Skip to main content
Download PDF

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan

BMC Emergency Medicine volume 22, Article number: 93 (2022) Cite this article

Abstract

Background

Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan.

Methods

Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR.

Results

The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27).

Conclusion

Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Peer Review reports

Background

Out of Hospital Cardiac Arrest (OHCA) is a major global health concern and one of the leading causes of death worldwide. In developing countries, it accounts for 10% of mortality [1,2,3,4] Globally, it is estimated that on average, less than 10% of all patients with OHCA will survive [5].

In the United States, Resuscitation Outcomes Consortium Registry (ROC), survival rates were significantly higher (43.6%) if layperson-initiated CPR occurred. In the Cardiac Arrest Registry to Enhance Survival (CARES) in the US, automated external defibrillator (AED) use and bystander CPR explained as much as 50.4% of survival variation across 132 counties [6, 7]. In developing countries, where there is a lack of knowledge about bystander CPR, survival rates are dismal. Studies from developing countries have shown varying survival from as low as 0% in Mexico to 2% in Islamabad, Pakistan, and 11% in Karachi, Pakistan [8,9,10].

The Pan-Asian Resuscitation Outcomes Study (PAROS) represents a concerted effort in prehospital emergency care research to document cardiac arrest epidemiology and ascertain possible outcomes of bystander CPR [11]. With regards to bystander CPR, it is important to recognize that bystanders refer to the population at large,who is responding to the cardiac arrest event before the arrival of an organized emergency response team.. Within Pakistan, numerous studies have affirmed the need for bystander CPR training. One study by Mawani et al. found that amongst a cohort of OHCA patients brought to an Emergency Department, most of the patients (92.9%) had witnessed cardiac arrest out of which only a small percentage (2.3%) received bystander CPR [12]. Another study by Khursheed et al. found that Pakistan had a higher burden of dead on arrival (DOA) patients than other similar resource settings (about 1 to 2 per 1000 visits) and one of the causes they cited was lack of bystander CPR and prehospital care [13].

It is important to reach out to a diverse spectrum of the population and provide them with life-saving knowledge and skills to reduce the burden of OHCA mortality. However, the baseline knowledge of a population is equally important in assessing the impact of life-saving interventions including CPR training.

Aim of the study

The aim of this study was to determine the retention of knowledge and skills of Hands-Only CPR training among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan.

Methods

Study design and setting

We conducted a pre and post-test study from July 2018 to October 2019 in Karachi, Pakistan.

Participants

We recruited 652 participants that included teachers, ambulance drivers, traffic police officers, patrolmen, and military officers. Ambulance drivers were not trained in emergency medical services in our setting. They were predominantly drivers without any kind of formal training in basic life support. These drivers typically follow “scoop and run” approach instead of “stay and play”. The military officers included Pakistan Rangers, a paramilitary force in Karachi that is conventionally deployed in heavily trafficked neighborhoods, making them potential first responders alongside traffic police. We selected this population to train because all these professions are related to public dealing and they can be mobilized easily in emergencies to act as potential first responders. Their nature of work and training make them more appropriate for the practical application and long-term sustainability of this life-saving procedure. Moreover, given the lack of Samaritan law (protecting those legally who willingly assist individuals in medical emergency) in our setting, this set of population will be actively responding to the OHCA events without much fear.

Study instruments

Knowledge assessment questionnaires and skill checklists were developed with the help of a literature review of CPR training [14,15,16] along with expert opinion from emergency physicians.

The knowledge assessment questionnaire consisted of nine multiple-choice and five binary response (Yes/No) questions related to CPR knowledge, attitude, and practice such as “what do you think CPR means, what are the signs of sudden heart arrest, what are the critical components of high-quality CPR, have you received CPR training and what concerns may prevent you from performing CPR if needed” (For further details on the questionnaire, see Supplementary Item 1). Demographics of participants were also asked. All the participants underwent this CPR knowledge questionnaire which took them 25–30 minutes to complete. The questions were read out loud to the participants in the Urdu language. In addition, guidance was provided to the participants who were unable to comprehend the questions.

