SECTION 5: TEST OF PERFORMANCE
1. The place of cardiopulmonary resuscitation Philip Tombleson, MBE, FRCGP SUMMARY: Following the report of a working party of the Royal College of Physicians in July 1987, a decision was taken to make the skill of cardiopulmonary resuscitation mandatory for entrants to the College. The options for introducing this criterion are discussed, including the ultimate decision reached by the Examination Board to accept presentation of a certificate of competence by candidates on application to take the examination.
for the general practitioner, as about 5% of victims of myocardial infarction experience a cardiac arrest in the presence of their general practitioner (Rawlins, 1981; Pai et al., 1987). Indeed a substantial number, possibly half, may be saved if the general practitioner has a defibrillator and basic life support skills (Pai et al., 1987; Colquhoun, 1988). Public training programmes in cardiopulmonary resuscitation have shown that lives can be saved by simple basic techniques as in Seattle, USA and Brighton, UK (Vincent et al., 1984). In fact evidence from Brighton shows that from January 1984 to early 1988, a period of little over four years, 626 patients were admitted to hospital having had a resuscitation attempt from cardiac arrest in the pre-hospital phase. Of these, 133 patients survived to be discharged home, and 493 died. In 16 incidences a general practitioner arrived in time to give cardiopulmonary resuscitation (or was present at the time of the arrest) and there were 12 long-term survivors (Chamberlain D, personal communication). There was thus overwhelming evidence of the need for general practitioners to have training in cardiopulmonary resuscitation. Furthermore, family practice examinations elsewhere in the English-speaking world laid considerable emphasis on this skill. In Australia, for example, "all candidates will be examined in the technique of heart lung resuscitation . . . which must be passed by all candidates". In Canada and New Zealand resuscitation procedures were considered a mandatory skill. In the Republic of Ireland (MICGP examination) "skill in initiating immediate or emergency treatment including life-saving procedures" was considered man-
Introduction
T HE Royal College of General Practitioners was represented on the working party that reported to the Royal College of Physicians in July 1987 on cardiopulmonary resuscitation (CPR). Comments made in the report included the following: "The availability and efficiency of resuscitative procedures are lacking in both the community and the hospital, due mainly to inadequate training and organization." The report went on to recommend that general practitioners should train regularly in basic life support and should be encouraged to become competent in advanced life support techniques. The working party felt that general practitioners should attend a course in basic life support within two years of becoming a principal, and recommended the training of practice staff and implementation of public education programmes in emergency aid by the general practitioner (Royal College of Physicians, 1987). The working party's anxiety about the efficiency and training of doctors in cardiopulmonary resuscitation was justified by several papers giving evidence that junior hospital doctors and nursing staff were generally not familiar with basic life support techniques. For example, in one study, 55% of preregistration house officers were able to carry out basic cardiopulmonary resuscitation with none able to do so at an advanced level (Skinner et al., 1985). A further study showed that only 29% of junior medical and surgical house officers were able satisfactorily to ventilate a manikin (Lowenstein et al., 1981). In another study only 8% of medical and surgical house officers were able to manage a cardiopulmonary arrest adequately (Casey, 1984). About three quarters of candidates for the MRCGP examination are trainees whom it would have been reasonably expected to be competent in cardiopulmonary resuscitation. About 400 candidates each year are non-trainees, that is principals, assistants in general practice, and others, and no evidence is available about the competence of general practitioners in the procedure - although there is no evidence to suggest that they are any more competent than their junior hospital colleagues. Nevertheless proficiency in cardiopulmonary resuscitation should be a high priority
datory. Implementation
The above evidence was presented to the Examination Board of the Royal College of General Practitioners in April 1988, when Dr Judith Fisher, College representative on the Working Party on Resuscitation and member of the Resuscitation Council (UK), was present. It became clear at this time that the examination could be used as an educative tool, as over 10 000 candidates would be stimulated into improving their skills and
35
36
gaining a certificate in the next seven years. It the need for mandatory competence in cardiopulmonary resuscitation was to be implemented consideration needed to be given to the testing of every candidate at the examination, as was currently taking place in the MICGP examination in Ireland. It was noted, however, that this would be logistically difficult with up to 2000 candidates each year, and would reduce the sampling process in other areas and attributes by shortening the time available for them, thus reducing reliability. Furthermore it would involve training a large number of examiners in order to produce a standardized format as well as denying the candidate a second chance to prove his skills which would be available if he or she undertook assessment in his/her own time. The decision was therefore made that a certificate of proficiency in cardiopulmonary resuscitation should be produced by candidates at the time of entry for the MRCGP examination.
