Although paediatric cardiorespiratory arrest is a rare event,¹ it is associated with high mortality. In cardiorespiratory arrest, cardiopulmonary resuscitation (CPR) can be an important life-saving measure because when performed correctly, patient outcomes are better.² Given that paediatric cardiorespiratory arrest has a high mortality, doctors must be equipped to perform paediatric cardiopulmonary resuscitation (pCPR) correctly and timeously using a structured evidence-based approach. Three critical aspects are associated with performing effective pCPR, namely doctors’ knowledge of how to perform pCPR, their confidence levels and their knowledge of the availability of the required equipment in their facility.^2,3,4

Cardiopulmonary resuscitation skills have a positive impact on the return of spontaneous circulation and neurological outcomes, and this knowledge should be shared in the form of teaching and ongoing simulated practices.⁴ There is a proven link between knowledge of the CPR guidelines and the likelihood of being able to follow and perform the guidelines correctly.^4,5,6 Multiple studies demonstrate that doctors working in clinical settings where pCPR may be required lack the knowledge levels required to perform it effectively.^7,8 Furthermore, medical professionals are only able to retain the knowledge of CPR guidelines for short amount of time. This occurs as early as 3–6 months post-training⁸ and ultimately results in a decrease in the quality of CPR⁹ and poorer patient outcomes.¹⁰

Confidence levels amongst doctors concerning pCPR can be defined as their belief in their ability to perform effective CPR on paediatric patients.¹¹ Positive correlations have been found between confidence levels in performing pCPR and attending a pCPR course, as well as with seniority level of doctor.¹¹ No literature has explored confidence in performing pCPR in different aspects such as anxiety levels, specific CPR courses and experience levels across broader groups of doctors. Therefore, a more in-depth understanding of how self-confidence impacts preparedness for pCPR is necessary.

Equipment availability is an important precursor in being able to perform pCPR adequately. All doctors should be familiar with the equipment as well as its location.¹² No studies were found that examined doctors’ knowledge regarding equipment availability. Such knowledge is integral to the chain of survival.

There is currently a paucity of data on the incidence and outcomes of pCPR in Cape Town. South Africa has a high level of income inequality¹³ and high trauma rates¹³; both have been linked to poor health outcomes including higher infant mortality rates.¹⁴ It can, therefore, be postulated that South African doctors may see more cases of paediatric cardiorespiratory arrest. Thus, it is imperative that South African doctors working in the public healthcare system be adequately prepared to perform pCPR.

The aims and objectives of the study were to assess the preparedness for pCPR of medical doctors working in primary health care facilities (PHCFs) in the Cape Metropole of the Western Cape (WC). Preparedness was defined as sufficient knowledge and confidence to perform pCPR competently and knowledge of the availability of the necessary equipment.

The study findings indicate that doctors working in the PHC sector of the Cape Metropole do not meet the required resuscitation council of SA standards in terms of knowledge. Not only is the knowledge waning, but pCPR appears to be performed infrequently within the facilities. Confidence levels in performing pCPR are also low, and this is associated with low knowledge levels on pCPR, infrequent clinical presentations of patients requiring pCPR, as well as ill-prepared healthcare facilities. Furthermore, doctors have poor knowledge of the availability of equipment required to perform pCPR within their facilities.

A low knowledge score of pCPR has been found in this study, with an average knowledge score of 61.7%, which is significantly lower than the general pass mark of 80.0% for most CPR courses. Research evidence shows that a lack of knowledge of the guidelines results in an inability to apply pCPR guidelines correctly, thereby resulting in poorer patient outcomes.^1,2,3

It is well documented in studies performed globally that knowledge wanes with time.^8,19 This is reflected in this study with knowledge levels decreasing as the grade of doctor (which is a proxy for length of time since last exposure to formal training) increased with grade 3 MOs obtaining the lowest grading on the questionnaire. However, consultants and registrars performed better on the questionnaire than MO grades 2 and 3. This finding can possibly be attributed to their involvement in post-graduate training as well as the finding that more consultants and registrars had done APLS and PALS courses compared to any other grades of doctor. This suggests that knowledge decreases with time since graduation, but education/training may increase and sustain it. Considering that 28.4% of the participants were interns and community service doctors, and that these are not permanent staff, knowledge levels may be lower in PHC settings run only by MOs. This may be the case in many PHC facilities across the WC and South Africa. A possible solution to this problem would be regular training within facilities, with a focus on junior and non-permanent staff members. Furthermore, incentives to regular course attendance could be offered, such as unpaid time off work to attend pCPR courses as well as monetary subsidisation on courses.

