obtaining the best scores among those who had completed the neonatal resuscitation course in the last year. We found the best test results in the medical doctors and pediatrics residents who underwent a real neonatal resuscitation in the last year. Conclusions: Neonatal CPR knowledge of medical doctors and pediatric residents of the third and fourth year are optimal, first and second year residents are good and medical students are deficient. It is found that adequate training and periodic updating is necessary to maintain adequate competencies in neonatal CPR. Keywords: Neonatal resuscitation, Skills, CPR training course,

INTRODUCTION: Up to 5 to 10% of the newborns will require some assistance to begin breathing at birth. Therefore, every practitioner who attends newborns must have the skills that can be required. When a newborn needs resuscitation, the most experienced person must act. Therefore, it is difficult to obtain the capacity in real situations (Sandroni, Gonnella et al. 2010). When a neonatal CPR training course is made, we expect to optimize and standardize the resuscitation skills and therefore to reduce the mistakes than can occur. Doing so, we can reduce mortality and morbidity (Mosley and Shaw 2013). A crucial part in these courses is the simulation of real settings, that can

favour the reflexive learning and prepare the professional to solve usual settings in our daily practice. In 2001, the Spanish group for “Cardiopulmonary Resuscitation” was created. Since that time, many courses have been carried out. The objectives of these courses are: neonatal resuscitation, stabilization and transport of critically ill children and training courses for CPR training courses. In our hospital an annual training course in advanced neonatal CPR is made. The course is designed to help update health care professionals: paediatricians, pediatric residents, gynecology residents, pediatric nurse residents and midwifes. All the courses follow the recommendations from the Spanish group in neonatal resuscitation and the recommendations from the

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International Liaison Committée of resuscitation (ILCOR) and the European Resuscitation Council (ERC) from 2010 (Iriondo, Szyld et al. 2011, Iriondo Sanz and Grupo de Reanimación Neonatal de la Sociedad Española de Neonatología 2012). Many studies suggest a quick loss in knowledge and skills acquired some months after have received a CPR course (Charalampopoulos, Karlis et al. 2014). Therefore, we aimed to establish the knowledge in the paediatricians and pediatric residents so as to determine the most suitable periodicity in our courses.

OBJECTIVES To analyze the knowledge in neonatal CPR in Medical doctors (MD) and pediatric residents from the hospitals of our city. To assess the acquisition of knowledge in neonatal resuscitation of the students in their last year of degree in Medical school, after finishing Pediatrics subject and to adapt the contents and the tools used.

TABLE 1: Mean, median, standard deviation and percentiles of study populations POPULATION Pediatrician (MD+PR)(52) Medical Doctor (29) PediatricReside nt (PR) (23) PR 1st & 2nd (15) PR 3rd& 4th (8) Students (31)

Mean

Median

P25

P75

7,54

7,75

1,33

6,5

8,5

7,87

1,24

8,75

7,13

1,35

6,5

7,75

6,51

1,10

7,50

8,28

8,37

7,56

9,18

4,32

4,19

0,82

3,72

5,12

Figure 1: Box diagram of attachments, MD, residents and students

To establish the need for adequate training periodicity to maintain an optimum competence in resuscitation skills.

POPULATION AND METHOD Simultaneously, anonymously and without prior notification, a sample of MD and residents of the Pediatric Services of the two hospitals in our city and Pediatric students from our School of Medicine answered a questionnaire composed of 20 multiple-choice questions (MCQ) and a Modified Evaluation Questionnaire (MEQ) with 20 questions. Variables analyzed: mark of questionnaire, study group (medical doctor, resident and Resident's year, student), CPR course in the previous year and time since the last real resuscitation. For the numerical variables the median and interquartile range are expressed. For the qualitative ones the relative frequency was used. Comparisons were made using non-parametric statistics (Mann-Whitney test) between the different study groups, considering statistically significant p-values less than 0.05. Cronbach's alpha was calculated to measure the correlation between questionnaire questions and to assess their reliability, and the Difficulty Index and Percentage Discrimination were calculated.

