Witnessed Cardiac Arrest by Nigerian Health Workers; Improving the Outcomes

Aim: To assess the involvement of health workers in Cross River State, Nigeria with CPR during witnessed sudden cardiac arrest and the resources available to them for intervention. Settings and Design: The study was carried out in Cross River State, Southern Nigeria which has an international boundary with Cameroon in the East. It is a descriptive, Cross sectional study among health workers. Methods and Material: Consenting health workers belonging to the various categories who met the eligibility criteria were selected using the non-probability method. They included; Doctors, Pharmacists, Nurses, Laboratory scientists, Physiotherapists, Optometrists, Radiographers and Anaesthetic Technicians. Those who declined to complete the questionnaire were excluded. Statistical analysis used: Descriptive statistics (frequency proportions, means and standard deviation) was used to summarize variables. The level of signifi cance was set at P<0.05 Results: One hundred and eighty-two (52.8%) out of the 345 respondents surveyed, had witnessed and been involved in CPR for cardiac arrest. Common sites of witness were the ward (79, 43.4%), A & E unit (36, 19.8%), theatre (27, 14.8%), home (23, 12.6%) and ICU (17, 9.4%). Approximately half of respondents (50.5%) were involved in chest compressions for cardiopulmonary resuscitation (CPR), while 45.1%, 36.3%, 31.3%, 28.6% and 22.0% were involved in oxygen therapy, IV fl uid therapy, rescue breathing, IV adrenaline therapy and transportation to hospital, respectively. Only 13.2% performed defi brillation as part of the CPR. Approximately half of respondents (48.9%) had participated in successful CPR. Contribution to successful CPR were attributed to immediate recognition (38.2%), prompt CPR (38.2%), oxygen therapy (30.3%), adrenaline administration (20.2%) and fl uid therapy (19.1%). Conclusion: Health workers will occasionally encounter SCA and participate in resuscitation. To improve resuscitation outcome, the triad of insuffi cient awareness, infrastructure and capacity building must be addressed. There is a critical need to make automated external defi brillators available especially in hospitals. Research Article Witnessed Cardiac Arrest by Nigerian Health Workers; Improving the Outcomes Queeneth Ndukwe Kalu1*, Oku Oboko Oboko1, Oti Stephen1, Kalu Ndukwe Nwaogburu2 1Department of Anaesthesiology, Faculty of Medicine, University of Calabar, Calabar, Nigeria 2Department of Pharmacy, University of Uyo, Akwa Ibom State, Nigeria Received: 10 September, 2018 Accepted: 25 October, 2018 Published: 26 October, 2018 *Corresponding author: Queeneth Ndukwe Kalu, Department of Anaesthesioloigy, University of Calabar, Calabar, Nigeria, Tel: +234 8037045989; E-mail: queen_kalu@yahoo.com; qkalu@unical.edu.ng


Introduction
Witnessed sudden cardiac arrest (SCA) managed promptly and correctly by a bystander increases the chance of survival [1]. It is a public health problem which can occur in the hospital, at home or public places like church, stadium, cinema hall, market and other meeting places. The presence of a skilled healthcare provider should be an added advantage to the victim. The triad of insuffi cient awareness, infrastructure and capacity building however, continue to pose a challenge to the performance of optimum cardiopulmonary resuscitation (CPR) even among healthcare workers [2].
In many low and medium income countries (LMIC), prehospital care is under developed [3]. With this near absence of out of hospital(OOH) emergency medical service(EMS), and in line with the African culture, healthcare workers are frequently summoned in the neighbourhood to attend to any occurrence of SCA. They may be the fi rst to arrive even where out of hospital emergency medical services exist. They have to be conversant with both the initial intervention as well as subsequent transportation of the victim to the hospital. In our locality, this is mostly through private arrangements using any available vehicle from family, friends or commercial taxis. It is a sharp contrast to what obtains in the western world where emergency dispatchers, fi rst responders, Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) ambulances are engaged [4,5]. The situation is similar in various other professional groups.
A systematic review found that Resuscitation training in developing countries was well received and viewed as valuable training by the students and local counterparts [6]. It concluded that institution of training in trauma and newborn resuscitation in developing countries has signifi cantly reduced mortality.
In practice, despite these training programs, the professionals require regular updates. This is in view of knowledge and skill decay as well as the advancement in resuscitation science with consequent revised resuscitation advisory statements. Solagberu [7] in his work reported a common statement made in mortality review meetings in our sub region 'all resuscitative efforts failed and patient certifi ed dead'. A careful scrutiny of these resuscitative efforts reveals various defi ciencies. While Solagberu [7], identifi ed the need for resuscitation equipment, Tobi [8] and colleagues in another centre in Nigeria stressed the need for training and certifi cation on BLS/ACLS as well as the establishment of cardiac arrest teams as a means of improving resuscitation outcomes. Zha [9] and colleagues on the other hand in a multi-centre study across Nigeria, corroborated the above fi ndings and in addition stressed a need for quality improvement measures, application of real-time resuscitation documentation with structured meetings for continuous quality evaluation as low-cost, nonresource-intensive measures. These recommendations have the potential to identify areas of dysfunction, opportunities for improvement and problems to be addressed in all aspects of the resuscitation process.
The objective of this study was to assess the involvement of health workers in Cross River State with CPR during witnessed SCA and the resources available to them for intervention.

