Keywords
basic life support - COVID-19 - dental practitioners - interim guidelines for BLS
Introduction
Coronavirus disease 2019 (COVID-19) is an infectious disease which is caused by the
severe acute respiratory syndrome coronavirus 2 virus. It leads to various signs and
symptoms that causes severe acute respiratory syndrome. Most people who get affected
by COVID-19 experience mild to moderate symptoms and recover under moderate care;
however, some become seriously ill and require timely cardiopulmonary resuscitation
(CPR) for a favorable outcome.[1] Owing to the contagious nature of the disease several guidelines were proposed while
handling COVID-19-affected individuals. One such guideline was in view of Basic Life
Support (BLS) implementations and the knowledge of which had to be widespread among
all professionals in the health care services. This concept led to the foundation
for present study.
In view of any medical emergency, the biggest challenge was to ensure that patients
with or without COVID-19 who experience cardiac arrest get the best possible chance
of survival without affecting or compromising the life of care giver.[2] Like any other health care professionals, the members of dental team have a duty
of care to set the seal to provide an effective and safe services to the patients.[3]
Emergency in dental practice is a well-known fact. Since ages, we have been tackling
the medical emergency in dental setup with the recommended BLS guidelines. COVID-19
has had a substantial impact on every aspect of our lives including our candidacy
toward medical emergencies.
The current guidelines of BLS do not address the challenges of providing resuscitation
in the setting of COVID-19 global pandemic.[2] In addition, this fact was also emphasized by Indian Resuscitation Council by stating
that resuscitation guidelines may require modifications in line with the emerging
scientific data related to resuscitation of patients with suspected or confirmed COVID-19
infection.[1]
To address this gap, the American Heart Association, in collaboration with the American
Academy of Pediatrics, American Association for Respiratory Care, American College
of Emergency Physicians, The Society of Critical Care Anaesthesiologists, and American
Society of Anaesthesiologists, and with the support of the American Association of
Critical Care Nurses and National Association of EMS Physicians, has compiled guidelines
to help rescuers treat individuals with medical emergency with suspected or confirmed
COVID-19.[2] Similar detailed methodology of resuscitation has been published and described by
the Indian Resuscitation Council.[1] Hence, this study was conducted to assess the awareness regarding these amendments
among dental health care professionals.
Aim
The aim of the study was to assess the awareness about interim guidelines for BLS
of adults with suspected or confirmed COVID-19 among various dental health care professionals.
Materials and Methods
This study was cross-sectional, anonymous online questionnaire-based survey conducted
during September to October 2020 among various dental health professionals including
undergraduates, postgraduates, and dental practitioners. The study was conducted by
assessing the response to 15 dichotomous questions (set of self-prepared multiple
choice question) pertaining to general BLS guidelines and updated interim guidelines
for suspected COVID-19 cases. The reliability and validity of questionnaire was designed
based on Consensus Reports by the American Heart Association, June 30, 2020, on knowledge
of BLS.
[Fig. 1] describes the summary of BLS health care provider adult cardiac arrest algorithm
for patients with suspected or confirmed COVID-19.[2]
Fig. 1 Summary on Basic Life Support (BLS) algorithm in adults. AED, automated external
defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; PPE,
personal protective equipment.
The questionnaire was framed in a type of online survey form using Google Form—a service
for forms and questionnaire designing which is free of cost for every individual having
a Google account. This tool allows to collect data that were sent to various dental
health care professionals through different social media platforms.
Statistical Analysis
The collected data were calculated with Microsoft Excel and then statistical analysis
was made by Statistical Package for Social Science (SPSS) 21 version. The results
were calculated in the form of frequency and percentages. Mean score of correct responses
were compared between professional qualification groups using one-way analysis of
variance. p-Values of < 0.05 were considered statistically significant.
[Table 1] shows the questionnaire asked in the survey.