Certification A problem for the Examination Board at this time was that there was no nationally agreed criterion for basic cardiopulmonary resuscitation and no national certificate. It was therefore necessary for the Board to agree on the standard obtained by the applicant and what certification was to be used. Previous work among medical students had shown a fairly rapid decay in cardiopulmonary resuscitation skills (Mancini and Kaye, 1985) and it was decided that any certificate should be valid for a period of only three years. Fortunately, in April 1988 a modification to existing manikins was introduced with interactive teaching facilities. This was demonstrated to the Examination Board and consisted of a 'skill meter' - a liquid crystal scoring of individual scores with a print-out summary at the end of the assessment (Figure 1). It was decided that a skill meter report would be accepted for certification and a test certificate based on this was drawn up for candidates without access to such a machine (Table 1). Following some debate about the level of skill required which would be considered compatible with successful resuscitation, the panel of examiners all took an assessment of their resuscitation skills at their annual conference in February 1989 using the manikin with the skill meter. As a result of this it was decided that the level of 76% was both feasible and valid. Candidates who were physically challenged and incapable of taking the test were permitted to prove competence in instructing a physically able person to perform cardiopulmonary resuscitation at the requisite level. Lower volume ventilation (0.8-1.2 litres) was recommended following the work of Melker (1984) suggesting that this amount was compatible with good resuscitation technique and that larger volumes might be introduced into the stomach. Thus the level of competence having been established and the content of the certification drawn up, it remained to decide who should make the assessment. Nationally neither the Resuscitation Council of Great Britain nor the members of the British Association for Immediate Care (BASICS) nor the Casualty Surgeons
LAERDAL SKILLMETER REPORT
Cx"QlO"
VEJriIATION
W W TOTf
110 (91%)
avea94
avera9e
66
15:2
121
releaSe
lete
iT0
cW.MTE
0
Too little Too much Wrong hand mition
2 8 I
m
14 (88%)
16
Stomach distention Too much Too little
2 l 0
(Scale in sec.) r
,
_ I
*n
.
I-I
_
_
~
_ I
1
~
W.
15
_ I
10i
240
210
Studnt :DI.. Loek,e Date : I g-? -93
270
-( 30
lnstructor:
Figure 1. Laerdal skillmeter report.
Association were sufficiently widespread through the United Kingdom to give adequate cover for all prospective candidates who wished to be tested. It was therefore decided that the Regional Ambulance Officers Group should be considered the outside examining body and should co-ordinate testing through approved regional training/testing centres in each district. These would be required to sign each certificate to validate the assessment. Copy signatures were retained by the administrator at the College in order to check the certificates on submission. Special arrangements were made for overseas candidates. Results At the closing date of the first examination after the new regulations had been introduced 1251 candidates had applied to sit the examination, 25 of whom had on the closing date asked for deferment for production of a certificate. This excellent result was not achieved without a considerable amount of disruption in the Examination Department of the College. Furthermore, there was a surprising degree of resistance from some doctors to being assessed by ambulance officers on the grounds that it was "totally unacceptable that lay people should examine doctors in basic medical skills". It was also alleged that ambulance officers have "far less educational standing, training and experience", but as was
pointed out
in
reply by
a
general practitioner
37
Table 1. Test certificate for candidates without access to a skill meter EXAMINATION FOR MEMBERSHIP CARDIOPULMONARY RESUSCITATION PERFORMANCE TEST
Candidate's name: ......... Activity
Date: ...................... Ideal performance
Acceptable variation
1 Determine responsiveness Call for help
Shake by shoulders Call for help immediately
None Call within first 60 seconds
2 Open airway Determine breathlessness
Head tilt with chin support Look, listen and feel for breathing for at least 3 seconds
Head tilt with neck lifted None
3 Initial ventilations
2 slow ventilations Vol per ventilation 0.8-1.2 litres Inspiratory time per ventilation 1-1.5 seconds
1-5 slow ventilations
4 Determine pulst tessness
Palpate carotid artery for at least 5 seconds
For at least 3 seconds
5 Cycles of chest compressions 15 chest compressions of 1.5"-2" and ventilations each on the lower part of the sternum avoiding pressing the xiphisternum and the ribs. Compression rate 80 per minute. Followed by 2 slow ventilations
6 Reassessment of
pulselessness 7 Timing of activities
Pass
Fail
70% correct ventilations 70% correct compressions Compression rate 50-110 per minute Average compression: ventilation ratio over assessment period 10-20:2-3
Vol per ventilation 0.8-1.2 litres. Inspiratory time per ventilation 1-1.5 seconds. At least 4 cycles of compressions and ventilations must be performed
A ratio of 4-6:1 is acceptable if at least 10 cycles are performed
Palpate carotid artery for at least 5 seconds after 4 cycles of compressions and ventilations
Reassessment after 3-5 cycles
Steps I to 5 (to end of first 4 cycles of compressions and ventilations) to be performed in
Performed with 80-120 seconds
90 seconds
Examiner: Signature ..................................................