In addition, CPR performance checklists had three distinctive criteria to assess the participant’s performance that included a participant’s ability to initiate CPR, perform high-quality CPR and discontinue CPR when needed (For detailed information on the checklist, see Supplementary Item 2). The facilitator independently assessed the CPR skills of the participants via a Yes/No checklist.

Training

The group of 25–30 participants were approached for one-time CPR training sessions. The arrangement of participants was made through appointment, either via phone or email to the participant’s primary organization. The training was conducted based on the availability of the participants during the study period. The training was carried out at the participant’s primary organization or the emergency department of the AKU. Each group of participants received a well-designed 2-hour CPR training based on the American Heart Association (AHA) guidelines. The facilitators were BLS certified and had prior CPR training. The facilitators included emergency faculty, master trainers, medical interns, and emergency medicine residents. There were two leading facilitators with the team of co-facilitators. There were two to five faciltitators per session. First, the facilitator shared information related to CPR in the Urdu language. Second, a video-based CPR demonstration was displayed to participants with a live translation into Urdu language simultaneously for each step of CPR demonstrated in the video. Third, we asked all the participants to demonstrate the steps of CPR independently on the manikins. In addition, we provided scenario-based training to the participants to help them reflect on true situations and enhance their understanding. Moreover, the facilitators provided continuous feedback to the participants regarding CPR techniques while they were demonstrating on manikins. Furthermore, we conducted a post-training evaluation to improve the training experience for participants in the succeeding trainings.

Assessment

The CPR knowledge assessment questionnaires and skill checklist were completed anonymously. Participants were assessed for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after pre-test (re-test). All the facilitators were trained to use the checklist and rate the performance of participants objectively. The facilitator verbally read out different case scenarios to the participants on drowning, poisoning and road traffic crashes, etc., and asked the participants to perform the critical steps of CPR identified in the scenario on manikins. The facilitator rated the CPR skills of the participants on maximum three attempts while observing the specific skill for at-least 2 minutes. Feedback was given to the participants who failed to perform the correct skills in their attempts. The participants to facilitator ratio ranged from 5 to 10:1 for skill assessment. Each participant was evaluated by a single facilitator and used an uniform checklist approach to minimize inter-rater variability. Moreover, these facilitators were not involved in the analysis of the study.

Outcome measure

The primary outcome was the mean difference in score on knowledge and skills of the participants related to the recognition of OHCA and initiation of CPR.

Ethical considerations

This study was conducted after obtaining approval from the ethical review committee of the Aga Khan University (AKU). Written informed consent was obtained from all the participants before enrolment in the study. The confidentiality of the participants was maintained throughout the study and anonymity was ensured by using unique identification numbers for each participant.

Statistical analysis

All data were entered and analysed using the Statistical Package for Social Sciences (SPSS) version 21 [17]. Descriptive statistics were used for demographic variables and presented as frequencies and percentage. The mean knowledge score was computed for pre, post and retest. Parametric tests were used since the data obtained were normally distributed. We also used repeated measures ANOVA to determine the significant mean between pre, post and re-test. The association between knowledge score and demographic characteristics was analyzed using generalised estimating equation regression. A p-value of less than 0.05 was considered significant.

Results

Sociodemographics of the study participants

The pre and post-tests were completed by 652 participants, whereas the re-test was completed by 322 participants. Table 1 shows the sociodemographic characteristics of the participants. Most of the participants were male (n = 553, 84.8%) and had secondary school (grade 9–10) education (n = 284, 43.6%). The majority of the participants (n = 404, 62%) were in the age group of 25–44 years. In addition, a majority of the participants (n = 257, 64.7%) had no training in CPR before pre-testing. The number of participants dropped to half of the original sample size (n = 322) at the time of knowledge retention assessment (re-test). The reduction in sample size was primarily due to military postings that change quarterly.

