various internationally and nationally accepted guidelines for cpr have been published , and formal training programs based on these guidelines are being conducted by certified training centers . the aim of these training courses is to impart both cognitive knowledge and psychomotor skills of cpr and to provide a standardised care to cardiac arrest victims in accordance with the specific guidelines .
a lot of literature is available on survival after cpr in different clinical settings , but very few studies have been conducted to assess the effectiveness of formal resuscitation training programs on the outcome of cpr .
we designed a retrospective study to evaluate the impact of an american heart association ( aha)-certified basic life support ( bls ) and advanced cardiac life support ( acls ) training course on the outcome of cpr in our hospital .
they initiate cpr whenever there is a cardiac arrest in the hospital and continue till the arrival of the code blue team .
the hospital has a designated code blue team that responds to all in - hospital cardiac arrest alarms , announced through the public announcement system .
the code blue team consists of an anesthesiology registrar , a medicine registrar , on - duty resident medical officer , attending staff nurse and nursing supervisor of the shift .
. do not resuscitate ( dnr ) policy is not legal in india . a code blue running sheet
is filled by a record keeper during the course of cpr . before the intervention , the code blue team followed aha guidelines for cpr , but
an aha - certified 3-day bls and acls provider course was conducted in our hospital in the first week of october 2009 .
the course included lectures and hands - on training of periarrest case scenarios , which were followed by a written test and skill assessments .
all the anesthesiologists and doctors working in the emergency and intensive care units participated in the course and got certified . after getting approval from the hospital ethics committee , we designed a retrospective study to evaluate the effectiveness of the above intervention on the outcome of cpr in in - hospital cardiac arrest victims .
cardiac arrest was defined by the absence of a detectable pulse ( pulselessness ) , by patient 's unresponsiveness or by any arrest rhythm noticed on the monitor .
we identified all cases of in - hospital cardiac arrest in adults ( > 14 years of age ) that occurred over an 18 months period between january 2009 to june 2010 .
we compared the code blue data from january 2009 to september 2009 , i.e. pre - acls training period , with post - acls training period from october 2009 to june 2010 .
the patients on whom cpr was started outside the hospital or on arrival in the emergency ward were not included in the study .
when a patient suffered several cardiac arrests in the hospital , only the first episode was included in the analysis for avoiding falsely elevated rate of successful cpr , or falsely diminished rate of survival to hospital discharge .
immediate survival was defined as the return of spontaneous circulation ( rosc ) for more than 20 min .
the relevant data was entered in the excel sheet and was analysed using epi info software .
chi square test was used to compare the immediate survival rates ( rosc ) and survival to hospital discharge rates in the pre - bls / acls training period and post - bls / acls training period . for all statistical analysis ,
they initiate cpr whenever there is a cardiac arrest in the hospital and continue till the arrival of the code blue team .
the hospital has a designated code blue team that responds to all in - hospital cardiac arrest alarms , announced through the public announcement system .
the code blue team consists of an anesthesiology registrar , a medicine registrar , on - duty resident medical officer , attending staff nurse and nursing supervisor of the shift .
. do not resuscitate ( dnr ) policy is not legal in india . a code blue running sheet
is filled by a record keeper during the course of cpr . before the intervention , the code blue team followed aha guidelines for cpr , but
an aha - certified 3-day bls and acls provider course was conducted in our hospital in the first week of october 2009 .
the course included lectures and hands - on training of periarrest case scenarios , which were followed by a written test and skill assessments .
all the anesthesiologists and doctors working in the emergency and intensive care units participated in the course and got certified . after getting approval from the hospital ethics committee , we designed a retrospective study to evaluate the effectiveness of the above intervention on the outcome of cpr in in - hospital cardiac arrest victims .
cardiac arrest was defined by the absence of a detectable pulse ( pulselessness ) , by patient 's unresponsiveness or by any arrest rhythm noticed on the monitor .
we identified all cases of in - hospital cardiac arrest in adults ( > 14 years of age ) that occurred over an 18 months period between january 2009 to june 2010 .
we compared the code blue data from january 2009 to september 2009 , i.e. pre - acls training period , with post - acls training period from october 2009 to june 2010 .
the patients on whom cpr was started outside the hospital or on arrival in the emergency ward were not included in the study .
when a patient suffered several cardiac arrests in the hospital , only the first episode was included in the analysis for avoiding falsely elevated rate of successful cpr , or falsely diminished rate of survival to hospital discharge .
immediate survival was defined as the return of spontaneous circulation ( rosc ) for more than 20 min .
the relevant data was entered in the excel sheet and was analysed using epi info software .
chi square test was used to compare the immediate survival rates ( rosc ) and survival to hospital discharge rates in the pre - bls / acls training period and post - bls / acls training period . for all statistical analysis ,
they initiate cpr whenever there is a cardiac arrest in the hospital and continue till the arrival of the code blue team .
the hospital has a designated code blue team that responds to all in - hospital cardiac arrest alarms , announced through the public announcement system .
the code blue team consists of an anesthesiology registrar , a medicine registrar , on - duty resident medical officer , attending staff nurse and nursing supervisor of the shift .
