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RESEARCH ARTICLE
Year : 2009  |  Volume : 13  |  Issue : 2  |  Page : 54-58

GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?


1 Pediatric Emergency Department, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, India
2 Acute and Critical Care Programs, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
3 Pediatric Intensive Care Unit Mehta's Children's Hospital, Chennai, India
4 Pediatric Intensive Care Unit, Apollo Hospitals, Chennai, India
5 Kanchi Kamakoti Childs Trust Hospital, Chennai, India

Date of Web Publication26-Sep-2009

Correspondence Address:
Indumathy Santhanam
A/3, Sreshta Apartments, 473, Kilpauk Garden Road, Kilpauk, Chennai 600 010
India
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DOI: 10.4103/0972-5229.56049

PMID: 19881184

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 » Abstract 

Objective: To determine whether physicians were aware of and had the skills to implement the American College of Critical Care Medicine/Pediatric Advanced Life Support Course septic shock protocol. Design: A cross-sectional questionnaire survey. Setting: Four academic institutions in Chennai, Manipal, Mangalore, and Trivandrum - cities representing the three southern states of Tamil Nadu, Karnataka, and Kerala, respectively, between February and April 2006. Interventions: Pre and post lecture questions. They were evaluated using 11 questions testing knowledge and 10 questions testing their comfort level in performing interventions related to the initial resuscitation in septic shock. Measurement and Main Result: The ACCM/PALS sepsis guidelines were taught during the PALS course conducted in the four academic institutions. A total of 118 delegates participated, of whom 114 (97%) were pediatricians and four (3%) were anaesthetists. The overall mean number of correct responses for the 11 questions testing knowledge before and after the lecture was 2.1 and 4.07, respectively P=0.001(paired t test). Although, 42% of the respondents (n=50) were aware of the ACCM guidelines, 88% (n=104) did not adhere to it in their practice. A total of 86% (n=101) and 66% (n=78) did not feel comfortable titrating inotropes or intubating in the ED; 78% (n=92) and 67% (n=78), respectively felt that central venous access (CVA) and arterial pressure (AP) monitoring were unimportant in the management of fluid refractory shock. Of the physicians, 20% (n=24) had never intubated a patient, 78% (n=92) had not introduced a central venous catheter, and 76% (n=90) had never introduced an intra-arterial catheter. Conclusions: In view of the lack of skills and suboptimal knowledge, the ACCM/PALS sepsis guidelines may be inappropriate in its current format in the Indian setting. More emphasis needs to be placed on educating community pediatricians with a simpler clinical protocol, which has the potential to save many more children.


Keywords: Septic shock, recognition, children, emergency department, ACCM guidelines, PALS, knowledge barriers, critical illness


How to cite this article:
Santhanam I, Kissoon N, Kamath S R, Ranjit S, Ramesh J, Shankar J. GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?. Indian J Crit Care Med 2009;13:54-8

How to cite this URL:
Santhanam I, Kissoon N, Kamath S R, Ranjit S, Ramesh J, Shankar J. GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?. Indian J Crit Care Med [serial online] 2009 [cited 2014 Sep 17];13:54-8. Available from: http://www.ijccm.org/text.asp?2009/13/2/54/56049



 » Background Top


The World Health Organization has reported that 60% of deaths in developing countries occurred as a result of communicable diseases.[1] A total of 50% of the deaths due to severe sepsis in these countries occurred within the first 24 hours of admission and often shock preceded death.[2] In India, a lack of responsive emergency medical systems,[3] late presentation with little pre-hospital resuscitation,[4] and very few well-equipped and appropriately staffed pediatric emergency departments (PED),[5] are some of the reasons contributing to the high mortality in pediatric septic shock. In addition, front-line physicians often fail to recognize early signs of septic shock resulting in the failure to institute appropriate therapy. Literature reports that when shock was unresolved, progression to multi-organ failure would be inevitable resulting in an overall mortality of 46% to 54%.[6],[7],[8],[9]