When we analyzed the results of the residents by groups, it was observed that the third and fourth year residents had significantly better results than the first and second year residents: 8.37 (7.56 - 9.18) versus 7 (6-7 , 50) (p = 0.001) (Table 1) (Figure 2).

Figure 2: Box diagram of resident's notes by groups

Statistical analysis was performed using the statistical software SPSS version 15.0.

RESULTS We obtained 81 completed questionnaires: MD: 29 (78%), pediatrics resident: 23 (72%) and students:31 (20%). Internal consistency of the questionnaire showed a Cronbach's alpha of 0.826. The mean difficulty index was 0.75 and the discrimination rate was 0.21%. The median scores (interquartile range) were: Pediatricians, 8 (7-8.75), Residents, 7 (6.5-7.75) and Students, 4.19 (3.72-5.12), (Table 1), with significant differences when comparing each of the groups (Figure 1).

When we grouped Medical Doctor (MD) and Pediatrics residents and analyzed their origin, we found significant differences in the results obtained between the two hospitals: 8

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(7-9) vs 7.6 (6-8), p = 0.018. (Figure 3)

Figure 3: Diagram of boxes with the notes of the 2 hospitals surveyed.

neonatal resuscitation in the last year: (n = 37, median: 8, interquartile range: 6,75 – 8,87) vs (n = 15, median: 7, interquartile range: 5,75 - 7,75) (figure 5).

Figure 5: Diagram of boxes of the notes regarding the time of last resuscitation.

The percentage of MD and Pediatric residents who underwent neonatal CPR course training in the last year was significantly higher in the hospital with the best score (47% vs 11.1%, p = 0.008) (figure 4). When we analized the group of MD and residents (n = 52) we did not find significant differences between those who did a neonatal CPR training course in the last year and those who didn’t: 7.87 (7.25-850) vs 7, 62 (6.25-8.75), p = 0.385.

Figure 4: Number of pediatricians who performed a CPR course in the last year

DISCUSSION Numerous studies confirm that having undergone a previous Neonatal Resuscitation course markedly improves the results obtained (Sandroni, Gonnella et al. 2010, Fischer, Strunk et al. 2012, Yang, Yen et al. 2012). Traditionally, it was recommended to carry out refreshe courses every two years (Yang, Yen et al. 2012). Evidence from several studies suggests that knowledge and skills decline between 6 months and 1 year (Birnbaum, Robinson et al. 1994, Yang, Yen et al. 2012), and skills decline earlier than knowledge (Boonmak, Boonmak et al. 2004, Charalampopoulos, Karlis et al. 2014), although some. Some authors contribute with discordant results that reflect that skills do not diminish over time (Hammond, Saba et al. 2000) or that abilities remain better (Boonmak, Boonmak et al. 2004, Charalampopoulos, Karlis et al. 2014). In our study, it was not possible to demonstrate that the grade was related to having done or not a course in the last year grouping all pediatricians. However, by assessing separately medical staff and residents, in the latter, we have found significant differences. We also have observed that in the hospital where more participants had completed a training course the previous year, the achieved results were better.

When we analyzed the MD (n = 29), we found better results in those who had undergone a neonatal resuscitation course in the last 5 years:(n = 14, median: 8.50, interquartile range: 7,75– 9), versus (n = 15, median: 8, interquartile range: 6.25 - 8.75) without reaching statistical significance (p = 0.07). In the group of Pediatrics residents (n = 23), there were statistically significant better scores in those who had undergone a neonatal resuscitation course in the previous year (n = 14, median: 7.50, interquartile range: 6,50 - 8,62) versus those who had done it more than a year before (N = 9, median: 7, interquartile range: 5.37-7), p = 0.014.

The preservation of specific knowledge and skills inCPR is influenced by frequent exposure to real situations of neonatal resuscitation (Fischer, Strunk et al. 2012, Mosley and Shaw 2013), as demonstrated in the results of our series:medical staff showed better results than residents, and within this group, better results in their third and fourth year of residency, and those who have attended a neonatal resuscitation in the delivery room. This affirmation is reinforced by the results obtained in our sample, when finding better scores in the pediatricians who had performed at least one neonatal resuscitation in the last year, comparedto those who had not resuscitated a new born for more than a year.