. do not resuscitate ( dnr ) policy is not legal in india . a code blue running sheet
before the intervention , the code blue team followed aha guidelines for cpr , but no formal training had been conducted . with the aim of improving cpr skills , an aha - certified 3-day bls and acls provider course was conducted in our hospital in the first week of october 2009 .
the course included lectures and hands - on training of periarrest case scenarios , which were followed by a written test and skill assessments .
all the anesthesiologists and doctors working in the emergency and intensive care units participated in the course and got certified .
after getting approval from the hospital ethics committee , we designed a retrospective study to evaluate the effectiveness of the above intervention on the outcome of cpr in in - hospital cardiac arrest victims .
cardiac arrest was defined by the absence of a detectable pulse ( pulselessness ) , by patient 's unresponsiveness or by any arrest rhythm noticed on the monitor .
we identified all cases of in - hospital cardiac arrest in adults ( > 14 years of age ) that occurred over an 18 months period between january 2009 to june 2010 .
we compared the code blue data from january 2009 to september 2009 , i.e. pre - acls training period , with post - acls training period from october 2009 to june 2010 .
the patients on whom cpr was started outside the hospital or on arrival in the emergency ward were not included in the study .
when a patient suffered several cardiac arrests in the hospital , only the first episode was included in the analysis for avoiding falsely elevated rate of successful cpr , or falsely diminished rate of survival to hospital discharge .
immediate survival was defined as the return of spontaneous circulation ( rosc ) for more than 20 min .
the relevant data was entered in the excel sheet and was analysed using epi info software .
chi square test was used to compare the immediate survival rates ( rosc ) and survival to hospital discharge rates in the pre - bls / acls training period and post - bls / acls training period . for all statistical analysis ,
a total of 627 adult patients suffering in - hospital cardiac arrest for the first time over the study period were included in the study .
cpr was attempted in 284 patients during the pre - bls / acls training period and in 343 patients in the post - bls / acls training period .
there was no significant association between either the age or sex with the outcomes in the study .
of the 284 cardiac arrest victims during the pre - bls / acls training period , 52 patients ( 18.3% ) had rosc , while during the post - bls / acls training period , 97 patients ( 28.3% ) of 343 patients had rosc . on statistical analysis ,
this was considered to be a significant difference in the immediate survival rate ( p = 0.003 ) [ table 2 ] .
outcomes of cardiopulmonary resuscitation of the 52 patients who survived during the pre - bls / acls training period , only 12 patients ( 23.1% ) were discharged from the hospital . during the post - bls / acls training period , 67 patients ( 69.1% ) were discharged of the 97 cardiac arrest victims who had rosc . the survival to hospital discharge rate in the post - bls / acls training period was statistically significant ( p < 0.0001 ) when compared with the pre - bls / acls training period [ table 2 ] .
in - hospital cardiac arrest is an emergency situation that requires teamwork and the appropriate sequential actions to rescue the patients .
the outcome of cardiac arrest and cpr is dependent on critical interventions , particularly early defibrillation , effective chest compressions and assisted ventilation . over the last 50 years , after the introduction of modern cpr , there have been major developments and changes in the performance of resuscitation .
but , despite considerable efforts to improve the treatment of cardiac arrest , most reported survival outcome figures are poor . even in the hospitalised patients , the rate of successful cpr has been reported by some studies to be as low as 26% , although most studies report successful cpr outcome in the range of 1359% .
the lack of resuscitation skills of nurses and doctors in basic and advanced life support has been identified as a contributing factor to poor outcome in cardiac arrest victims . in an effort to improve cardiac arrest outcomes ,
several guidelines on performing cpr have been published and certified training courses based on these guidelines have become a standard in medical professionals training in many parts of the world .
the aim of these courses is to provide information and hands - on practice in the management of periarrest situations in accordance with the latest guidelines .
very few studies are available in the literature on comparative cpr outcomes after formal resuscitation training .