Cognizant of the need for early recognition and treatment, a time sensitive, goal directed, step-wise protocol was published by the American College of Critical Care Medicine (ACCM)[10] to guide the bedside physician in the recognition and management of shock in the initial hours of presentation. This protocol was incorporated into the Pediatric Advanced Life Support (PALS) Course Manual in 2002.[11] Aggressive emergency management using this protocol has been successful in decreasing mortality from septic shock in various countries.[12],[13],[14],[15],[16],[17] In 1993, the PALS was formally accredited by the Indian Academy of Pediatrics (IAP) as a separate cell of the IAP. Since then, this course has been conducted by certified PALS instructors.[18]

We chose to conduct this survey to determine whether physicians involved in the care of children were aware of the ACCM/PALS sepsis guidelines, and whether they had the skills necessary to implement the guidelines.


 » Methods Top


The ACCM/PALS sepsis guidelines were taught as a separate interactive presentation during the PALS courses conducted in 4 academic institutions in Chennai, Manipal, Mangalore, and Trivandrum - cities representing the three southern states of Tamil Nadu, Karnataka, and Kerala, respectively, between February and April 2006. Various case scenarios were discussed in the shock work station. Each respondent was required to provide some demographic data and answer 11 clinical questions testing their knowledge and ten questions testing their comfort level in performing interventions related to the initial resuscitation in septic shock. The 7th question had three sub-components testing the choice of inotrope in the different clinical scenarios in shock. We assigned a score of 1 for each correct answer resulting in a maximum score of 11. Acceptable answers were based on the recommendations provided by the ACCM/PALS sepsis guidelines 2002. A student t test was used to compare the mean scores of correctly answered individual questions pre and post lecture. A p-value of less than 0.05 was considered significant.


 » Results Top


A total of 118 delegates participated of whom 114 (97%) were pediatricians and four (3%) were anesthetists. A total of 105 (89%) had less than three years of experience in their specialties. Eighty-two (75%) worked in teaching institutions that catered to both adults and children. Sixty-two (53%) physicians worked in hospitals with an outpatient census of less than 20,000, 35 physicians worked in hospitals that had between 20,000 to 30,000 patients in the out patient department (OPD), while 15 physicians (13%) were employed in institutions that register more than 40,000 patients every year. While all institutions treated children with serious sepsis, the number of children managed in each institution is unknown.

(a) Knowledge

There were more correct answers to all questions post lecture than before the lecture [Table 1],[Figure 1]. The overall mean number of correct responses for the 9 questions testing knowledge before and after the lecture was 2.1 and 4.07, respectively (P=0.001 paired t test).

(b) Skills and Attitude

Although 42% respondents (n=50) were aware of the ACCM/PALS sepsis guidelines, 88% (n=104) did not adhere to it in their practice. However, 98% (n=115) were interested in learning the protocol. A total of 86% (n=101) and 66% (n=78), respectively did not feel comfortable titrating inotropes or intubating in the ED, 78% (n=92) and 67% (n=78), respectively felt that CVA and AP monitoring were unimportant in the management of fluid refractory shock. Of the physicians, 20% (n=24) had never intubated a patient, 78% (n=92) had not introduced a CV catheter, and 76% (n=90) had never introduced an arterial pressure catheter [Table 2].


 » Discussion Top


We conducted this survey to determine the knowledge of the ACCM/PALS sepsis guidelines, the skills needed to treat sepsis using these guidelines, and the immediate impact of an interactive presentation. Although, we found modest improvement in knowledge following the lecture, physicians lacked the skills needed to implement this protocol.