Table 1
List of questionnaire with answers
|
General BLS guidelines questions
|
|
1. What does BLS stands for?
|
|
2. Is chest compression the first step when you find a person unresponsive?
|
|
3. Is compression given at least 2-inch-deep at center of chest?
|
|
4. Is 30:2 compression to ventilation ratio?
|
|
5. Do you look for presence or absence of pulse at carotid artery?
|
|
BLS for suspected or confirmed COVID-19 patients
|
|
6. Is the delivery of chest compression an aerosol generating procedure?
|
|
7. Does delivery of chest compression increase infection transmission?
|
|
8. Do limiting personnel at the scene reduces chances of infection spread?
|
|
9. Is it necessary to don PPE during resuscitation?
|
|
10. Is face shield or pocket mask sufficiently effective viral filters during resuscitation?
|
|
11. Can mechanical device be used as an alternative to manual chest compression?
|
|
12. Is hand-only CPR recommended in current COVID-19 scenarios?
|
|
13. Is it recommended to place mask over patients face before starting chest compression?
|
|
14. Do you know about minimum droplet precautions PPE?
|
|
15. What does HEPA stands for?
|
|
Answer key
|
|
1) Basic Life Support
|
|
2) No
|
|
3) Yes
|
|
4) Yes
|
|
5) Yes
|
|
6) Yes
|
|
7) Yes
|
|
8) Yes
|
|
9) Yes
|
|
10) No
|
|
11) Yes
|
|
12) Yes
|
|
13) Yes
|
|
14) Yes
|
|
15) High efficiency particulate air
|
Abbreviations: COVID-19, coronavirus disease 2019; CPR, cardiopulmonary resuscitation;
PPE, personal protective equipment.
Results
In the study, 224 responders were included comprising 127 (57%) postgraduates, 54
(24%) dental practitioners, and 43 (19%) undergraduates. [Table 2] demonstrates the demographic data of participants.
Table 2
Demographic data of participants
|
Undergraduate
|
Postgraduate
|
Dental practitioner
|
|
Gender (total)
|
43
|
127
|
54
|
|
Female
|
28
|
77
|
34
|
|
Male
|
15
|
50
|
20
|
|
Age (average years)
|
22 ± 3.54
|
25 ± 3.54
|
30 ± 3.54
|
Unfortunately, none of the responders had hundred percent knowledge on the basic and
updated BLS guidelines. However, knowledge on universal BLS guidelines had better
response with 69, 78, and 80% correct answers by undergraduates, postgraduates, and
dental practitioners, respectively ([Fig. 2]). While considering the responses on updated interim guidelines on BLS for suspected
or confirmed COVID-19 cases, the data revealed quiet a low level of correct responses
irrespective of the categories of respondents. Thirty-two percent of undergraduates,
42% of postgraduates, and only 44% of dental practitioners responded correctly to
the questions ([Fig. 3]). Mean score comparison of correct responses by these groups showed statistically
significant value (p < 0.001) ([Table 3]).
Fig. 2 Universal Basic Life Support (BLS) guidelines responses by undergraduates, postgraduates,
and dental practitioners.
Fig. 3 Basic Life Support (BLS) guidelines for coronavirus disease 2019 (COVID-19) cases
(suspected or confirmed) responses by undergraduates, postgraduates, and dental practitioners.
Table 3
Intergroup comparison of correct mean score
|
Mean score of correct response
|
Standard deviation
|
p-Value
|
|
Undergraduates
|
22.1333
|
9.723805
|
< 0.0001
|
|
Postgraduates
|
68.06667
|
32.88609
|
|
Dental practitioners
|
30.66667
|
14.20094
|
Looking closely at the individual groups, the knowledge on both universal BLS guidelines
and updated interim guidelines were at very low percentage among undergraduates. Only
36% were aware of the full form of BLS which shows that BLS course should be considered
for inclusion in the Bachelor of Dental Surgery curriculum. Among postgraduates, the
basic guidelines were well known and had better idea on the personal protective guidelines
as compared with undergraduates but the knowledge on newer guidelines were still in
question. In regard to dental practitioners, data showed that they had awareness on
the BLS knowledge and skills but needs to be updated with change in protocols done
by the American Heart Association after COVID-19 pandemic ([Table 4]).