an in - hospital investigation demonstrated that cardiac arrest detected by an acls - trained nurse was strongly associated with a four - fold increase in survival to discharge ( 38% vs. 10% ) than those detected by a nurse without acls training .
this indicates that acls - trained nurses provided an independent contribution to increased survival rate .
the results of the present study show that the rate of immediate survival was 18.3% during the pre - bls / acls period , which increased to 28.3% during the post - bls / acls period .
the rates of rosc during both the study periods were not much different from those of previous studies of in - hospital cardiac arrests .
but , our study clearly shows an improved rate of immediate survival after the formal bls / acls training ( p < 0.005 ) . a brazilian study by moretti et al .
also shows a significant increase in rosc from 27.1% to 43.4% even on inclusion of a single acls - trained personnel in the resuscitation team .
another study by sanders also reported improved resuscitation success in a rural community hospital after an acls provider course .
a study by borimnejad et al . also showed that initial survival after cpr improved significantly with the cpr - trained emergency team ( 18.430% ) .
although a previous study by olasveengen reported a weak trend with survival to discharge rates improving only from 11% to 13% after implementation of the modified 2005 cpr guidelines , the study by moretti et al . reported a statistically significant increase in survival to discharge in patients resuscitated by the cpr team having an acls - trained personnel versus the team having no acls personnel ( 20.6% vs. 31.7% ) .
our study also reports markedly improved survival to hospital discharge rates ( 23.1% vs. 69.1% ) after formal bls / acls training ( p < 0.0001 ) . the survival to discharge rates during the pre - bls / acls period of our study are almost comparable to that reported in the literature ( 11.732.2% ) , but the significant increase in survival to discharge rates after the bls / acls training to 69% highlights
that formal training of code blue team members enormously improved the skills of cpr and their level of competence in resuscitation.[13121517 ] this also shows that the quality of cpr performed might be better after acls training .
this highlights the importance of certified hands - on training program on the outcome of resuscitation
first , because this study was conducted at a single institution , external validity is relative and uncertain .
second , our results might be biased because of increased attention on resuscitation during the post - training period .
first , because this study was conducted at a single institution , external validity is relative and uncertain . thus , other multicenter studies are required to ascertain the validity .
second , our results might be biased because of increased attention on resuscitation during the post - training period .
first , because this study was conducted at a single institution , external validity is relative and uncertain . thus , other multicenter studies are required to ascertain the validity .
second , our results might be biased because of increased attention on resuscitation during the post - training period .
successful resuscitation after cardiac arrest requires early recognition of cardiac arrest , rapid activation of trained responders , timely initiation of bls , early defibrillation and early acls . in accordance with a few data available in the literature
, our study reveals that formal training of the cpr team drastically improves the survival rates and survival to hospital discharge rates following resuscitation of cardiac arrest victims .
we conclude that formal certified bls and acls training courses with hands - on practice and their periodic renewal are crucial in improving the outcomes of cpr .
 background : guidelines on performing cardiopulmonary resuscitation ( cpr ) have been published from time to time , and formal training programs are conducted based on these guidelines . very few data are available in world literature highlighting the impact of these trainings on cpr outcome.aim:the aim of our study was to evaluate the impact of the american heart association ( aha)-certified basic life support ( bls ) and advanced cardiac life support ( acls ) provider course on the outcomes of cpr in our hospital.materials and methods : an aha - certified bls and acls provider training programme was conducted in our hospital in the first week of october 2009 , in which all doctors in the code blue team and intensive care units were given training . the retrospective study was performed over an 18-month period . 
 all in - hospital adult cardiac arrest victims in the pre - bls / acls training period ( january 2009 to september 2009 ) and the post - bls / acls training period ( october 2009 to june 2010 ) were included in the study . 
 we compared the outcomes of cpr between these two study periods.results:there were a total of 627 in - hospital cardiac arrests , 284 during the pre - bls / acls training period and 343 during the post - bls / acls training period . in the pre - bls / acls training period , 52 patients ( 18.3% ) had return of spontaneous circulation , compared with 97 patients ( 28.3% ) in the post - bls / acls training period ( p < 0.005 ) 
 . survival to hospital discharge was also significantly higher in the post - bls / acls training period ( 67 patients , 69.1% ) than in the pre - bls / acls training period ( 12 patients , 23.1% ) ( p < 0.0001).conclusion : formal certified bls and acls training of healthcare professionals leads to definitive improvement in the outcome of cpr . 
Introduction
Materials and Methods
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Clinical setting
Intervention
Study design
Statistical analysis
Results
Discussion
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Limitations of the study
Conclusions