On recognition of septic shock, the ACCM/PALS 2002 sepsis protocol recommended attention to the airway, establishment of ventilation, and administration of 20 ml/kg fluid boluses up to or more than 60 ml/kg. If shock was still refractory, it suggested the initiation of an inotrope and placement of CVA and AP catheters to estimate ventricular filling pressures.[19]

Various barriers unique to India prevent the successful translation of these guidelines to practice. Although the ACCM/PALS septic shock guidelines were published in Indian text books,[20],[21],[22] contemporary resuscitation in the PED is not widely known. Typically, emergency care in India is provided in areas known as "casualty" where infra-structure is poor.[23],[24] Specialty training is neither available nor mandatory for personnel involved in Pediatric Emergency Medicine (PEM). Besides, currently there is no Medical Council of India accredited residency program in emergency medicine.[3] Although there are a few hospitals with organized PED services, these are located in large cities affiliated with corporate hospitals and a few apex medical schools. Mostly, the majority of institutions catering to the economically disadvantaged children in India do not have separate PEDs.[8] Furthermore, the medical curriculum fails to place sufficient emphasis on resuscitation training in PEM.[25]

The lack of hands-on experience and comfort levels in performing procedures such as intubation, CVA or AP catheter placement, and resuscitation pharmacology is therefore not surprising. Skippen, et al. observed that the ACCM/PALS sepsis guidelines cannot be used in environments that lack the skills necessary to implement the guidelines.[26] Our findings lend evidence to this observation. In fact, although, these guidelines were nicely laid out, even community pediatricians in the USA were found lacking in their performance of critical care procedures and in the coordination of the temporal aspects of a prolonged resuscitation.[19]

Predictably therefore, the death rates in severe sepsis cases reported by apex pediatric intensive care units in India are high at 30 to 50%.[27],[28],[29] The surviving sepsis campaign for 2008 envisages a global fall in mortality to 10%.[30] In order to move closer to this goal, a protocol less dependent on invasive monitoring and more dependent on clinical assessment may be more appropriate in the Indian context.[4] Indeed, class 1a evidence from an academic PED of a government children's hospital in Southern India showed that administration of fluids at the rate of 20 ml/kg over 20 minutes up to 60 ml/kg of fluid in the first hour and initiation of an inotrope and performance of intubation when "intubation triggers" were identified followed by further fluids boluses until clinical goals of shock resolution were achieved had demonstrated a dramatic drop in mortality from 50% to 17.6% (P=0.0001) 95%; CI 11.9-24.8%. This data also established the impact of meticulous and serial clinical cardiopulmonary assessment on survival. (OR for survival if shock due to sepsis was corrected in the initial hour was 9.2; 95% CI, 2.1-40.8).[4]

Another major barrier highlighted by our survey was our inability to provide a reasonable educational experience even for those who chose to seek this knowledge. The experience from other continuing medical education strategies has also not been encouraging. A review of 32 studies, with almost 3,000 health professionals[31] found didactic teaching to be ineffective, interactive workshops to be moderately effective and combining workshops with didactic learning only moderately effective. In a Canadian report of 17 studies examining all resuscitation courses, five showed no improvement in knowledge and eight showed no improvement in skills retention.[32] In a study from Baltimore, 45 PALS trained doctors showed poor performance for skills and prolonged time to skill completion.[33] In another study, successful performance improved for airway management, intra-osseous access, and defibrillation immediately after completion of the PALS course.[34] Pediatric residents were confident in their ability to manage emergencies in two surveys.[35],[36] However, when they were examined, none of the residents were able to successfully perform both basic and advanced airway skills, and only 11% completed two vascular skills. In the UK, a survey of 88 pediatricians reported poor knowledge in resuscitation with only 9% having had training in PEM.[35] In a later survey, only 26% of 57 physicians (1/3rd who had training in PEM) provided satisfactory answers to questions about cardiac arrest protocols.[36] These surveys, however, did not include the PALS/ACCM sepsis guidelines and cannot be directly compared with our current study. Computerized mannequins with realistic cardio-respiratory responses may improve mastering of skills in emergency care.[37],[38] The expense and non availability of these mannequins limit its use in the predominantly non-profit PALS courses conducted in India.

However, despite the barriers to knowledge transfer, the eagerness of virtually all delegates to learn current concepts is heartening. Perhaps, inclusion of a module demonstrating the management of septic shock using clinical goals[4] may be more appropriate in the Indian context.[39]


 » Conclusion Top


In view of the lack of skills and suboptimal knowledge, the ACCM/PALS sepsis guidelines may be inappropriate in its current format in the Indian setting. More emphasis needs to be placed on educating community pediatricians with a simpler clinical protocol that has the potential to save many more children.