Table 1 Sociodemographic characteristics of the study participants from July 2018 to October 2019
Full size table

Knowledge of CPR at pre, post, and re-tests

On the pre-test, Q13, which is related to the understanding that survival is high when CPR is done immediately received the highest number of correct responses (n = 600, 93.9%). Other questions on which participants scored high in the pre-test included (Q10) the understanding that CPR is an emergency procedure that is attempted to restart the heart that has stopped beating (n = 571, 89.9%) and (Q12) understanding that CPR is generally continued until the person regains consciousness or is declared dead (n = 566, 88.9%). Table 2 shows the frequency and percentage of the participants with correct responses for knowledge assessment questions at pre-test, post-test, and re-test. The retention of CPR knowledge related to the rate of chest compression (Q6) reduced from n = 596, 92.4% to n = 245, 76.1% followed by (Q7) force that must be applied during chest compressions (from n = 411, 63% to n = 151, 46.9%) and (Q9) switching roles when performing two-rescuer CPR (from n = 571, 87.6% to 167, 51.9%). More than 90% of the participants had knowledge retention for the questions that had binary (Yes/No) responses; questions number 10 to 14 (See Supplementary Item 1 for knowledge assessment questions).

Table 2 Score of CPR knowledge among participants from July 2018 to October 2019
Full size table

Mean CPR knowledge score

Figure 1 shows the mean percentage of the knowledge score at pre, post, and re-test phases. The mean percentage of the knowledge score at pre-test was 48.5 (SD ±13.5) which increased to 70.7 (SD ±12.2) at post-test and decreased to 63.5 (SD ±10.8) at re-test. This was statistically significant (p < 0.001). .

Fig. 1
figure 1

Mean CPR knowledge score (%) at pre, post and re-test (n = 322). The mean value of the knowledge score calculated by repeated measures ANOVA has been statistically significant p-value < 0.001 between. 1) Pre-test & post-test. 2) post-test & re-test. 3) Pre-test & re-test

Full size image

CPR skill performance and retention

The CPR skills of the participants were assessed post-training and after 6 months (re-test). Figure 2 shows the percentage of the participants who performed CPR skills correctly at the first attempt at post-test and re-test. Majority of the participants were able to perform skills correctly regarding checking for the scene safety (n = 504, 77.4%), checking for response (n = 446, 68.5%), calling for help (n = 413, 63.4%), and activating emergency response system (n = 497, 76.3%). Furthermore, 81.3% (n = 530) of the participants were able to place their heels of hands appropriately while performing CPR whereas, 73.1% (n = 476) had an adequate rate of chest compressions. The retention of CPR skills slightly deteriorated for placing the heel of hands correctly from 81.3 to 78.8%, checking for scene safety from 77.4 to 72.1% and checking for breathing from 84.4 to 75.2%. Participants performed better on achieving an adequate rate of chest compressions from 73.7% in post-test to 76.7% in re-test and allowing complete chest recoil from 69.3 to 77.4%.

Fig. 2
figure 2

Participants CPR skills performance at post and re-test. The percentage of the participants performed CPR skills correctly at post-test and re-test was computed. The CPR skills assessed are given in y-axis

Full size image

Generalized estimating equation regression for sociodemographic characteristics

The Generalized Estimating Equation (GEE) analysis revealed that gender and prior CPR training were found to be strongly associated with improved CPR knowledge scores. Table 3 shows the regression coefficients for the GEE model relating CPR knowledge score to sociodemographic characteristics. The females scored on an average of 3.56 points (95% CI: 1.7, 5.4) higher than males. In addition, participants who had prior CPR training scored on an average of 2.61 points (95% CI: 0.8, 4.4) higher than those who had not. The increase in CPR knowledge scores overtime did not vary significantly by age groups and education status of the participants.