Result: Pass .....
...
Fail
.
Name ......................................................
Candidates must obtain a pass in each activity
Address ...................................................
Candidates who fail the test may be re-tested after instruction
...................................................
...................................................
ATIACH MANIKIN PERFORMANCE RECORD IF AVAILABLE
member of the Resuscitation Council, "teaching resuscitation to doctors often reveals inadequate and outdated skills associated with considerable anxiety" (Colquhoun and Job, 1990). The point was also made that ambulance training officers in this country have teaching expertise and, it was suggested, considerably more training and experience in resuscitation than most practising doctors. Nevertheless there were problems regarding accessibility to regional ambulance training schools and it became clear that other organizations
THIS CERTIFICATE REMAINS VALID FOR THREE YEARS
and many hospital specialists were keen to take part in the training and assessment. Regulations were therefore relaxed and accreditation by medical members of St John, Red Cross, and consultants or general practitioner members of the Resuscitation Council who undertake such training and assessments were therefore accepted. The Examination Department retained the right to validate any examiner or assessment process as it had now lost its ability to accredit the signature of the assessor.
38
Conclusion The introduction of cardiopulmonary resuscitation as a mandatory skill for candidates to be accepted for the MRCGP examination from May 1990 was achieved with some administrative difficulties. The raised level of awareness amongst the medical profession has not only stimulated more training for doctors but ensured that candidates have the necessary ability without detracting from the sampling process of the examination itself.
References Casey W F (1984) Cardiopulmonary resuscitation: a survey of standards among junior hospital doctors. Journal of the Society of Medicine 77, 921-4. Colquhoun M C (1988) Use of defibrillators by general practitioners. British Medical Journal 297, 336. Colquhoun M C and Job R S (1990) Cardiopulmonary resuscitation and the MRCGP examination. British Medical Journal 300, 258.
Lowenstein S R, Libby L S, Mountain R D et al. (1981) Cardiopulmonary resuscitation by medical and surgical house officers. Lancet 2, 679-81. Mancini M E and Kaye W (1985) The effect of time since training on house officers - retention of cardiopulmonary resuscitation skills. American Journal of Emergency Medicine 1, 31-2. Melker R (1984) Asynchronous and other alternative methods of ventilation during CPR. Annals of Emergency Medicine 13, 758-61. Pai G R, Haites N E and Rawles J M (1987) One thousand heart attacks in Grampian: the place of cardiopulmonary resuscitation in general practice. British Medical Journal 294, 352-4. Rawlins D C (1981) Study of the manageme.-t of suspected cardiac infarction by British immediate cars doctors. British Medical Journal 282, 1677-9. Royal College of Physicians of London (1987) Resuscitation from cardiopulmonary arrest. Journal of the Royal College of Physicians of London 21, 175-81. Skinner D V, Camm A J and Myles S (1985) Cardiopulmonary resuscitation skills of pre-registration house officers. British Medical Journal 290, 1549-50. Vincent R, Chamberlain D A et al. (1984) A community training scheme in cardiopulmonary resuscitation. British Medical Journal 288, 617-20.