International literature shows that a large proportion of doctors only manage cardiac arrest on an average twice a year,²⁰ with South African studies showing that doctors who had more exposure to CPR cases performed better in CPR questionnaires compared to those who did not.²¹ The latter concurs with the findings in this study that suggest that doctors do not see many patients requiring pCPR regularly. This, coupled with the findings of low knowledge scores amongst doctors who performed pCPR less regularly or not at all, fits in with studies showing that less experience is associated with lower knowledge scores.²² Within the context of this study, this will likely have a negative impact on patient outcomes. pCPR training in the form of regular simulated training and drills, course attendance and CPR algorithms in clear view is advised to enhance recollection of pCPR.

International studies show that the provision of more training in the form of pCPR courses results in a significant increase in resuscitated patients surviving to discharge and having improved neurological outcomes.^1,2 Whilst this study does not show any association that attending a pCPR course improves knowledge of pCPR, there is a trend related to attendance of the BLS course and higher knowledge scores. The study also shows that the overall knowledge of pCPR amongst doctors is low, regardless of whether they ever attended a course or not. A possible explanation could be that doctors do not perform pCPR frequently, thereby resulting in poor knowledge retention.

The doctors in this study were specifically lacking in knowledge related to rates of rescue breathing and heart rate needed to initiate pCPR, management of VF, as well as knowledge regarding chest compressions. The lack of knowledge on VF is particularly concerning as it is a potentially reversible cause of cardiac arrest. Furthermore, knowledge of rescue breathing and heart rate needed to perform pCPR as well as knowledge regarding chest compressions and the management of VF are integral core aspects of pCPR and performing it incorrectly will lead to poorer patient outcomes.²³ The study results, therefore, show that doctors lack knowledge on important aspects of pCPR. This is likely to be the result of having never attended a pCPR training course, having last attended a course more than two years prior to the study or performing pCPR infrequently in practice to sustain their skills.

Confidence levels amongst doctors in performing pCPR were low, and those who were confident had higher knowledge levels, even though the overall average knowledge score amongst doctors was low. This suggests that some doctors may be overconfident in their ability to perform pCPR. The results also show that higher confidence levels are associated with attending a paediatric life support course, concurring with findings in the literature.¹¹ This emphasises the importance of pCPR course attendance.

Just over 50% of doctors felt anxious about performing pCPR with the main reasons for anxiety noted to be ill-prepared healthcare facilities, inadequate training and the fact that the need to perform pCPR was too infrequent. The latter fits in with the finding of low levels of frequency in performing pCPR.

There is no correlation in studies performed abroad between the general medical experience of the healthcare professional and CPR knowledge and performance.⁷ No studies were found comparing this in South Africa. There is no significant association between confidence and grade of the doctor in this study; however, the findings showed that consultants were the most confident followed by registrars, whereas MO grades 2 and 3 and interns were the least confident. This may be explained by the fact that MO grades 2 and 3 have the lowest knowledge levels compared to the registrars and consultants because they have lower education levels and had lower course attendance levels, whilst the interns, being the most junior, had the lowest experience levels. However, confidence is a self-reported perception and not objectively measurable, particularly because this study did not show statistically significant differences between groups.

Regarding the knowledge of equipment availability, the study shows that participants were most sure of the items in their facility being present that were general items used regularly as well as in adult CPR. Participants were most uncertain about the availability of items specifically needed for pCPR, suggesting they have never used or very seldom use these items at their facility – a finding that may be explained by the infrequent need for pCPR at facilities studied and also that doctors are not in charge of asset control within these facilities. However, considering the low knowledge levels amongst doctors, this is a concerning finding.

In conclusion, the study shows that PHC doctors are poorly prepared to perform pCPR in their facilities. Regardless of their category, the doctors exhibited low levels of knowledge on how to perform pCPR, lacked confidence levels in their abilities to do so, and poor knowledge of the equipment available in their facilities to adequately perform pCPR. Considering that these findings have implications for poorer patient outcomes amongst paediatric patients presenting with cardiorespiratory arrest, it is recommended that doctors in PHCFs attend emergency care courses regularly in order to maintain their pCPR skills. Recertification in these courses every two years should be mandatory amongst all healthcare workers within PHCFs. Additional measures should be put in place within facilities to enhance recollection of knowledge during pCPR, such as clearly visible pCPR algorithms in the resuscitation room of the facility. Furthermore, doctors should be regularly educated on the locations and availability of equipment required for pCPR within their facility.

Further research is needed to determine the outcomes of cases of pCPR performed within PHCFs. This could be done utilising data from recurring morbidity and mortality meetings. Regular audits of the equipment available for pCPR within healthcare facilities are also advised.