Table 3 Overall impact of sociodemographic characteristics on the CPR knowledge
Full size table

Discussion

This study determined the retention of CPR knowledge and skills after hands-only bystander CPR training among non-healthcare professionals in Pakistan. The mean CPR knowledge score of the participants improved substantially after CPR training. In addition, participants were able to retain considerable knowledge and skills of CPR after 6 months of the initial training. We found out that gender, and prior CPR training were strongly associated with an increase in the CPR knowledge scores.

CPR knowledge and skill retention were tested after 6 months of the initial training. This duration reflects findings from previous literature which suggests that skill retention is usually till 6 months [18]. Evidence suggests that retention of theoretical CPR knowledge is higher than skills performance [19]. However, our study results showed that CPR skills retention was higher than knowledge. The greater retention of CPR skills in our study might be attributed to video-based CPR demonstration, scenario-based drills on manikins, feedback from the facilitator, and the flexibility to perform skills on multiple attempts during assessment.

The evidence affirms that CPR knowledge and skills fade over time but at different rates and various factors influence the retention of CPR knowledge and skills [20]. Previous studies have highlighted that ‘low dosage, high frequency’ refresher training, in which participants undergo brief but frequent CPR training sessions, improves the quality and retention of skills significantly [21, 22]. Healthcare systems that integrate CPR training into civic, work, or school activities offer a useful and effective means to assure retention [23].

A prospective, randomized intervention trial involving 874 prehospital cardiac arrest patients revealed that survival following prehospital cardiac arrest is more likely when witnessed, but not necessarily when bystander CPR is administered [24]. A multi-center study conducted in Pakistan showed that nearly 90% of OHCA patients are witnessed, yet only 2.3% received bystander CPR [25]. The high number of OHCA witness in Pakistan could be attributable to joint family system as most of the cases in this study occurred in residences, similar to what was seen in India [26]. However, nearly 50% of the witnessed cardiac arrest in European countries receive bystander CPR, particularly in public places [27, 28].

The ability to perform effective CPR is critical and a lifesaving skill for bystanders in line with the pre-hospital emergency care system. Previous studies have confirmed that learning bystander CPR can improve OHCA outcomes [29, 30]. Our study revealed that a combination of video and instruction-based CPR training is an effective method to improve the knowledge and skills of bystanders which is widely used in other contexts [31, 32] and had similar positive effects. In addition, implementing effective training methods to increase bystander CPR knowledge may improve resuscitation in high-risk groups [33, 34]. In a Swedish longitudinal study, efforts to provide conventional training significantly increased the number of individuals with CPR training and nearly doubled the proportion receiving bystander CPR from 31 to 55% in two decades [35]. In addition, previous research indicates that training targeted populations, such as neighbourhoods with poor bystander CPR rates, may be an effective strategy to increase bystander CPR rates and OHCA outcomes [36].

Bystander CPR is the first and foremost component in the chain of survival following cardiac arrest [37]. Based on the chain of survival that focuses on an integrated continuum of care; Pakistan lacks access to automated external defibrillators, a robust prehospital emergency care system, and health care facilities capable of both continuing resuscitative efforts and providing integrated and intensive post-resuscitative care and rehabilitation [38,39,40]. Even though, bystander CPR has gained widespread recognition as a life-saving skill; implementation of bystander CPR training and public access to it is generally limited in low-and-middle income countries (LMICs). However, in Pakistan, healthcare professionals have inadequate knowledge of CPR [41, 42]. There are several major concerns that bystanders may have regarding their readiness to perform CPR in Pakistan, including making a mistake when performing CPR or unintentionally injuring the patient, being concerned about legal consequences, and hesitating to perform CPR on the opposite gender which is consistent with the previous findings [43]. In addition, the reluctance to perform CPR on women is linked with fears of inappropriate touching and allegations of sexual assault [44]. This again underlines the importance of CPR training particularly with regards to bystander receptivity.

