This study demonstrates that direct mail significantly improves the knowledge of specific changes in BLS guidelines. However, the study also demonstrates room for improvement in the knowledge of the diagnosis of cardiac arrest and activation of the EMS.
Direct mail is a simple way of disseminating information to a large group of individuals. The significant improvement in knowledge of guidelines caused by this simple intervention makes this a favourable way of drawing attention to changes in guidelines. The improvement was restricted to the changes outlined in the personal cover letter (compression depth and frequency), whereas the poster outlining the entire BLS sequence did not seem to have an effect. This finding indicates that pushing information to GPs should be personally directed, easy to assess and preferably not in the form as a poster.
Compression depth and frequency have been changed in the ERC Guidelines for Resuscitation 2010 due to the importance of chest compressions in improving survival[1, 8]. Even though direct mail significantly improved knowledge of compression depth and frequency there is nevertheless room for improvement since 1/3 of the direct mail group did not know the correct answer. This is in accordance with the physicians’ self-evaluated need for relevant BLS training among GPs.
The lack of knowledge of current guidelines was even more pronounced when it came to diagnosing cardiac arrest. Checking for carotid pulse is an inaccurate way of diagnosing cardiac arrest and is not recommended[9–11]. We found that more than 50% in both groups would check for pulse as a diagnostic criteria for cardiac arrest and not evaluate whether breathing is abnormal or absent. This diagnostic delay may result in loss of valuable time before initiation of BLS. Likewise, no less than 40% of GPs would initiate BLS instead of calling the EMS as the first action after diagnosing cardiac arrest. The importance of early activation of the EMS among GPs needs to be emphasised although the response to a questionnaire and what the physician would do in real life may differ. In almost all general practice clinics, the physician is not alone, and a secretary or a nurse would possibly immediately activate the EMS.
Previous studies have shown a discrepancy between self-evaluated compliance with guidelines and clinical practice. Similar, in our study a high proportion of physicians stated familiarity with the ERC Guidelines for Resuscitation 2010 even though many answers were consistent with 2005 or even 2000 guidelines.
Another important finding of this study is that many GPs eventually will need to manage cardiac arrest in their clinic. Even though cardiac arrest is a rare event, 40% had performed an average of 2 BLS attempts in their clinic, making GPs an important factor in the chain of survival. It is well documented that BLS increases chances of successful defibrillation and increases survival to discharge. Because 2/3 of GPs do not have access to an AED, BLS is their only treatment option during a cardiac arrest until the EMS arrives. Accordingly, it is crucial that new resuscitation guidelines are implemented in general practice.
Ideally GPs should attend a BLS/AED refresher course every two years and when new resuscitation guidelines are published. Unfortunately time and money may be a considerably barrier for GPs to attend a hands-on training course and alternative training methods are needed. E-learning is suitable for reaching small groups over large distances, however the limited studies on this topic show conflicting results[15, 16]. Retraining using a poster and a manikin may be a cost effective way of introducing skills and refresher training in general practice, but the beneficial effect must be evaluated in further studies[17, 18]. Direct mail is suitable for drawing attention to changes, but the optimal method to improve general knowledge and skills on resuscitation guidelines is still to be found.
Cardiac arrest carries a dismal prognosis and is frequently encountered in general practice, although rarely by the individual GP. Our findings call for a better implementation of guidelines in clinical practice. Furthermore, this study presents direct mail as a way to facilitate the implementation of guidelines to GPs.
This study tested the theoretical knowledge of BLS guidelines and not practical skills. Theoretically, BLS knowledge may not convert to practical skills. Studies on laypeople have however shown that training increases willingness to perform BLS. Despite a follow up letter to non-responders the overall response rate was 58%, which may introduce selection bias. However, the controlled design with cluster-randomisation of the GPs and a non-differential selection bias makes the comparisons between the groups valid. If the responders were those most interested in the area and thus, with the highest knowledge, we may have overestimated the proportions with specific knowledge. Finally, based on this study it is not possible to elucidate the long-term implementation in the direct mail group as the assessment was made two weeks after mailing the cover letter and poster.