1. The place of cardiopulmonary resuscitation Philip Tombleson, MBE, FRCGP SUMMARY: Following the report of a working party of the Royal College of Physicians in July 1987, a decision was taken to make the skill of cardiopulmonary resuscitation mandatory for entrants to the College. The options for introducing this criterion are discussed, including the ultimate decision reached by the Examination Board to accept presentation of a certificate of competence by candidates on application to take the examination.
for the general practitioner, as about 5% of victims of myocardial infarction experience a cardiac arrest in the presence of their general practitioner (Rawlins, 1981; Pai et al., 1987). Indeed a substantial number, possibly half, may be saved if the general practitioner has a defibrillator and basic life support skills (Pai et al., 1987; Colquhoun, 1988). Public training programmes in cardiopulmonary resuscitation have shown that lives can be saved by simple basic techniques as in Seattle, USA and Brighton, UK (Vincent et al., 1984). In fact evidence from Brighton shows that from January 1984 to early 1988, a period of little over four years, 626 patients were admitted to hospital having had a resuscitation attempt from cardiac arrest in the pre-hospital phase. Of these, 133 patients survived to be discharged home, and 493 died. In 16 incidences a general practitioner arrived in time to give cardiopulmonary resuscitation (or was present at the time of the arrest) and there were 12 long-term survivors (Chamberlain D, personal communication). There was thus overwhelming evidence of the need for general practitioners to have training in cardiopulmonary resuscitation. Furthermore, family practice examinations elsewhere in the English-speaking world laid considerable emphasis on this skill. In Australia, for example, "all candidates will be examined in the technique of heart lung resuscitation . . . which must be passed by all candidates". In Canada and New Zealand resuscitation procedures were considered a mandatory skill. In the Republic of Ireland (MICGP examination) "skill in initiating immediate or emergency treatment including life-saving procedures" was considered man-
Introduction
T HE Royal College of General Practitioners was represented on the working party that reported to the Royal College of Physicians in July 1987 on cardiopulmonary resuscitation (CPR). Comments made in the report included the following: "The availability and efficiency of resuscitative procedures are lacking in both the community and the hospital, due mainly to inadequate training and organization." The report went on to recommend that general practitioners should train regularly in basic life support and should be encouraged to become competent in advanced life support techniques. The working party felt that general practitioners should attend a course in basic life support within two years of becoming a principal, and recommended the training of practice staff and implementation of public education programmes in emergency aid by the general practitioner (Royal College of Physicians, 1987). The working party's anxiety about the efficiency and training of doctors in cardiopulmonary resuscitation was justified by several papers giving evidence that junior hospital doctors and nursing staff were generally not familiar with basic life support techniques. For example, in one study, 55% of preregistration house officers were able to carry out basic cardiopulmonary resuscitation with none able to do so at an advanced level (Skinner et al., 1985). A further study showed that only 29% of junior medical and surgical house officers were able satisfactorily to ventilate a manikin (Lowenstein et al., 1981). In another study only 8% of medical and surgical house officers were able to manage a cardiopulmonary arrest adequately (Casey, 1984). About three quarters of candidates for the MRCGP examination are trainees whom it would have been reasonably expected to be competent in cardiopulmonary resuscitation. About 400 candidates each year are non-trainees, that is principals, assistants in general practice, and others, and no evidence is available about the competence of general practitioners in the procedure - although there is no evidence to suggest that they are any more competent than their junior hospital colleagues. Nevertheless proficiency in cardiopulmonary resuscitation should be a high priority
datory. Implementation
The above evidence was presented to the Examination Board of the Royal College of General Practitioners in April 1988, when Dr Judith Fisher, College representative on the Working Party on Resuscitation and member of the Resuscitation Council (UK), was present. It became clear at this time that the examination could be used as an educative tool, as over 10 000 candidates would be stimulated into improving their skills and
35
36
gaining a certificate in the next seven years. It the need for mandatory competence in cardiopulmonary resuscitation was to be implemented consideration needed to be given to the testing of every candidate at the examination, as was currently taking place in the MICGP examination in Ireland. It was noted, however, that this would be logistically difficult with up to 2000 candidates each year, and would reduce the sampling process in other areas and attributes by shortening the time available for them, thus reducing reliability. Furthermore it would involve training a large number of examiners in order to produce a standardized format as well as denying the candidate a second chance to prove his skills which would be available if he or she undertook assessment in his/her own time. The decision was therefore made that a certificate of proficiency in cardiopulmonary resuscitation should be produced by candidates at the time of entry for the MRCGP examination.