In this study, skill assessment was primarily done by master trainers. These are healthcare professionals who are BLS certified and have received prior CPR training. They are qualified to teach and evaluate laypersons who can act as providers in a community setting. Master trainers represent a sustainable model of community CPR training, leading to the ‘Train the Trainer’ models [45]. A pragmatic example of this within Pakistan is the Pakistan LifeSavers Program (PLSP) with the mission of training 10 million laypersons in 10 years [46].

Limitations of the study

This study has various limitations. For one, it could not capture all participants for a refresher training session and so comparison of post-test and re-test results may depict a less than the accurate picture but is still consistent in terms of reasonable depreciation of knowledge after a considerable period. Secondly, there could be a difference in the rating consistency among facilitators because the co-faciltiators were less trained which may affect the inter-rater reliability. Also, there was a lack of participation from rural settings where access to care in case of emergencies is limited and where the need for such training would be greater. In addition, we were unable to evaluate the quality of the educational skills of trainers due to the time constraints of the instructors.

Future studies could focus on assessing baseline knowledge amongst participants from a variety of backgrounds and residential settings, both urban and rural areas. In addition, different methods of training delivery can be evaluated, particularly, video-based learning for refresher training and assessment of CPR skill retention.

Conclusion

The bystander CPR training program did not only improve the knowledge and skills of the participants but also had a reasonable retention rate. This study may prove to be a steppingstone for researchers specially in the LMICs to explore interventions that may help to strengthen the chain of survival for patients with out of hospital cardiac arrest.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to institutional policies on data sharing but are available from the corresponding author on reasonable request.

Abbreviations

CPR:

Cardiopulmonary Rescussitation

OHCA:

Out of Hospital Cardiac Arrest

ROC:

Resuscitation Outcomes Consortium Registry

CARES:

Cardiac Arrest Registry to Enhance Survival

AED:

Automated External Defibrillator

LMICs:

Low-and-middle Income Countries

AKU:

Aga Khan University

AHA:

American Heart Association

GEE:

Generalized Estimating Equation

PLSP:

Pakistan LifeSavers Program

References

  1. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Lund-Kordahl I, Olasveengen TM, Lorem T, Samdal M, Wik L, Sunde K. Improving outcome after out-of-hospital cardiac arrest by strengthening weak links of the local chain of survival; quality of advanced life support and post-resuscitation care. Resuscitation. 2010;81(4):422–6.

    Article  PubMed  Google Scholar 

  3. Rao BH, Sastry B, Chugh SS, Kalavakolanu S, Christopher J, Shangula D, et al. Contribution of sudden cardiac death to total mortality in India—a population based study. Int J Cardiol. 2012;154(2):163–7.

    Article  PubMed  Google Scholar 

  4. Noc M, Fajadet J, Lassen JF, Kala P, MacCarthy P, Olivecrona GK, et al. Invasive coronary treatment strategies for out-of-hospital cardiac arrest: a consensus statement from the European association for percutaneous cardiovascular interventions (EAPCI)/stent for life (SFL) groups. EuroIntervention. 2014;10(1):31–7.

    Article  PubMed  Google Scholar 

  5. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation. 2010;81(11):1479–87.

    Article  PubMed  Google Scholar 

  6. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–492.

  7. Beck B, Bray J, Cameron P, Smith K, Walker T, Grantham H, et al. Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: results from the Aus-ROC Epistry. Resuscitation. 2018;126:49–57.

    Article  PubMed  Google Scholar 

  8. Fraga-Sastrias JM, Asensio-Lafuente E, Martinez R, Barcenas IA, Prieto-Sagredo J, Castillo L, et al. Out-of-hospital cardiac arrest: first documented experience in a Mexican urban setting. Prehosp Disaster Med. 2009;24(2):121–5.

    Article  PubMed  Google Scholar 

  9. Ishtiaq O, Iqbal M, Zubair M, Qayyum R, Adil M. Outcome of cardiopulmonary resuscitation-predictors of survival. J Coll Physicians Surg Pak. 2008;18(1):3–7.

