Hrev_master Abstract Advanced cardiac life support (ACLS) refers to a set of life- saving protocols and skills for urgently and emergently treat- inglife-threatening conditions that result in cardiac arrest. An insti- tutional-based cross-sectional study was conducted to assess knowledge, practices, and associated factors of ACLS among gen- eral practitioners (GPs) and nurses in Ethiopia. Data were collected using self-administered questionnaires. Data entry was carried out using EpiData version 4.6, and the analysis was performed using STATA 14. Bivariate and multivariable logistic regression analyses were employed. The study included 147 GPs and nurses, yielding a response rate of 94.2%, with 39.5% (95% CI: 32.3-47.7) and 35.37% (95% CI: 28.68-43.8) demonstrating good knowledge and practice, respectively. Sex, education, experience, and the avail- ability of emergency equipment were significantly associated with the knowledge. Workplace, exposure to cases of cardiac arrest, training, and experience were found to be significantly associated with practice. There is a significant gap in both knowledge and practice. Based on our results, we recommend simulation-based in- service training and the inclusion of ACLS protocols in the formal education of health students. Introduction Cardiac arrest is the sudden loss of the heart’s ability to pump, causing the heart to stop beating unexpectedly. This cessation of heart activity leads to the interruption of blood flow to the brain, lungs, and other organs. Breathing becomes abnormal or ceases altogether, and the affected person loses consciousness.1 Cardiac arrest is the most common type of emergency in adults, children, and newborns, and it can have fatal outcomes accounting for roughly half of all cardiovascular disease deaths worldwide.2-4 In a hospital setting, cardiac arrest is an event that can potentially affect any hospitalized patient and is associated with a significant mortal- ity risk if not recognized and managed promptly. Advanced cardiac life support (ACLS) is a set of life-saving protocols and skills for urgently and emergently treating life-threatening conditions that result in cardiac arrest. This involves the use of advanced medical procedures, medications, and techniques.5 Recognizing signs of sudden cardiac arrest, performing cardiopulmonary resuscitation (CPR), and using an automated external defibrillator (AED) for defibrillation are all part of ACLS.6 The ACLS guidelines were first published in 1974 by the American Heart Association and have been updated several times until 2020. ACLS has a profound impact on patients’ outcomes,7 as resuscitation skills can restore life or consciousness. Survival rates can be two to four times high- er when initiated within the first minute of cardiac arrest.8 In most cases of hospital cardiac arrest, healthcare workers are typically the first responders. To reduce the mortality rate and increase the survival ratio, healthcare providers must have a solid understanding of basic ACLS knowledge and practices.9 Their knowledge is essential for improving patient outcomes,10 as ACLS is a key component of the survival chain that increases the rate of Emergency Care Journal 2023; volume 19:12036 [Emergency Care Journal 2023; 19:12036] [page 52] Advanced cardiac life support knowledge, practice, and associated factors among general practitioners and nurses at primary hospitals in Ethiopia Tirunesh Geremew Senbeta,1 Seada Jemal Seid,2 Birhanu Asrat Wudineh,3 Helina Bogale Abayneh3 1Department of Emergency, Holota Primary Hospital, West Shoa; 2Department of Pediatric Nursing, St. Paul Hospital Millennium Medical College, Addis Ababa; 3Department of Emergency and Critical Care Nursing, St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia Correspondence: Helina Bogale Abayneh, Department of Emergency and Critical Care Nursing, St. Paul Hospital Millennium Medical College, Addis Ababa, P.O.Box: 1271, Ethiopia. Tel.: +251.912218245 - Fax: +251.112774787. E-mail: helinabogale2005@gmail.com Key words: advanced cardiac life support; cardiac arrest; general practitioner. Acknowledgments: the authors would like to thank the study partic- ipants, acting hospital heads, and staff, for their cooperation throughout the data collection. Contribution: TGS, HBA, carried out the study starting from con- ception, data collection, analysis and interpretation of data, drafting, and reviewing of the manuscript; SJS, BAW, participated in the study design, data analysis, interpretation, and critical review of the manuscript. All the authors read and approved the final version to be published. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and informed consent: this study was conducted fol- lowing the principles outlined in the Declaration of Helsinki. Approval was obtained from the Institutional Review Board of St. Paul's Hospital Millennium Medical College. Administrative per- mission was granted by the respective hospitals. Informed written consent was obtained from all participants before collecting data. Confidentiality was maintained by excluding their names and other identifiers from the data collection tools. Funding: none. Received: 27 October 2023. Accepted: 3 November 2023. Early view: 5 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:12036 doi:10.4081/ecj.2023.12036 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly survival.11 Every medical professional prone to emergencies must be on call at all times to save lives and improve the quality of CPR.12 While resuscitation guidelines recommend that all medical personnel working in the intensive care unit and emergency depart- ment (ED), as well as those responsible for patient resuscitation, should regularly receive ACLS training,13 healthcare workers, par- ticularly nurses, may lack knowledge of ACLS. This is often attributed to the fact that ACLS training is not required as part of their education and certification requirements.12 Many health pro- fessionals suggest that resuscitation knowledge is underdeveloped due to a lack of formal training in medical and nursing careers.12 International studies on the knowledge, attitude, and skills/prac- tices of various professionals regarding ACLS and basic life sup- port (BLS) have revealed a widespread deficiency in ACLS knowl- edge and practice.9-12 In Ethiopia, ACLS and even BLS are not as widely developed as they are in other developed countries, primar- ily due to the lack of modern medical instruments and well-trained professionals. Many healthcare workers, especially nurses, have underestimated their knowledge of ACLS.14-16 A study conducted among healthcare workers at Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar, Ethiopia, revealed that 59.5% of healthcare workers, including nurses and physicians, had poor knowledge of ACLS.16 According to a study conducted at Debre Markos Referral Hospital in Ethiopia, 64.2% of all healthcare providers had negative attitudes toward CPR, while 88.9% prac- ticed unsafe CPR.17 A similar study at Gondar Comprehensive Specialized Hospital in Northwest Ethiopia found that only 25% of healthcare professionals had a good level of knowledge about adult CPR.18 In contrast to Western nations, Ethiopia does not impose stringent licensing regulations that require physicians, nurses, and other healthcare practitioners to be trained in up-to-date BLS and ACLS guidelines. The lack of a mandatory requirement may potentially result in a gap in knowledge and practical skills. Currently, no research has been conducted to assess the levels of knowledge, practical application, and factors associated with advanced cardiac life support among nurses and general practition- ers (GPs) in three specific public primary hospitals in Oromia, Ethiopia. As a result, this study was designed to investigate the healthcare workforce’s understanding, implementation, and influ- ential factors related to ACLS at these aforementioned hospitals. Material and Methods Study design and setting An institution-based cross-sectional study design was employed from March 15 to April 15, 2023, at Holota, Ginchi, and Enchini primary hospitals in West Shoa, Oromia, Ethiopia. These three public hospitals are located 40 kilometers west of the capital, Addis Ababa. Holota Primary Hospital has over 90 beds and serves a population of over 500,000 people, with over 300 daily visitors. The hospital employs 132 health professionals and has ED, inter- nal medicine, pediatrics, surgery, obstetrics and gynecology, and dental care. Enchini Primary Hospital has over 250 daily visitors and more than 75 beds, serving a population of over 600,000 peo- ple. It also has emergency, internal medicine, pediatrics, surgery, obstetrics and gynecology, and dental care departments, with a staff of 130 health professionals. Ginchi Primary Hospital caters to a population exceeding 500,000 and serves more than 200 individ- uals daily, with over 70 beds. It has 86 health professionals work- ing in emergency, internal medicine, pediatrics, surgery, obstetrics and gynecology, and dental