Certification A problem for the Examination Board at this time was that there was no nationally agreed criterion for basic cardiopulmonary resuscitation and no national certificate. It was therefore necessary for the Board to agree on the standard obtained by the applicant and what certification was to be used. Previous work among medical students had shown a fairly rapid decay in cardiopulmonary resuscitation skills (Mancini and Kaye, 1985) and it was decided that any certificate should be valid for a period of only three years. Fortunately, in April 1988 a modification to existing manikins was introduced with interactive teaching facilities. This was demonstrated to the Examination Board and consisted of a 'skill meter' - a liquid crystal scoring of individual scores with a print-out summary at the end of the assessment (Figure 1). It was decided that a skill meter report would be accepted for certification and a test certificate based on this was drawn up for candidates without access to such a machine (Table 1). Following some debate about the level of skill required which would be considered compatible with successful resuscitation, the panel of examiners all took an assessment of their resuscitation skills at their annual conference in February 1989 using the manikin with the skill meter. As a result of this it was decided that the level of 76% was both feasible and valid. Candidates who were physically challenged and incapable of taking the test were permitted to prove competence in instructing a physically able person to perform cardiopulmonary resuscitation at the requisite level. Lower volume ventilation (0.8-1.2 litres) was recommended following the work of Melker (1984) suggesting that this amount was compatible with good resuscitation technique and that larger volumes might be introduced into the stomach. Thus the level of competence having been established and the content of the certification drawn up, it remained to decide who should make the assessment. Nationally neither the Resuscitation Council of Great Britain nor the members of the British Association for Immediate Care (BASICS) nor the Casualty Surgeons
LAERDAL SKILLMETER REPORT
Cx"QlO"
VEJriIATION
W W TOTf
110 (91%)
avea94
avera9e
66
15:2
121
releaSe
lete
iT0
cW.MTE
0
Too little Too much Wrong hand mition
2 8 I
m
14 (88%)
16
Stomach distention Too much Too little
2 l 0
(Scale in sec.) r
,
_ I
*n
.
I-I
_
_
~
_ I
1
~
W.
15
_ I
10i
240
210
Studnt :DI.. Loek,e Date : I g-? -93
270
-( 30
lnstructor:
Figure 1. Laerdal skillmeter report.
Association were sufficiently widespread through the United Kingdom to give adequate cover for all prospective candidates who wished to be tested. It was therefore decided that the Regional Ambulance Officers Group should be considered the outside examining body and should co-ordinate testing through approved regional training/testing centres in each district. These would be required to sign each certificate to validate the assessment. Copy signatures were retained by the administrator at the College in order to check the certificates on submission. Special arrangements were made for overseas candidates. Results At the closing date of the first examination after the new regulations had been introduced 1251 candidates had applied to sit the examination, 25 of whom had on the closing date asked for deferment for production of a certificate. This excellent result was not achieved without a considerable amount of disruption in the Examination Department of the College. Furthermore, there was a surprising degree of resistance from some doctors to being assessed by ambulance officers on the grounds that it was "totally unacceptable that lay people should examine doctors in basic medical skills". It was also alleged that ambulance officers have "far less educational standing, training and experience", but as was
pointed out
in
reply by
a
general practitioner
37
Table 1. Test certificate for candidates without access to a skill meter EXAMINATION FOR MEMBERSHIP CARDIOPULMONARY RESUSCITATION PERFORMANCE TEST
Candidate's name: ......... Activity
Date: ...................... Ideal performance
Acceptable variation
1 Determine responsiveness Call for help
Shake by shoulders Call for help immediately
None Call within first 60 seconds
2 Open airway Determine breathlessness
Head tilt with chin support Look, listen and feel for breathing for at least 3 seconds
Head tilt with neck lifted None
3 Initial ventilations
2 slow ventilations Vol per ventilation 0.8-1.2 litres Inspiratory time per ventilation 1-1.5 seconds
1-5 slow ventilations
4 Determine pulst tessness
Palpate carotid artery for at least 5 seconds
For at least 3 seconds
5 Cycles of chest compressions 15 chest compressions of 1.5"-2" and ventilations each on the lower part of the sternum avoiding pressing the xiphisternum and the ribs. Compression rate 80 per minute. Followed by 2 slow ventilations
6 Reassessment of
pulselessness 7 Timing of activities
Pass
Fail
70% correct ventilations 70% correct compressions Compression rate 50-110 per minute Average compression: ventilation ratio over assessment period 10-20:2-3
Vol per ventilation 0.8-1.2 litres. Inspiratory time per ventilation 1-1.5 seconds. At least 4 cycles of compressions and ventilations must be performed
A ratio of 4-6:1 is acceptable if at least 10 cycles are performed
Palpate carotid artery for at least 5 seconds after 4 cycles of compressions and ventilations
Reassessment after 3-5 cycles
Steps I to 5 (to end of first 4 cycles of compressions and ventilations) to be performed in
Performed with 80-120 seconds
90 seconds
Examiner: Signature ..................................................