    PubMed  Google Scholar 

  10. Rehmani R, Baqir SM, Amanullah S. Return of spontaneous circulation and survival at hospital discharge in patients with out-of-hospital and emergency department cardiac arrests in a tertiary care Centre. J Pakistan Med Assoc. 2007;57(6):278.

    Google Scholar 

  11. Doctor NE, Ahmad NSB, Pek PP, Yap S, Ong MEH. The Pan-Asian resuscitation outcomes study (PAROS) clinical research network: what, where, why and how. Singap Med J. 2017;58(7):456.

    Article  Google Scholar 

  12. Mawani M, Kadir MM, Azam I, Mehmood A, McNally B, Stevens K, et al. Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study. BMC Emerg Med. 2016;16(1):28.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Khursheed M, Bhatti JA, Parukh F, Feroze A, Naeem SS, Khawaja H, et al. Dead on arrival in a low-income country: results from a multicenter study in Pakistan. BMC Emerg Med. 2015;15(2):S8.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Berthelot S, Plourde M, Bertrand I, Bourassa A, Couture M-M, Berger-Pelletier É, et al. Push hard, push fast: quasi-experimental study on the capacity of elementary schoolchildren to perform cardiopulmonary resuscitation. Scand J Trauma Resusc Emerg Med. 2013;21(1):41.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Panchal AR, Meziab O, Stolz U, Anderson W, Bartlett M, Spaite DW, et al. The impact of ultra-brief chest compression-only CPR video training on responsiveness, compression rate, and hands-off time interval among bystanders in a shopping mall. Resuscitation. 2014;85(9):1287–90.

    Article  PubMed  Google Scholar 

  16. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med. 2006;13(6):596–601.

    Article  PubMed  Google Scholar 

  17. SpSS I. SPSS version 21.0. Chicago: IBM SPSS; 2012.

    Google Scholar 

  18. Lim SH, Aw SJ, Cheong MA, Chew J, Ler AC, Yong LP, et al. A randomised control trial to compare retention rates of two cardiopulmonary resuscitation instruction methods in the novice. Resuscitation. 2016;103:82–7.

    Article  PubMed  Google Scholar 

  19. Brown TB, Dias JA, Saini D, Shah RC, Cofield SS, Terndrup TE, et al. Relationship between knowledge of cardiopulmonary resuscitation guidelines and performance. Resuscitation. 2006;69(2):253–61.

    Article  PubMed  Google Scholar 

  20. Papalexopoulou K, Chalkias A, Dontas I, Pliatsika P, Giannakakos C, Papapanagiotou P, et al. Education and age affect skill acquisition and retention in lay rescuers after a European resuscitation council CPR/AED course. Heart Lung. 2014;43(1):66–71.

    Article  PubMed  Google Scholar 

  21. Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, et al. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics. 2011;128(1):e145–e51.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, et al. Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2018;138(6):e82–e122.

    Article  PubMed  Google Scholar 

  23. Halm M, Crespo C. Acquisition and retention of resuscitation knowledge and skills: what’s practice have to do with it? Am J Crit Care. 2018;27(6):513–7.

    Article  PubMed  Google Scholar 

  24. Vukmir RB. Witnessed arrest, but not delayed bystander cardiopulmonary resuscitation improves prehospital cardiac arrest survivial. Emerg Med J. 2004;21(3):370–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Mawani M, Kadir MM, Azam I, Mehmood A, McNally B, Stevens K, et al. Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study. BMC Emerg Med. 2016;16(1):1–10.

    Article  Google Scholar 

  26. Ramaka S, Nazir NT, Murthy VS, Hoek TV, Prabhakar BS, Chodavarapu R, et al. Epidemiology of out-of-hospital cardiac arrests, knowledge of cardiovascular disease and risk factors in a regional setting in India: the Warangal area out-of-hospital cardiac arrest registry (WACAR). Indian Heart J. 2020;72(6):517–23.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Nadolny K, Zyśko D, Obremska M, Wierzbik-Strońska M, Ładny JR, Podgorski M, et al. Analysis of out-of-hospital cardiac arrest in Poland in a 1-year period: data from the POL-OHCA registry. Kardiol Pol. 2020;78(5):404–11.

