Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Original Article
Year : 2016 | Volume : 3 | Issue : 4 | Page : 25-28

Experience of Pediatric Advanced Life Support (PALS) provider Courses in a tertiary care centre of Pakistan

Humaira Jurair*, Nasreen Alwani **, Ghazala Kazi ***, Anwar-ul-Haque****

* Senior Instructor, Department of Pediatrics and Child Health, **Assistant Manager Nursing Education Services,***Assistant Professor Department of Emergency Medicine, ****Associate Professor Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan

Correspondence Address:

Dr. Humaira Jurair
FCPS,Senior Instructor,Department of Pediatrics and Child Health, Aga Khan University Hospital,Stadium Road, Karachi, 74800, Pakistan, Cell: 03332437492, e-mail:,
Received: 25-Jun-16/Accepted: 17-Oct-16/Published online: 22-Nov-16

Source of Funding:None Conflict of Interest:None


Pediatric Advanced Life Support (PALS) courses prepare candidates to respond to life-threatening emergencies in children.

Objective:To describe the experiences of teaching the PALS course in a developing country.

Methods:We described the experience of teaching PALS courses conducted according to guidelines of American Heart Association to physicians and nurses at Aga Khan University Hospital from January 2011 to December 2015. The outcome of the courses was recorded as passing of participants both in written test as well as skill stations. The passing score for test was 84%. We also recorded participant’s evaluation of the course. Data were entered in the excel sheet and descriptive statistics were applied.

Results:During 5 years, 1044 candidates participated in 88 PALS courses. Majority were female (n=732, 70.1%). Physicians and nurses were 383 (36.6%) and 661(63.3%) respectively. Besides pediatricians, 373 participants (35.7%) were from emergency department and other clinical area. A passing grade was achieved by 936 (89.6%) of participants; the mean test score for whole sample was 88.37%. Four PALS instructor courses were also conducted and 33 new instructors were added to instructor pool. Evaluation of the course by students revealed that 98% of student felt able to respond in emergency situations while 93% felt confident in the use of taught skills.

Conclusion:We found that conducting PALS courses is a positive educational experience to participants which will help in saving the lives of acutely ill children by practical implications.

Key words: “PALS course”, children, participants

Introduction: Cardiac arrest and life-threatening emergencies are not uncommon in pediatric population. Reported incidence of pediatric cardiopulmonary arrest (CPA) is 8–20/100,000 in out-of hospital setting and 2-6 % of in hospital children admitted to pediatric intensive care unit.(1) Resuscitation of acutely ill child is quite challenging and distressing for treating physicians and nurses. Efficient and effective management in such situation is critical which requires training to achieve competency. Pediatric Advance Life Support (PALS) was introduced by American Heart Association and American Academy of Pediatrics in late 1980s and first formal course was conducted in1994. (2) Several revisions have been done and updated every-five year based on best evidence of research in the field of resuscitation. The latest version of PALS was published in 2015. (3) During the last three decades, the science of resuscitation has evolved and is almost compulsory for residency training program. It is important that healthcare provider of acutely ill children should have PALS certification (4). These life support courses haves been spread across the globe .There are few reports available on PALS courses from developing countries (5, 6).

Methods: The objective of this study is to describe our educational experience of conducting PALS courses at Aga Khan University Hospital in Pakistan The Aga Khan University (AKUH) is a tertiary-care, academic hospital and accredited by Joint Commission International Agency (JCIA). AKUH is also an international training center for courses of American Heart Association (AHA) including PALS for healthcare providers. PALS course was introduced in AKUH in 2008. All pediatric residents, consultants, and nurses have active basic life support as well as PALS certification. AKUH also has cardiopulmonary resuscitation (CPR) committee which schedule meetings quarterly. Each PALS course is conducted by one physician (pediatric intensivist / pediatric emergency physician) and a nurse. Our courses are in accordance with guidelines and format of AHA since 2011. We conduct 2-days PALS provider and 1-day renewal course as well as PALS Instructor course. This study was approved by local Ethical Committee Review (ERC # 4023-Ped-ERC-16). We retrospectively reviewed data of our all PALS courses conducted from January 2011 to December 2015. We collected the following data: number of provider and instructor courses, number of total participants, participants in each course, their designation (nurse/physician, area of practice), and outcomes were recorded as certified PALS provider (passing written as well as skill stations) & PALS Instructor. Participants’ evaluation were recorded regarding level of satisfaction and confidence of participants as well as the course objective and content. The format of evaluation form is in accordance with AHA PALS course. Basic Life Support course certification was mandatory prior to PALS course. The data was entered into excel sheet (MS Office 2010) into password-protected computer. All participants were anonymous to keep strict confidentiality. Data were presented as frequency with percentages or mean with standard deviation (mean with SD). Descriptive statistics were applied.

