15 years of Cardiopulmonary Resuscitation
In the Kingdom of Saudi Arabia
A critical Analysis
Prof. Mohammed A. Seraj
Professor and Consultant of Anesthesiology
Chairman , Department of anesthesiology
College of Medicine and University Hospitals
King Saud University
Cardio Pulmonary Resuscitation was introduced into the Kingdom of Saudi Arabia over a decade ago, after its introduction in the United States of America. The birth of CPR in the Kingdom was conducted by the American Heart Association (AHA) performance of the first instructor course in Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) in the autumn of 1983. The education activity started by the postgraduate center of the college of Medicine later on as the Saudi Heart Association (SHA) was established it continues such activities. The national heart center expands its activities and manages to organize and conduct over 450 courses of BCLS and ACLS.
It managed also to produce over 1100 instructors in both. The numbers of Centers established in the Kingdom over the span of 15 years are 80 centers for BCLS and 12 for ACLS. The Saudi Heart Association issued a total of 80190 Certificates.
The objective of this review is to establish a framework about the educational activities of the CPR National Committee of the SHA and determine if it has any effect on the survival rate in daily hospital work. Finally, the reviewer will put forward recommendations as the key success for future implementations and improvement in the outcome of heart attack in the Kingdom of Saudi Arabia.
Cardio-Pulmonary Resuscitation (CPR) was introduced in the USA in 1966. When the NAS-NRC Conference on CPR recommended to train medical, allied health and other professional personnel the application of external chest compression technique in accordance with the standard American Heart Association (AHA). Public at large was furnished with training in Basic Life Support (BLS) in 1973, the first Advanced Cardiac Life Support (ACLS) adult course was organized in 1974. Other courses in Advanced Life Support, such as pediatric and neonatal was introduced at later stages. Mortality due cardiovascular causes was reduced tremendously throughout the USA as implementation of CPR techniques were enforced. (1) Two decades later, Cardiopulmonary Resuscitation (CPR) was introduced to Saudi Arabia. The start was modest. In 1979 the Author taught CPR (B&ACLS) to undergraduate medical students. At the same time, limited activities of CPR (Basic only) were organized in a very closed community. In autumn of 1983, the American Heart Association (AHA) was invited by the College of Medicine, King Saud University (K.S.U.) to hold the first instructor’s CPR Course in Basic and Advanced Cardiac Life Support (B&ACLS) in Saudi Arabia. 24 Physicians of different specialties from various hospitals in the KSA were enrolled in this course. 18 candidates were successful and certified as Instructors, two of the successful Instructors, who were Faculty members of the College of Medicine were elected as Associate Faculties to the AHA (2). The Postgraduate Center of King Khalid University Hospital and College of Medicine was responsible in organizing and conducting all different courses in BCLS and ACLS for medical and non-medical personnel throughout the Kingdom. These educational activities started in 1984 and continued until the Saudi Heart Association (SHA) was officially recognized and established in 1987. Since that time, the SHA became the sole responsible body for this activity besides initiating other activities such as conferences, research, journals, etc.
The Saudi Heart Association appointed the author as the Chairman of the National CPR Committee. The committee’s main responsibility is to continue and set plans to expand on CPR educational activities throughout the Kingdom of Saudi Arabia (KSA) for medical and non-medical personnel in both languages. The National CPR Committee decided to organize and conduct only adult CPR courses (provider and instructor) for Basic and or Advanced Cardiac Life Support. These courses are divided as follows:
1. Basic Life Support (for medical & non medical personnel)
These courses are provided as separate or combined ones. As the years passed, hospital accreditation system was enforced. This in itself helped to expand not only by holding courses but also by organizing and conducting workshops in CPR Dental Anesthetic and Organ Transplant Congresses in and out of the Kingdom of Saudi Arabia.
Materials and Results:
15 years statistical data were analyzed. The data of each center were received by the National Heart Center regularly making the annual statistics easier to produce. Analysis of the activities of each center was carried out to produce statistics of different regions or hospitals beside the National Heart Center of the Saudi Heart Association (S.H.A.) and the
Department of Anaesthesia, College of Medicine, K.S.U. The National Heart Center alone managed to conduct 343 Basic (provider and instructor) courses and 116 advanced (provider and instructor) courses. Table.
Development and Training Centers
The National Heart Center was established when the criteria of the AHA. Were applied. The same policy and procedures was maintained, in addition to a regular supervision by a faculty member of the S.H.A to help and maintain the quality of CPR training programs. Once the following major requirements are fulfilled the center is established, and can begin its CPR courses. The requirements are as follows:
1. Instructors with valid certificates, by S.H.A or A.H.A.
2. Teaching facilities such as lecture halls, stations and audiovisual.
3. Mannequins for teaching basic, advanced or both
4. Handout material, the S.H.A provides these at cost without profit.
5. Secretarial and other essential office facilities, which help to continue, maintain and expand these educational activities.
The committee was able to establish 80 centers in the Kingdom for BLS of which 30 in Riyadh region alone and 12 centers for ACLS of which 6 are located in the other regions. Table () shows that 28 centers 77.8 percent were established in other government hospitals such as the university, Military, Security, National Guard and Specialist Hospitals. While 21 centers 28.4 percent were established in the private hospitals and only 31 centers 17.7 percent were established in the Ministry of Health hospitals. The Reasons why the Ministry of Health has a low number of Centers, in comparison to the other sectors, maybe the wide geographical distribution of hospitals, lack of enthusiastic instructors, and lack of financial support which directed towards the developing and maintaining these excellent training centers.