    Article  PubMed  Google Scholar 

  28. Reuter P-G, Baert V, Colineaux H, Escutnaire J, Javaud N, Delpierre C, et al. A national population-based study of patients, bystanders and contextual factors associated with resuscitation in witnessed cardiac arrest: insight from the french RéAC registry. BMC Public Health. 2021;21(1):1–9.

    Article  Google Scholar 

  29. Takei Y, Kamikura T, Nishi T, Maeda T, Sakagami S, Kubo M, et al. Recruitments of trained citizen volunteering for conventional cardiopulmonary resuscitation are necessary to improve the outcome after out-of-hospital cardiac arrests in remote time-distance area: a nationwide population-based study. Resuscitation. 2016;105:100–8.

    Article  PubMed  Google Scholar 

  30. Park YM, Shin SD, Lee YJ, Song KJ, Ro YS, Ahn KO. Cardiopulmonary resuscitation by trained responders versus lay persons and outcomes of out-of-hospital cardiac arrest: a community observational study. Resuscitation. 2017;118:55–62.

    Article  PubMed  Google Scholar 

  31. Paglino M, Contri E, Baggiani M, Tonani M, Costantini G, Bonomo MC, et al. A video-based training to effectively teach CPR with long-term retention: the ScuolaSalvaVita.It ("SchoolSavesLives.It") project. Intern Emerg Med. 2019;14(2):275–9.

    Article  PubMed  Google Scholar 

  32. Del Rios M, Han J, Cano A, Ramirez V, Morales G, Campbell TL, et al. Pay it forward: high school video-based instruction can disseminate CPR knowledge in priority neighborhoods. West J Emerg Med. 2018;19(2):423–9.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kappus RM, McCullough G. The feasibility of a novel method of bystander CPR training: a pilot study. Am J Emerg Med. 2020;38(3):594–7.

    Article  PubMed  Google Scholar 

  34. Nas J, Thannhauser J, Vart P, van Geuns RJ, Muijsers HEC, Mol JQ, et al. Effect of face-to-face vs virtual reality training on cardiopulmonary resuscitation quality: a randomized clinical trial. JAMA Cardiol. 2020;5(3):328–35.

    Article  PubMed  Google Scholar 

  35. Strömsöe A, Andersson B, Ekström L, Herlitz J, Axelsson Å, Göransson K, et al. Education in cardiopulmonary resuscitation in Sweden and its clinical consequences. Resuscitation. 2010;81(2):211–6.

    Article  PubMed  Google Scholar 

  36. Bergamo C, Bui QM, Gonzales L, Hinchey P, Sasson C, Cabanas JG. TAKE10: a community approach to teaching compression-only CPR to high-risk zip codes. Resuscitation. 2016;102:75–9.

    Article  PubMed  Google Scholar 

  37. Hansen CM, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010-2013. JAMA. 2015;314(3):255–64.

    Article  CAS  Google Scholar 

  38. Zia N, Shahzad H, Baqir S, Shaukat S, Ahmad H, Robinson C, et al. Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan. BMC Emerg Med. 2015;15(Suppl 2):S9.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Razzak JA, Baqir SM, Khan UR, Heller D, Bhatti J, Hyder AA. Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels. Emerg Med J. 2015;32(3):207–13.

    Article  PubMed  Google Scholar 

  40. Mawani M, Azam I, Kadir MM, Samad Z, Razzak JA. Estimation of the burden of out-of-hospital traumatic cardiac arrest in Karachi, Pakistan, using a cross-sectional capture-recapture analysis. Int J Emerg Med. 2020;13(1):26.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Majid A, Jamali M, Ashrafi MM, Ul Haq Z, Irfan R, Rehan A, et al. Knowledge and attitude towards cardiopulmonary resuscitation among doctors of a tertiary Care Hospital in Karachi. Cureus. 2019;11(3):e4182.