If we jointly analyzed MD and Pediatric residents (n = 52), the best results were found among those who had undergone a real

Another objective of our study was to analyze the knowledge of neonatal resuscitation of medical students who had taken the

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subject of Pediatrics. They had attended a seminar showing the resuscitation of the premature newborn, but only in a theoretical approach. The results disclosed the need to expand and improve teaching skills in this subject in the undergraduate Pediatric student, as introducing this topic in depth in new teaching plans.

knowledge." Resuscitation83(2): 227-231.

CONCLUSIONS

6. Iriondo, M., E. Szyld, M. Vento, E. Buron, E. Salguero, J. Aguayo, C. Ruiz, D. Elorza, M. Thio and N. Grupo de reanimacion neonatal de la Sociedad Espanola de (2011). "[Changes in the international recommendations on neonatal resuscitation, 2010: comments]." An Pediatr (Barc)75(3): 203 e201-214.

Conducting cardiopulmonary resuscitation courses, on an annual basis, improves the results of a knowledge assessment on neonatal resuscitation. Professional training as a pediatrician and the degree of professional development as a pediatric resident influences the results in an assessment of knowledge about neonatal resuscitation. The results obtained in a knowledge assessment about neonatal resuscitation are influenced by the frequent exposure to real situations of neonatal resuscitation. Medical students show a clear lack of knowledge in neonatal resuscitation skills.

LIMITATIONS

5. Hammond, F., M. Saba, T. Simes and R. Cross (2000). "Advanced life support: retention of registered nurses' knowledge 18 months after initial training." Aust Crit Care13(3): 99-104.

7. Iriondo Sanz, M. and Grupo de Reanimación Neonatal de la Sociedad Española de Neonatología (2012). Manual de Reanimación Neonatal. 8. Mosley, C. M. and B. N. Shaw (2013). "A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course." Arch Dis Child98(8):582-586.

We have investigated the level of knowledge through test-like questions and clinical cases, but we have not testedthe assessment of skills through simulation (Fischer, Strunk et al. 2012).

9. Sandroni, C., G. L. Gonnella, C. de Waure, F. Cavallaro, G. La Torre and M. Antonelli (2010). "Which factors predict candidate outcome in advanced life support courses? A preliminary observational study." Intensive Care Med36(9): 1521-1525.

The training and evaluation using simulation techniques are closer to reality to assess the abilities in the medical field. However, one of the strengths of our study was to have performed the examination without warning and without the possibility of consulting books or similar material (Fischer, Strunk et al. 2012).

10. Yang, C. W., Z. S. Yen, J. E. McGowan, H. C. Chen, W. C. Chiang, M. E. Mancini, J. Soar, M. S. Lai and M. H. Ma (2012). "A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers."Resuscitation83(9):1055-1060.

ACKNOWLEDGMENTS Our thanks to all who collaborated with the questionnaire

REFERENCES 1. Birnbaum, M. L., N. E. Robinson, B. M. Kuska, H. L. Stone, D. G. Fryback and J. H. Rose (1994). "Effect of advanced cardiac life-support training in rural, community hospitals." Crit Care Med22(5): 741-749. 2. Boonmak, P., S. Boonmak, S. Srichaipanha and S. Poomsawat (2004). "Knowledge and skill after brief ACLS training." J Med Assoc Thai87(11): 1311-1314. 3. Charalampopoulos, D., G. Karlis, D. Barouxis, A. Syggelou, C. Mikalli, D. Kountouris, N. Modestou, P. Van de Voorde, F. Danou, N. Iacovidou and T. Xanthos (2014). "Theoretical knowledge and skill retention 4 months after a European Paediatric Life Support course." Eur J Emerg Med. 4. Fischer, H., G. Strunk, S. Neuhold, D. Kiblbock, H. Trimmel, M. Baubin, H. Domanovits, C. Maurer and R. Greif (2012). "The effectiveness of ERC advanced life support (ALS) provider courses for the retention of ALS INTERNATIONAL EDUCATIONAL SCIENTIFIC RESEARCH JOURNAL