At the beginning, the majority of the courses were organized in Riyadh City at the national heart center, but recently numerous courses were held as more centers were established out of the capital. Table (1) shows the numbers of centers in Riyadh region more than other regions of the Kingdom of Saudi Arabia. It also indicates that more centers out side Riyadh region have ceased to function. Most of the inactive centers belong to the Ministry of Health hospitals. Once again the lack of human, financial support and dedication are the main reasons for the cessation of the activities of these centers. Unless the Ministry of Health Hospitals provides all the means to support CPR activities, the majority of medical personnel will not be certified and eventually the survival rate of cardiac arrest in their hospital will be at a lower level than other hospitals. These activities depend on dedication, enthusiasm, the number of instructors, facilities to expand, availability of courses other than CPR courses. Some centers are more active than others such as the National Heart Center, King Faisal Specialist Hospital & Research Center, Department of Anaesthesia, College of Medicine, KKUH, KAUH, etc. table (2). King Faisal Specialist Hospital & Research Center (KFSH &RC) has the ability to provide Pediatric Advanced Life Support (PALS) and Neonatal Advanced Life Support (NALS) (Provider & Instructor) course. Table (3) Meanwhile the department of Anaesthesia College of Medicine, K.S.U. particularly focused its activities towards student in medical, dental, applied health colleges besides Saudi Red Crescent Society Personnel (Basic and Advanced EMT’s). And the community at large in the form of First Aid. And Citizen CPR in both languages. Table (4).
CIRTIFICATION OF INSTRUCTORS:
The National Heart Center has managed to organized several instructor courses in Basic & Advanced Cardiac Life Support and able to produce until now 197 instructors in ACLS of which 36 were (18.3%) Saudis and 916 instructors in BLS of which 81 (8.8%) were Saudis. Table (5). The validity of instructor certificates is 2 years. Rectification of the instructor is carried out only if the instructors participate actively in 4 courses within the validity of the certificate or enrolled again in a Rectification course. The active instructors are less than the inactive ones in both Saudi and Non-Saudi.
Analysis of the number of instructors into Saudi verses non-Saudi and Active non-Active have been illustrated in table (***) In general, it has been found that the number of Saudi instructor in BLS is 81 (8.8% of the total number of instructors) of which 36 (44%) are still active. While the number of non-Saudi instructors is 835 of which 439 (48%) are still active, in the case of ACLS the number of Saudi instructors are 36 (18.3% of the total instructors) of which 24 (66%) are still active.
The total Saudi Instructor is 117 (10.5% of the total instructors). The above figures show three important points concerning the activity and number of Saudi verses non-Saudi instructors, they are:
CPR TEACHING HOURS:
Each course has fixed teaching hours. These hours are divided into theoretical and practical, between teaching and testing. These are the hours needed for the different CPR courses:
1. Heart saver 4 hours
2. Health care provider 8 hours
3. Instructor 16 hours (8 provider & 8 instructor)
4. Rectification 2 hours
In the case of ACLS, the AHA usually conducts its private course in two days in addition a third for the instructor part. In our 15 years experience in teaching CPR, we found it difficult to apply the AHA’s method of teaching due to the fact that CPR is not part of the curriculum of the under graduate Medical colleges in Saudi Arabia. . Also there are more than 50 nationalities of physicians working in the Kingdom , who are products of several hundred medical schools from around the world? Therefor non of them are exposed to the new methodology of CPR teaching.
Evaluation of each course and the analysis of the response of candidate were carried out in the first year, the result show the majority requested the expansion of the duration of the course. Particularly the teaching stations. The Instructors also requested the same. The decision was made to expand the duration of the ACLS provider into 4 days, with an addition of a fifth day for the instructor courses. Rectification of these providers or instructors is 6 to 8 hours. In conclusion the total hours spent in teaching CPR courses (Provider & Instructor) only at the National Heart Center are *** respectively. It has been estimated that 21 academic years have been spent in teaching CPR in the last 15 years, since the birth of CPR in Saudi Arabia. This is based on 10 teaching hours allocated for Associate Professor per week according to the King Saud University’s rules and regulations.
Achivement or FAILIAR?
Saudi Heart association issued 80.190 certificates. All forms of CPR courses were organized and conducted (Provider, Instructor and rectification). The number of certificates issued for Riyadh & other regions are 63118 and 17072 respectively.
The majority of the medical personnel may consider this as an achievement as the resources are limited, the lack of recognition of the importance of CPR and the late introduction of hospital Accreditation and Quality Assurance scheme.
Several questions arise in ones mind:
Others may consider this as a failure, as only 80190 certificates were issued. While there are 122___ medical personnel working in health care delivery systems. If they were rectified in the past 15-years only 5 times, making the number of certificates issued to medical personnel ____. In addition 13____ of all students in the medical field, plus 10% of personnel working in the medical system, are rectified only twice over a span of 15 years. Making the total student and medical personnel as follows.
13___ * 2 = 27.000
1100 * 2 = 2200
There for, a conservative estimate of the total number of certificates, which should be issued during the past 15 years of the NHC activities are _______.
The number of centers for BCLS is 80 (28%) of the total number of hospitals in the Kingdom of Saudi Arabia, while 12 centers (40%) of the total health regions of Ministry of Health and other health agencies. The above established center, was not what the SHA expected or aimed for.
Future plan and recommendation:
The Saudi Heart Association will succeed if aimed to eliminate all questions asked above. The following recommendation should be tackled in the next five to ten year’s plan.