Result: Pass .....
...
Fail
.
Name ......................................................
Candidates must obtain a pass in each activity
Address ...................................................
Candidates who fail the test may be re-tested after instruction
...................................................
...................................................
ATIACH MANIKIN PERFORMANCE RECORD IF AVAILABLE
member of the Resuscitation Council, "teaching resuscitation to doctors often reveals inadequate and outdated skills associated with considerable anxiety" (Colquhoun and Job, 1990). The point was also made that ambulance training officers in this country have teaching expertise and, it was suggested, considerably more training and experience in resuscitation than most practising doctors. Nevertheless there were problems regarding accessibility to regional ambulance training schools and it became clear that other organizations
THIS CERTIFICATE REMAINS VALID FOR THREE YEARS
and many hospital specialists were keen to take part in the training and assessment. Regulations were therefore relaxed and accreditation by medical members of St John, Red Cross, and consultants or general practitioner members of the Resuscitation Council who undertake such training and assessments were therefore accepted. The Examination Department retained the right to validate any examiner or assessment process as it had now lost its ability to accredit the signature of the assessor.
38
Conclusion The introduction of cardiopulmonary resuscitation as a mandatory skill for candidates to be accepted for the MRCGP examination from May 1990 was achieved with some administrative difficulties. The raised level of awareness amongst the medical profession has not only stimulated more training for doctors but ensured that candidates have the necessary ability without detracting from the sampling process of the examination itself.
References Casey W F (1984) Cardiopulmonary resuscitation: a survey of standards among junior hospital doctors. Journal of the Society of Medicine 77, 921-4. Colquhoun M C (1988) Use of defibrillators by general practitioners. British Medical Journal 297, 336. Colquhoun M C and Job R S (1990) Cardiopulmonary resuscitation and the MRCGP examination. British Medical Journal 300, 258.
Lowenstein S R, Libby L S, Mountain R D et al. (1981) Cardiopulmonary resuscitation by medical and surgical house officers. Lancet 2, 679-81. Mancini M E and Kaye W (1985) The effect of time since training on house officers - retention of cardiopulmonary resuscitation skills. American Journal of Emergency Medicine 1, 31-2. Melker R (1984) Asynchronous and other alternative methods of ventilation during CPR. Annals of Emergency Medicine 13, 758-61. Pai G R, Haites N E and Rawles J M (1987) One thousand heart attacks in Grampian: the place of cardiopulmonary resuscitation in general practice. British Medical Journal 294, 352-4. Rawlins D C (1981) Study of the manageme.-t of suspected cardiac infarction by British immediate cars doctors. British Medical Journal 282, 1677-9. Royal College of Physicians of London (1987) Resuscitation from cardiopulmonary arrest. Journal of the Royal College of Physicians of London 21, 175-81. Skinner D V, Camm A J and Myles S (1985) Cardiopulmonary resuscitation skills of pre-registration house officers. British Medical Journal 290, 1549-50. Vincent R, Chamberlain D A et al. (1984) A community training scheme in cardiopulmonary resuscitation. British Medical Journal 288, 617-20.