Subjects and Methods
This descriptive Cross sectional study was carried out in

Sociodemographic characterisitics
Three hundred and forty-fi ve healthcare workers were surveyed, out of which 182 (52.8%) had witnessed and been involved in CPR for cardiac arrest. Mean age of the witnesses was 41.3 ± 9.2 years, ranging from 19 to 62 years. Approximately half of subjects (50.6%) were within 31 and 50 years old, and female: male ratio was 1:0.53. Also, approximately half of respondents (48.9%) were nurses, and other cadres of workers were pharmacist (13.2%), medical doctor (12.6%) and physiotherapist (4.4%) ( Table 1). There was signifi cantly higher proportion of respondents that were nurses and pharmacists in government compared with private hospitals (p<0.00).
Approximately half of respondents (51.6%) had more than 10 years of practice experience, but there was no signifi cant difference in this proportion comparing respondents in government and private hospitals (p>0.05). Also, approximately half of respondents (48.4%) had never had previous training on CPR. Signifi cantly higher proportion of respondents in government compared with private hospitals, had had prior training on CPR (p<0.00). Among respondents that had had previous training, most (87.2%) had the training within 10 years prior to the study. There was no signifi cant difference in proportion that had training within 10 years, comparing respondents in government and private hospitals (p>0.05, Table 1).

Witness and Involvement in cardiopulmonary resuscitation
Of the one hundred and eighty-two respondents that had home (23, 12.6%) and ICU (17, 9.4%). Except at home, witness of cardiac arrest at other sites was commoner among respondents from government compared with private hospitals, but statistical signifi cance was found only for witness on the ward (Table 2).
Approximately half of respondents (50.5%) were involved in chest compressions for CPR, while 45.1%, 36.3%, 31.3%, 28.6% and 22.0% were involved in oxygen therapy, IV fl uid therapy, rescue breathing, IV adrenaline therapy and transportation to hospital, respectively (Table 3). Involvement in defi brillation, intracardiac adrenaline and cardiac pacing, were found in 13.2%, 9.3% and 4.9% of respondents, respectively. Involvement in chest compression, oxygen therapy, IV fl uid therapy and IV adrenaline therapy was signifi cantly commoner among respondents in government compared with private hospitals (p<0.05, Table 3).  Table 4).