 
 » References Top

1.The World Health Report 2004: Health systems improving performances. Geneva, Switzerland, World Health Organization, 2000.  Back to cited text no. 1      
2.Molyneux EM, Maitland K. Intravenous fluids-getting the balance right. N Engl J Med 2005;353:941-4.Das AK, Gupta SB, Joshi SR, Aggarwal P, Murmu LR, Bhoi S, et al.   Back to cited text no. 2      
3.White paper on academic Emergency Medicine in India: INDO-US Joint Working Group(JWG). JAPI 2008;56:789-97.  Back to cited text no. 3      
4.Santhanam I, Pai M, Kasthuri KR, Radhamani MP. Mortality after admission in the pediatric emergency department: A prospective study from a referral children's hospital in Southern India. Pediatr Crit Care Med 2002;3:358-63.  Back to cited text no. 4      
5.Santhanam I, Sangareddi S, Venkataraman S, Kissoon N, Thiruvengadamudayan V, Kasthuri RK. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatr Emerg Care 2008:10: 647-55.  Back to cited text no. 5      
6.Kutko MC, Calarco MP, Flaherty MB, Helmrich RF. Sepsis/ Septic shock. In: Fuhrman BP, Zimmerman JJ eds. Pediatric Critical Care. 2 nd edition. United States of America: Mosby:1998; pgs1088-1100.7)  Back to cited text no. 6      
7.Wilkinson JD, Pollack MM, Glass NL, Kanter RK, Katx RW, Steinhart C, et al. Mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit. J Pediatr 1987;111:324-8.  Back to cited text no. 7      
8.Wilkinson JD, Pollack MM, Ruttimann UE, Glass NL, Yeh TS. Crit Care Med 1986;14:271-4.   Back to cited text no. 8      
9.Proulx F, Fayon M, Farrel CA, Lacroix J, Gauthier M l. Epidemiology of sepsis and multi-organ dysfunction syndrome in children. Chest 1996;109:1033-7.  Back to cited text no. 9      
10.Carcillo JA, Fields A. American College of Critical Care Medicine Task Force Committee Members: Clinical parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002;30:1365-78.  Back to cited text no. 10      
11.Zaritsky AL, Nadkarni VM, Hickey RW, Schexnayder SM. Berg RA. Textbook of Pediatric Advanced life support. Dallas, TX. American Heart Association; 2002.  Back to cited text no. 11      
12.Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003;112:793-99.  Back to cited text no. 12      
13.Ninis N, Phillips C, Bailey L, Pollock JI, Nadel S, Britto J et al. The role of healthcare delivery on outcome of meningococcal disease in children: case-control study of fatal and non-fatal cases. BMJ 2005;330:1475.   Back to cited text no. 13      
14.De Oliveira CF, De Oliveira DSF, Gottschald AFC, Moura JDG, Graziela A, Costa AG, et al. An outcomes comparison between ACCM-PALS implementation with and without continuous S CV O 2 monitoring for Pediatric Septic Shock. Intensive Care Med 2008;34:1065-75.  Back to cited text no. 14      
15.Karapinar B, Lin JC, Carcillo JA. ACCME guidelines use, correct antibiotic therapy, and immune suppressant withdrawal are associated with improved survival in pediatric sepsis, severe sepsis, and septic shock. Crit Care Med 2004;32:S573;A161.   Back to cited text no. 15      
16.Verbruggen SCAT BC, de Hoog M, Hazelzet JA, Joosten KFM. Are we getting better? Dramatic changes in mortality in children with sepsis and purpura in Rotterdam. Europediatrics 2006;236.  Back to cited text no. 16      
17.Maitland K, Pamba A, English M, Peshu N, Marsh K, Newton C et al. Randomized trial of volume expansion with albumin or saline in children with severe malaria: Preliminary evidence of albumin benefit. Clin Infect Dis 2005;40:538-45.  Back to cited text no. 17      
18.Shankar J, Janakiraman L, Ramesh J, Ranjith S. Impact of PALS on Pediatric resuscitation knowledge. Asian J Pediatr Pract 2006;9:38-41.  Back to cited text no. 18      