care departments. Study participants The hospitals were chosen using a simple random sampling technique, the lottery method, from among the seven West Shoa primary hospitals. We selected Holota, Enchini, and Ginchi prima- ry hospitals for the study, with Guder Hospital serving as the pretest site. The sample size was calculated using the single population proportion formula, with a confidence interval of 95% and a mar- gin of error (d) of 5%. In the absence of research on the prevalence of ACLS practices and associated factors in primary hospitals in Ethiopia, we used 50% as the best estimate. Initially, this calcula- tion yielded a sample size of 384. However, because the population in the study area is less than 10,000, we used a correction formula to determine the sample size. With this correction, the sample size for the study of practice and associated factors was reduced to 201 participants after accounting for non-respondent rates. For the study of knowledge and associated factors related to ACLS, a sta- tistical formula based on previous research conducted at Bahidar16 revealed a prevalence of 40.5%. Therefore, the final sample size for this aspect of the study was determined to be 198, taking no response rates into account. Finally, we decided to use the larger sample size of 201 for both knowledge and practice. The total number of nurses and GPs in the study area was 180, which was the predetermined number of study participants. All study partici- pants in these hospitals worked in the ED on a rotational basis. The study included all GPs and nurses who were working during the study period. GPs or nurses who refused to participate were excluded. Based on the exclusion criteria, 24 participants were removed from the original study population of 180. The study included 156 participants, with 9 being excluded after data collec- tion due to incomplete data. As a result, 147 participants were included in the final analysis as follows: 12 GPs and 51 nurses from Enchini Primary Hospital; 11 GPs and 36 nurses from Ginchi Primary Hospital; and 15 GPs and 31 nurses from Holota Primary Hospital. Data collection tool and procedure Data were collected through self-administered structured ques- tionnaires. Three data collectors were involved in the data collec- tion process after receiving training. The questionnaires were derived from the standard reference, American Heart Association (AHA) guidelines for ACLS, based on the course content of the 2020-2025 AHA BLS and ACLS.5 The study tools were also checked for reliability, yielding a Cronbach’s alpha result of 0.851 for knowledge and 0.818 for practice. They were validated by the AHA’s teaching manual. The questionnaire had an English version and was divided into four parts. The first part consisted of 12 ques- tions related to the socio-demographic characteristics of the respondents. The second part contained 17 questions to assess the knowledge of the respondents regarding ACLS, with the scores classified into two levels: good and poor knowledge. The third part included 9 questions related to practice in ACLS, with the scores classified into two levels: good practice and poor practice. The fourth part comprised 12 questions related to associated factors of ACLS knowledge and practice. Data quality control The three data collectors have a Bachelor of Science (BSc) degree. They underwent a 2-day training session in ACLS guide- lines before the actual data collection. Throughout the data collec- tion period, the principal investigator closely monitored the pro- cess, checking for data completeness and consistency. Article [page 53] [Emergency Care Journal 2023; 19:12036] Non -co mmerc ial us e o nly Leveling of knowledge and practice Good knowledge of advanced cardiac life support Study participants who answered 80% or more of the knowl- edge questions about ACLS. Poor knowledge of advanced cardiac life support Participants scored below 80% on the knowledge questions about ACLS. Good practice of advanced cardiac life support Participants who meet above the mean score of ACLS (>50%) practice questions. Poor practice of advanced cardiac life support Participants who scored below the mean score of ACLS (≤50%) practice questions. Data analysis The data were entered using EpiData version 4.6, and subse- quently, the data were exported and analyzed with STATA version 14. Categorical variables are presented as numbers and percent- ages, and continuous variables as mean with standard deviation or median with interquartile range, depending