Discussion
Witnessed sudden cardiac arrest (SCA) offers the best chance of survival to the victim provided the rescuer has requisite skills and resources 1 . This study reveals that 52.8% of respondents had witnessed SCA either within or out of hospital.
Witnessed sudden cardiac arrest is relatively common among  health workers both in the workplace [12] and at home. In this study, among the respondents who witnessed SCA, 43.4% were witnessed on the ward. Higher fi gures were expected in critical areas such as operating theatres, intensive care unit (ICU), and Accident and Emergency (A&E). This was the case in a study of in-hospital cardiac arrests in a Saudi hospital which revealed most of the cardiac arrests as occurring in the intensive care unit and A&E [12]. It is possible that a larger percentage of our own study participants work in the wards in their various hospitals rather than the specialized areas of A&E, theatre, and ICU. Witnessed cardiac arrest at home was reported by 12.6% of respondents. This can be used as a surrogate for out of hospital cardiac arrest. Population based data are needed to compile the prevalence of out of hospital SCA in our locality. Health care workers are likely to observe SCA among their relatives or neighbours at home. Given the delay usually encountered in getting such victims to our emergency rooms, it is not surprising that only 19.8% respondents reported SCA witnessed in the accident and emergency unit. Many sudden cardiac arrest victims are usually brought in dead. Early recognition and call for help remains the fi rst step in the chain of survival for basic life support [13]. It is imperative to have a government organised transportation for moving critically ill, accident and cardiac arrest victims rapidly to the hospital.
It is surprising that only 50.4% of respondents who witnessed SCA reported involvement in chest compression.
High quality chest compression and rescue breathing are  the hallmarks of effective CPR [12,13]. High quality chest compression is defi ned as at least 2cm depth at a frequency of at least 100 per minute with adequate recoil and no interruption [14]. It is so important that chest compression only CPR is recommended where rescuers are unwilling to carry out expired air ventilation in the absence of barrier devices [15]. Studies have shown that appropriate prompt and high quality chest compression greatly enhances survival from sudden cardiac arrest [16]. Mechanical chest compression devices have been deigned to improve the quality of chest compressions though not yet widely accepted nor approved by many resuscitation councils [17]. A study in Sweden found an increased rate of resuscitation when bystanders unwilling to perform expired air ventilation, were encouraged to carry out chest compression only CPR. The survival rate was not signifi cantly different between this group and conventional CPR group [16].
An even smaller percentage 31.3% of our respondents were involved in rescue breathing. Rescue breathing during in-hospital CPR is expected to be higher than what was found in the study because self-infl ating bags (SIBs) ought to be available for use. It is a sad reality that SIB's may not be readily available and accessible in every area of the hospital for emergency rescue breathing. 9 Only 22% of respondents attested to the availability of SIBs in their various A&E units. This leaves victims to the willingness or otherwise of healthcare providers to carry out expired air ventilation. Mouth to mouth rescue breathing is not advisable where the possibility of transmission of deadly pathogens such as SARS [18] or Ebola exists.
Defi brillation either automated or manual is still rarely used during resuscitation following cardiac arrests in our locality. Victims of SCA having shockable rhythms are therefore not given the best possible chance to achieve return of spontaneous circulation (ROSC). Recent evidence is in favour of making defi brillation available to all victims of SCA who may have a shockable rhythm [13]. For this reason, automated external defi brillation has been recommended as part of BLS since the year 2000 [19]. Many countries now have public access defi brillators strategically positioned in public places [20]. In this study, use of AED was not listed among the reasons for successful resuscitation by any of the respondents. This situation is similar to a study by El Sayed [21] and colleagues in Lebanon where AED was used in only 1.5% of OOH cardiac arrests. Kitamura 20 and colleagues in Japan on the other hand, found improved outcomes when public access defi brillators were deployed for out of hospital cardiac arrest. A study in Bosnia revealed 82% prevalence of ventricular fi brillation among SCA victims. 3 Defi brillation is critical in treating adult SCA and LMIC should avail their citizens of this intervention for improved outcome. Surprisingly even in developed countries, delayed defi brillation is common and is associated with lower rates of survival after in-hospital cardiac arrest [22].
Although majority of respondents knew the recommended route of adrenaline administration to be intravenous, 9.2% of respondents still administer adrenaline through the intra-cardiac route. Intravenous adrenaline has been demonstrated in various studies as a positive prognostic factor during resuscitation [19,23,24]. The intra-cardiac route of administering adrenaline and other obsolete practices can be corrected through CPR capacity building workshops. Studies have shown the need for regular refresher courses to improve skills [25]. There however, appears to be no strong evidence clearly defi ning frequency or intervals of these courses. Different countries adopt a position that safeguards the health of their citizenry. In Korea, fi rst responders are expected to undergo CPR and AED training at least once a year [1]. This study reveals that only 51.9%of respondents had received CPR training and these were mostly public servants. A similar study in Spain revealed that public servants were four times more likely to be trained in defi brillation than the rest of the workers [26].
Despite the above fi ndings, 48.7% of respondents have experienced successful outcome in terms of ROSC. The success was attributed to immediate recognition, prompt CPR, oxygen therapy and fl uid therapy in that order. Other researchers have reported that witnessed arrests and shorter time of CPR were associated with higher survival rates when compared to unwitnessed arrests or a longer duration of resuscitation [27,28].

Conclusion
The willingness of health workers in LMIC to promptly attend to witnessed sudden cardiac arrest occurrences at home and in hospitals is highly commendable. To improve the outcome of these resuscitation attempts, however, the triad of insuffi cient awareness, infrastructure and capacity building must be addressed. Among other interventions, there is an urgent need to make automated external defi brillators available in every emergency room.