19.Kirby A, Goldstein B. Improved outcomes associated with early resuscitation in septic shock: Do we need to resuscitate the patient or the physician? Pediatrics 2003;112:976-7.  Back to cited text no. 19      
20.Gupta P, Paul VK, Ghai OP. Essential Pediatrics. 6 th edition. New Delhi: CBS Distributors and publishers; 2004. p. 657-62.  Back to cited text no. 20      
21.Jayshree M ,Singhi S. Shock. In: IAP Textbook of Pediatrics. 3 rd edition. New Delhi: JAYPEE; 2006. p. 906-12.  Back to cited text no. 21      
22.Ghosh TK, Yewale V, Parthasarthy A, Shah NK. IAP Specialty series on Pediatric Infectious Diseases. New Delhi: JAYPEE;2006. p. 13-29.  Back to cited text no. 22      
23.Alagappan K, Cherukuri K, Narang V, Kwiatkowski T, Rajagopalan A. Early development of Emergency Medicine in Chennai (Madras), India. Ann Emerg Med 1998;32:604-8.  Back to cited text no. 23      
24.Miller I, Alagappan K, Pai M, van der Vlugt T, Doraisamy D, Rajagopalan A. Recognizing Emergency Medicine in India. Natl Med J India 2001;14:297-300.   Back to cited text no. 24      
25.Indian Academy of Pediatrics: Guidelines for post graduate Medical Education in Pediatrics. Ind Pediatr 2001;38:847-862.  Back to cited text no. 25      
26.Skippen P, Kissoon N, Waller D, Northway T, Krahn G. Sepsis and Septic Shock: Progress and Future considerations. Indian J Pediatr 2008;75:599-607  Back to cited text no. 26      
27.Singh D, Chopra A, Pooni PA, Bhatia RC. A clinical profile of shock in children in Punjab, India. Indian Pediatr 2006;43:619-23.  Back to cited text no. 27      
28.Sarthi M, Lodha R, Vivekananadan S, Arora NK. Adrenal status in children with septic shock using low dose stimulation test. Pediatr Crit Care Med 2007;8:23-8.  Back to cited text no. 28      
29.Jayshree M, Gehlot S, Singhi S. Predictors of multiple organ system failure and death in children with severe sepsis. Pediatr Crit Care Med 2007;8:A59.  Back to cited text no. 29      
30.Dellinger RP, Levy M, Carlet JM, Julian Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36:296-327.   Back to cited text no. 30      
31.Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001:CD003030  Back to cited text no. 31      
32.Quan L, Shugerman RP, Kunkel NC, Brownlee CJ. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course. Pediatrics 2001;108:E110.  Back to cited text no. 32      
33.Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Assessing pediatric senior residents' training in resuscitation: Fund of knowledge, technical skills and perception of confidence. Pediatr Emerg Care 2000;16:73-76.  Back to cited text no. 33      
34.Bowen KA, Ball TM. Pediatricians' evaluations of their residency curriculum in emergency medicine. Pediatr Emerg Care 2003;19:79-83.  Back to cited text no. 34      
35.Buss PW, McCabe M, Evans RJ, Davies A, Jenkins H. A survey of basic resuscitation knowledge among resident pediatricians. Arch Dis Child 1993;68:75-8.  Back to cited text no. 35      
36.Buss PW, Evans RJ, McCarthey G, Scorrer T, Kumar V. Pediatricians' knowledge of cardiac arrest guidelines. Arch Dis Child 1996;74:47-9.  Back to cited text no. 36      
37.Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care 2004;13:11-8.  Back to cited text no. 37      
38.Issenberg SB, McGaghie WC, Petrusa ERl, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 2005; 27:10-28.  Back to cited text no. 38      
39.Santhanam I, Ramesh J, Sangareddi. S, Ranjit. S. Pediatric Emergency Medicine Course. New Delhi: JAYPEE Brothers, Indian Society of Critical Care Medicine. Chennai; 2008.  Back to cited text no. 39      


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