Botswana's gross national income (GNI) per capita (PPP int. $) is 13,710 and 1341 (9.8%) of the GNI is spent on healthcare [31
]. It is classified as an Upper Middle Income country by the World Bank [32
]. Despite this, The World Health Organization classifies Botswana as a resource limited setting [30
]. Botswana's Human Development Index is 0.633, which gives the country a rank of 118 out of 187 countries with comparable data [33
]. The average life expectancy is 61 years, Under 5 Mortality Rate (U5MR) is 57/1000 live births, and prevalence of HIV is 248/1000 persons aged 15–49 [31
]. The official language of Botswana is English. Setswana is spoken by approximately 78% of the population. Botswana's healthcare system includes 10 district hospitals and two referral hospitals, a national drug formulary consistent with the World Health Organization (WHO) Essential Drugs Programme and both private and government emergency transport services. At the district hospital level, general medical officers and nurses staff general medical wards, operating theatres, and the Accident and Emergency department. District hospitals have limited specialist availability and restricted capabilities for advanced airway, IV access, and defibrillation. The referral hospitals have intensive care units with capability for invasive mechanical ventilation, central venous access, invasive hemodynamic monitoring, peritoneal dialysis, and an expanded availability of specialists. In addition, University of Botswana Schools of Medicine and Nursing maintain academic affiliations and training programs at the referral hospital.
2.2. Participants and training
All in-hospital health care providers engaged in clinical care at Princess Marina Hospital (PMH, Tertiary/Referral) or Athlone (Secondary/District) at the time of the study with no previous CPR training in the past 12 months were eligible for training. Those providers unable to complete training or testing (N = 1) were excluded from the analysis. The American Heart Association approved all instruction methods prior to the study. For CPR skills assessment by AHA checklist criteria, a single rater was used for each station. Any HCP that did not achieve a passing score on either the written or skills test after initial training received additional remediation until they could demonstrate sufficient knowledge and skills to pass (i.e., 100% eventually were certified in BLS for HCP by 2009 AHA criteria before moving into the skill retention portion of the study). Each course was completed within 1 day, and training was conducted using the same small, highly trained group using scripted materials and schedule. The educational officer of each hospital gave AHA educational materials to each provider 1 week prior to their training date. All training and testing was conducted using the same type of manikins, standard Laerdal infant, child and adult models (Laerdal Resusci Anne, Laerdal Resusci Junior, Laerdal HeartCode BLS baby).
2.3. Study design
This investigation was a prospective, quasi-randomized interventional trial. The primary objective of this study was to determine the effectiveness of AHA CPR training to acquire and retain CPR skills for 6 months in a cohort of hospital-based HCP in a resource-limited setting. A secondary objective was to determine if novel teaching methods would have similar training effectiveness compared to instructor intensive standard training.
The primary outcome variable was Excellent CPR
, prospectively defined as having at least 4 of the following 5 characteristics: chest compressions with adequate depth (≥23 mm for infant and ≥38 mm for adult), compression rate (≥90 and ≤120 CC/min), ≤20% of compressions with incomplete release (<5 mm), a no flow fraction (NFF) ≤0.40, and ventilation rate (≥2 and ≤10 ventilations/min). This definition was adapted from our previously reported composite variable for 2-rescuer CPR, and NFF was increased from 0.3 to 0.4 because the simulated skill was single rescuer CPR [21
]. Inter-rater reliability for the primary outcome variable, Excellent CPR, was not appropriate as Excellent CPR is a summary variable based on quantitative manikin output and was not reliant on subjective assessment by instructors.
All providers completed an initial demographic and work environment survey, a 20 multiple-choice question (MCQ) cognitive assessment (2005 AHA BLS exam A) in English, and single-rescuer simulated resuscitation scenario of both the infant and adult prior to training. Acquisition of knowledge and skills was assessed immediately following training, and retention was evaluated at 3 and 6 months. Providers repeated the MCQ and performed quantitative CPR skills on both the infant and adult manikin at each time point. During the CPR psychomotor skill evaluation sessions, providers performed single-rescuer CPR without manikin or instructor feedback [34
Our study was a quasi-randomized to evaluate our secondary objective. The hospital training officer, blinded to instruction method, scheduled providers for CPR training. Courses were conducted in three ways:
Traditional instruction (TI) was the 2005 BLS HCP course (5 h of instruction, AHA 2005 BLS DVD use, student: instructor ratio of 6:1, student: manikin ratio of 2:1, and computerized feedback from the manikins turned off).
Limited Instruction with Feedback (LIwF) was the 2005 BLS for HCP course (5 h of instruction, use of AHA 2005 BLS DVD) with a student: instructor ratio of 18:1, student: manikin ratio of 2:1, with the automated computerized manikin feedback turned on (Laerdal Resusci Anne™ with skill reporter, Laerdal Resusci junior™ with skill reporter, Laerdal HeartCode™ BLS baby with HeartCode™ software via Laptop).
Self-Directed Learning (SDL) training consisted of HeartCode™ BLS for the training without an instructor and the automated computerized manikin feedback on. Student: manikin ratio was 1:2, but only a single manikin was used at a time. HeartCode™ BLS is an interactive, self-directed, comprehensive, computer-based training program from the American Heart Association.
2.4. Data analysis
Standard descriptive and univariate analysis was performed. Summary results are presented as the mean and standard deviation for normally distributed variables and median with interquartile ranges for variables that were not normally distributed. Continuous variables were analyzed using paired t-test for parametric and Wilcoxon signed-rank test for nonparametric variables. Differences between groups for discrete variables were tested with chi-square or Fisher's exact test. Significance was set at p ≤ 0.05.
To evaluate for possible bias due to non-random loss to follow up and loss of interpretable data, we used paired testing where possible, and reported separate baseline scores for each set of comparisons.
In a multivariable model, differences in the retention rate over time and between groups were assessed using generalized estimating equations. Candidate variables were identified a priori, and included English fluency, working in an acute area (Intensive Care Unit, Accident + Emergency, Operating Room or “more than one ward” if at the district hospital), any previous CPR training, frequent performance of resuscitation (>1/month), profession, pre-course BLS cognitive score of ≥84% (AHA Course passing criteria), needing any remediation after training, and years since graduation from professional school. To assess collinearity, we conducted a bi-variable analysis of cognitive skills success and English fluency, as well as cognitive success on needing remediation and found independence between the variables.
The Q-CPR Review software program (Version 184.108.40.206, Laerdal Medical, Stavanger, Norway) was used to acquire, analyze and report manikin data from the log file. Statistical analysis was completed using the Stata-IC statistical package (Version 10.0, StataCorp, College Station, TX). Technical limitations precluded real-time quality control of CPR data collection, and quantification of skills was performed retrospectively.
The Institutional Review Board of the Botswana Ministry of Health, the Children's Hospital of Philadelphia, and the ethics boards of both participating hospitals, PMH and Athlone Hospital, approved the study protocol including consent procedures. Data collection procedures were completed in compliance with the guidelines of the Health Insurance Portability and Accountability Act (HIPAA) to ensure subject confidentiality. Informed written consent was obtained from all HCP who participated in the simulated resuscitation attempts.