Indian Society of Anaesthesiologists cardiopulmonary resuscitation guidelines: Ushering in a new initiative.

Abstract

Clinical practice guidelines are recommendations for clinicians on the care of patients with specific conditions and are based on evidence in literature and best practice. The first definition of medical practice guidelines was possibly issued in the Institute of Medicine report, which defined guidelines as ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.’[1] Following guidelines improves quality of care, ensures consistency and enhances outcomes.[2] The recognition that mortality and morbidity associated with sudden cardiac arrest can be mitigated has led to a number of cardiopulmonary (CPR) guidelines being framed across the world. CPR algorithms need to be simpler than medical practice guidelines, as they may be primarily addressed to laypersons and paramedics. The guidelines likewise need to be short as time is the essence. Outcomes after sudden cardiac arrest have improved significantly wherever guidelines have been followed.[3] A successfully drafted guideline needs to be inherently simple and needs to have a short, easy to remember algorithm. A guideline, targeted to train less educated people, should be ‘simple to the extent of appearing naive.’ Structured algorithms are easy to teach/learn and are more acceptable. No widely accepted CPR practice guideline has yet been drafted in the Indian subcontinent. CPR guidelines currently taught and followed in most parts of our country have the disadvantage of being designed by and for the western world; containing all modalities of CPR in a single voluminous document; being very detailed; needing long periods of training and expensive periodic recertification; dependence on use of expensive training/resuscitation equipment; and not easily communicable to the common populace of India because of language/educational barriers. Automated Defibrillator Devices, for use by laypersons, are infrequently available, and early transfer of victims is not feasible in most parts of the country. In addition, copyright barriers make their training/certification unaffordable to the layperson on the streets. Internationally, CPR guidelines have remained in the domain of cardiologists. However, in India, anaesthesiologists took up the mantle of organising CPR training camps and workshops. Realising the dire need to beef up workforce trained in resuscitation, deficiencies in the present training modules and the need to train the masses of the country, the Indian Society of Anaesthesiologists (ISA) took up the task of developing indigenous CPR guidelines and thereafter organising affordable nationwide CPR training modules. A Resuscitation Council was formed by the ISA to brainstorm and develop resuscitation guidelines and plan out their implementation across the country. After a series of deliberations, the council has come out with three basic guidelines: one for laypersons [Compression-Only Life Support (COLS)], one for doctors and paramedics to resuscitate cardiac arrest victims outside hospitals [Basic cardiopulmonary life support (BCLS)], and the third for doctors and paramedics to resuscitate in-hospital cardiac arrest victims [Comprehensive cardiopulmonary life support (CCLS)]. These guidelines have been published in this issue of the journal. The focus of the council was to draft the guidelines as simple steps, which can be easily followed by the relatively less educated populace. Ample evidence on the benefits of hands-only CPR has been published in international literature. No international guideline has however been drafted recommending hands-only CPR as the sole resuscitation method to be followed by laypersons. COLS is the first guideline to be published, which is focussed primarily on hands-only CPR. The shift to this single intervention resuscitation protocol is novel and was designed considering the infrastructure and trained workforce limitations. Ideally, guideline panel recommendations should be specific, precise, have clarity, be executable and decidable.[4] Guidelines must be issued transparently. The Resuscitation Council faced a number of challenges in drafting the guidelines. A major challenge was a lack of national CPR data and publications in this field from the country. Other challenges were overcoming the shortage of sufficient training aids, designing modules keeping in mind the limited equipment/logistics available in emergency departments, catering to a vast population which was predominantly not well educated, economic constraints and language/cultural barriers. The CPR guidelines, framed by the Resuscitation Council, are limited to an amalgamation of the recommendations in contemporary literature, suitably modified so as to be implementable in the available infrastructure. The initial draft suggested by the ISA core academic team was restructured, after multiple meeting of experts, to apply the international evidence in an Indian context. They are simple, clear recommendations with simply designed algorithms but are not ideal guidelines, as they are without a systematic description of the scientific data behind the recommendations and also do not assign evidence quality and strength to the recommendations.[4] This limitation however must not hinder them from being followed across the country. Spreading awareness to maintain good records of resuscitation events in future, their audit and analysis of the data should help strengthen these guidelines in their future editions. Publication of the CPR guidelines is just a first step to develop a successful, vibrant and model resuscitation programme. Training modules, based on these guidelines, are being developed by the ISA. There is an emergent need to develop a large pool of trainers and hence train-the-trainer programmes are being developed. The pathway to active citizen participation involves continuous education and awareness programmes run across all social, print and audio-visual media. Successful implementation and acceptance of the guidelines would be achieved when the layperson is aware of the guideline. Success can also not be achieved without the involvement of the bureaucracy and the government in the campaign. Political endorsement is essential to run the program effectively on a long-term basis. The aim of ISA should be to get the programme endorsed by the Union government to give it sanctity. All members of ISA need to encourage public/private hospitals and institutions to follow these guidelines and train their staff using these algorithms.