Table 4
Questionnaire with correct responses by undergraduates, postgraduates, and dental
practitioners
|
Questionnaires
|
Undergraduates
correct answers (%)
|
Postgraduates
correct answers (%)
|
Dental practitioners
correct answers (%)
|
|
What does BLS stands for?
|
36 (83.33)
|
109 (85.92)
|
52 (96.55)
|
|
Is chest compression the first step when you find a person unresponsive?
|
25 (58.33)
|
88 (69.01)
|
39 (72.41)
|
|
Is compression given at least 2-inch-deep at center of chest?
|
33 (75)
|
107 (84.51)
|
45 (82.76)
|
|
Is 30:2 compression to ventilation ratio?
|
18 (41.66)
|
85 (67.61)
|
30 (55.17)
|
|
Do you look for presence or absence of pulse at carotid artery?
|
37 (87.5)
|
107 (84.51)
|
50 (93.10)
|
|
Is the delivery of chest compression an aerosol generating procedure?
|
14 (33.33)
|
12 (28.17)
|
11 (20.69)
|
|
Do delivery of chest compression increase infection transmission?
|
9 (20.83)
|
13 (29.58)
|
19 (34.48)
|
|
Do limiting personnel at the scene reduces chances of infection spread?
|
34 (79.17)
|
98 (77.47)
|
45 (82.75)
|
|
Is it necessary to don PPE during resuscitation?
|
23 (54.17)
|
73 (57.75)
|
41 (75.86)
|
|
Is face shield or pocket mask sufficiently effective viral filters during resuscitation?
|
14 (33.33)
|
70 (26.77)
|
19 (34.48)
|
|
Can mechanical device be used as an alternative to manual chest compression?
|
28 (66.67)
|
70 (54.92)
|
32 (58.62)
|
|
Is hands-only CPR recommended in current COVID-19 scenarios?
|
7 (16.67)
|
36 (28.17)
|
13 (24.14)
|
|
Is it recommended to place mask over patient's face before starting chest compression?
|
19 (45.83)
|
37 (29.58)
|
15 (27.59)
|
|
Are you aware of minimum droplet precautions PPE for resuscitation?
|
19 (45.83)
|
43 (33.80)
|
17 (31.03)
|
|
What does HEPA stand for?
|
16 (37.5)
|
73 (57.75)
|
32 (58.62)
|
Abbreviations: BLS, Basic Life Support; COVID-19, coronavirus disease 2019; CPR, cardiopulmonary
resuscitation; HEPA, high efficiency particulate air; PPE, personal protective equipment.
Discussion
It is said that “a patient could collapse on any premises at any time, whether they have received treatment
or not.”[3] Dental office is not immune to occurrence of any such life-threatening conditions.
Cardiac arrest or cardiopulmonary arrest is the most common medical crisis which can
occur leaving the victims with severe morbidities or can even lead to death if not
addressed straight away.[4]
BLS is the phase of emergency cardiac care that prevents respiratory or circulatory
arrest or insufficiency through prompt recognition and intervention. In addition,
it also supports the ventilation of a victim of respiratory arrest with rescue breathing
or the ventilation and circulation of a victim of cardiac arrest with CPR. The major
objective of performing any rescue breathing or CPR is to provide oxygen to the brain
and heart till the time appropriate, definitive medical treatment can restore normal
heart and ventilatory action.[5]
Several factors may affect the quality of CPR provided which can include feedback,
education, and monitoring and it has been accentuated that these should be developed
together to improve quality.[6]
[7] The window of opportunity for survival of patients from sudden cardiac arrest is
very narrow.[8] The lack of training and incompetence to deal with such emergencies can have legal
consequences and tragic outcomes.
This study shows that although there was an adequate knowledge on universal BLS guidelines,
updated interim guidelines were still unknown to maximum percentage of dental professionals.
More than 70% did not know that CPR can produce aerosols and pocket mask is not a
sufficiently effective viral filter, and many more. Several educational institutions
should focus toward organizing more of academic meets to refurbish the knowledge on
BLS among several health care professionals. Active workshop should be conducted for
students to learn and practice. Familiarizing oneself to such situation of urgency
can only be a way to avoid any mishap in future. Hence, there is need to keep ourselves
up-to-date to provide safe services.
However, as limitation of the study, the practical skills could not be analyzed and
only theoretical knowledge was assessed.
Conclusion
Knowledge of BLS is very important among all the health care providers. The present
study reveals the lack in knowledge about updated guidelines of resuscitation. We
suggest a strict accreditation program and periodic reassessment among students and
practitioners.