    PubMed  PubMed Central  Google Scholar 

  42. Iqbal A, Nisar I, Arshad I, Butt UI, Umar M, Ayyaz M, et al. Cardiopulmonary resuscitation: knowledge and attitude of doctors from Lahore. Ann Med Surg (Lond). 2021;69:102600.

    Article  Google Scholar 

  43. Becker TK, Gul SS, Cohen SA, Maciel CB, Baron-Lee J, Murphy TW, et al. Public perception towards bystander cardiopulmonary resuscitation. Emerg Med J. 2019;36(11):660–5.

    Article  PubMed  Google Scholar 

  44. Perman SM, Shelton SK, Knoepke C, Rappaport K, Matlock DD, Adelgais K, et al. Public perceptions on why women receive less bystander cardiopulmonary resuscitation than men in out-of-hospital cardiac arrest. Circulation. 2019;139(8):1060–8.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Pearce J, Mann MK, Jones C, Van Buschbach S, Olff M, Bisson JI. The most effective way of delivering a train-the-trainers program: a systematic review. J Contin Educ Health Prof. 2012;32(3):215–26.

    Article  PubMed  Google Scholar 

  46. Initiative launched to train 10 million youth in lifesaving skills. 2020.

Download references

Acknowledgements

The authors wish to thank the trainers who assisted in the training of the participants: Nazir Najeeb, Osama Zahid, Shahid, Aqeel Mehdi, Mustehsan, Hasnain, Noman, Mahreen Solanki, Safia Awan, Murtaza, Zubair, Mariam, Fatima and Hira.

Funding

This research was supported by the Singapore Clinical Research Institute (SCRI). The content is solely the responsibility of the authors and do not represent the views of SCRI.

Author information

Author notes

  1. Noor Baig

    Present address: Department of Emergency Medicine, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan

Authors and Affiliations

  1. Department of Emergency Medicine, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan

    Uzma Rahim Khan, Umerdad Khudadad, Fareed Ahmed, Ahmed Raheem & Nadeem Ullah Khan

  2. Harvard T.H. Chan School of Public Health, Boston, USA

    Butool Hisam

  3. Department of Emergency Medicine, Singapore General Hospital and Duke National University of Singapore, Singapore, Singapore

    Marcus Ong Eng Hock

  4. Department of Emergency Medicine, Weill Cornell Medicine, NewYork, USA

    Junaid Abdul Razzak

  5. Center of Excellence for Trauma and Emergencies, Aga Khan University, Karachi, Pakistan

    Junaid Abdul Razzak

Authors
  1. Uzma Rahim Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Umerdad Khudadad
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Noor Baig
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Fareed Ahmed
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ahmed Raheem
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Butool Hisam
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Nadeem Ullah Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Marcus Ong Eng Hock
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Junaid Abdul Razzak
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

U.R.K, N. B, F. A and N. K directly contributed to proposal development. U.R.K, U. K and BH contributed to research paper planning and manuscript development. A. R analyzed and interpreted data. J.A.R and M.O.E.H critically reviewed the paper and contributed to ensure that it is aligned with the current global perspective on the subject. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Uzma Rahim Khan.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the ethical review committee of the Aga Khan University in Karachi, Pakistan (reference number: 2020–0608-14608). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all subjects/participants legal guardian(s) or legally authorized representative (LAR).

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Khan, U.R., Khudadad, U., Baig, N. et al. Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan. BMC Emerg Med 22, 93 (2022). https://doi.org/10.1186/s12873-022-00652-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12873-022-00652-2

Keywords

  • Bystander
  • CPR
  • Training
  • Retention
  • Pakistan
  • Out of the hospital cardiac arrest

BMC Emergency Medicine

ISSN: 1471-227X

Contact us