Results: During 5-years, 1044 candidates participated in 88 PALS courses. Number of participants per course ranged between 16 and 19 with median of 16. Majority of participants were nurses (63.3%) and rests of them were physicians. Pediatric residents and pediatricians were 64.4% and 35.7% participants were from emergency room, catheterization suite, and radiology. The number of courses conducted per year was shown in Figure 1.

Seventy-one courses were two-day PALS provider course which was attended by 874 participants and 17 courses were PLAS renewal course, which was attended by 170 participants. Of total, 936 (89.6 %) participants passed both written test and skill stations. The mean test score of the physician and nurses were 89.65 and 87.1 respectively. Besides these courses, we also conducted four PALS instructor courses and added 33 new PALS instructors in our pool. Ninty-eight percent of participants agreed that content of the course was clear. Although 42% felt that the course is difficult and hard. Ninty-eight percent of the participants felt confident in handling acute emergencies in children while 93% participants felt confident in the use of taught skills.
Course evaluation Course content Course learning objectives were clear 98% yes 2% No Overall level of difficulty of the course 50% appropriate 42% too hard 8% too easy Content was presented clearly 100% yes Nil no Quality of videos and written materials 48% excellent 46% good 6 % fair Nil poor Equipment was clean and in good working condition 92% yes 8 % No Regarding course instructor Provided instruction and helped during skills practice session 99.6% yes 0.4% No Answered all questions before skills test. 100% yes Nil No Was Professional and courteous to the students 100% yes Nil No Participants skill mastery The course prepared to successfully pass the skills session. 96% Nil No 4% not sure Student feel confident in use of the taught skills 93% Yes Nil No 7% not sure Student feel able to respond in an emergency situations 98% yes Nil no 2 % not sure One objective for attaining course was to obtain professional education credit or continuing education credit. 100 % Yes Nil No Nil not sure

Discussion: To our knowledge, this is the first report on PALS courses from Pakistan. Similar reports have been published from Spain, Taiwan and Israel (5, 6, 7). Lopez-Herce et al conducted 10 courses, which was attended by 276 healthcare providers [214 physicians and 62 nurses] in 1994-96 in Spain (5). Weisman et al reported that 28 PALS course was conducted and 739 healthcare providers [226 physicians, 304 nurses and 209 paramedics] participated in 2001-2003 in Israel (7). We conducted 88 PALS courses 1044 healthcare providers [physician 383 and nurses 661] from 2011 to 2015 in Pakistan. Our report also includes 4 PALS instructor courses. Mean test-score of physician and nurses in our study were identical i.e 89.65 and 87.1 respectively, which is consistent with results of another study done in Israel (7). In study by Nadel et al. of a pediatric training program in the USA, postgraduate residents achieved 93.2 ± 5.5% score on the standardized PALS test. (8). Level of achievement in our courses is also similar with PALS results in Taiwan (mean score 86.8%) and Spain (mean score 90.5%) (6, 7) There is strong evidence that the education and training of such courses has a significant impact on the outcome (9, 10). Recently, in-hospital pediatric cardiopulmonary resuscitation outcome was above 44% on survival to hospital discharge (11). Published Literature demonstrated that PALS courses should be in core curriculum of pediatric residency training program worldwide like in our program to improve the survival of children from acute reversible illnesses. The outcome of in-hospital pediatric cardiopulmonary resuscitation is significantly improved from 11% in 2010 to 25% in 2015 at AKUH. (data in process to be submitted for publication) These courses play a vital role in improving healthcare providers’ knowledge, technical skills, confidence, and performance while dealing with a critically ill or injured children.(1, 5) Health care providers can become able to learn the utilization of different simulations scenarios for dealing with real critical situations with specific focus on most recent guidelines. (3) In most of courses in our setting, participants from the different disciplines were grouped together. Mixture of students from different specialty area and workplaces on the same course is usually consider positive, since different experiences contribute to the integration and teamwork. Studies have shown that only single training session of PALS course is not enough and a decline in resuscitation knowledge occurs over time. To keep retention of knowledge and skills of PLAS, regular mock-code sessions and recertification every-two year is recommended by AHA also. (2, 5, 12, 13) There is a strong need of PALS courses for healthcare providers involved in care of acutely ill or injured child; it becomes important that pool of PALS instructors should be increased. Besides provider courses, we conducted 4 PALS instructor course and added 33 new PALS instructors. Our study has few limitations like single-center, retrospective data collection and presentation of limited data. Authors did not describe components of checklist of skill stations. Despite all limitation, the present study will contribute to literature of resuscitation.

Conclusion: Our educational experience showed that there was very good overall achievement and a high level of satisfaction by participants. There is a strong need of disseminating such courses among acute pediatric healthcare provider.

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