on the distribution. After verifying all the assumptions for logistic regression, binary logistic regression analysis was employed to assess the associa- tions between dependent and independent variables. Variables with p<0.25 in bivariate logistic regression were entered into the multi- variable analysis. Crude and adjusted odds ratios were computed, each with appropriate 95 percent confidence intervals. In multi- variable logistic regression, independent variables with P<0.05 were considered statistically significant. Results Socio-demographic characteristics of the study participants One hundred eighty individuals were approached, and 156 agreed to participate. Due to incompleteness and inconsistency in their responses, 9 subjects were excluded from the analysis, yield- ing a response rate of 94.23%. Among the included participants, 75 (51.03%) were female. The average age of the participants was 30 years. 133 (90.47%) held a bachelor’s degree (BSc). 109 (74.15%) were nurses. The participants had a mean experience of 6.46 years (SD ±4.466). The emergency area was assigned to the majority of participants, 70 (47.6%) (Table 1). More than half of the study participants (61.95%) had never received ACLS training. The majority of the study participants, 135 (91.84%), had been exposed to cases of cardiac arrest cases and had been involved in resuscitation efforts. Less than half of 29 respondents (19.72%) reported the availability of emergency med- ication and equipment in the study area (Table 1). Knowledge of participants towards advanced car- diac life support The percentage of knowledge scores among the respondents ranged from 29.4% to 94%. The participants’ mean score on knowledge questions was 65.53±18.98. Notably, 39.5% of the study participants demonstrated good knowledge of ACLS. The quantity and percentage of right answers for each knowledge ques- tion among the participants are shown in Table 2. The percentage of correct answers ranged from 37.2% to 65.5%. Remarkably, 96 participants (65.5%) correctly identified the acronym for AED. Additionally, the questions related to “the critical characteristics of Article Table 1. Socio-demographic and characteristics of study participants at selected primary public hospitals in Ethiopia (2023). Variable Whole cohort n (%) Sex Female n (%) Male n (%) Educational level Bachelor degree 133 (90.4) 72 (54.1) 61 (45.8) Diploma 14 (9.5) 3 (21.4) 11 (78.5) Profession General practitioner 38 (25.8) 16 (42.1) 22 (57.8) Nurse 109 (74.1) 59 (54.1) 50 (45.8) Assigned workplace Emergency 70 (47.6) 32 (45.7) 38 (54.2) Medical ward 29 (19.7) 15 (51.7) 14 (48.2) Outpatient department 22 (14.9) 8 (36.3) 14 (63.6) Operating room 5 (3.4) 3 (60) 2 (40) Pediatric ward 11 (7.4) 11 (91.6) 1 (8.3) Surgical ward 10 (6.8) 6 (60) 4 (40) Age (Median, IQR) 30, (22-44) 28, (22-38) 32, (26-44) Experience (Mean, SD) 6.46, (±4.4) 4.32 (±2.6) 8.2 (±4.2) On job Training on ACLS Yes 56 (38) 25 (44.6) 31(55.3) No 91 (61.9) 50 (54.9) 41(45) Exposure to cardiac arrest case Never 12 (8.1) 5 (41.6) 7 (58.3) Yes 135 (91.8) 70 (51.8) 65 (48.1) ACLS, advanced cardiac life support; IQR, interquartile range; SD, standard deviation. [Emergency Care Journal 2023; 19:12036] [page 54] Non -co mmerc ial us e o nly high-quality CPR,” “the location of CPR for adults,” and “the first drug of choice during cardiac arrest” had the highest correct response rates, scoring 62%, 54%, and 54%, respectively. Conversely, 60.8% of participants answered the question regarding the proper order of the typical sinus rhythm of electrical cardiac activity incorrectly, and 60.1% of respondents correctly answered the definition of ACLS. Regarding other questions, such as “when to stop CPR,” “initial management of symptomatic bradycardia,” and “immediate management of ventricular fibrillation,” over half of the respondents provided correct responses at rates of 53%, 52.7%, and 51%, respectively. A significant discrepancy was seen when respondents’ total knowledge levels were broken down by profession: 12.9% of GPs and 47.6% of nurses had inadequate knowledge (Figure 1). The practice of participants towards advanced cardiac life support Out of the total study participants, 52 (35.37%) demonstrated good practice, while 95 (64.63%) had poor practice in ACLS. The practice questionnaire included nine questions, with a mean score of 50.50±20.67. Scores ranged from 11.1% to 100%. Participants who scored higher than the mean were categorized as having good ACLS practice, whereas those who scored lower than the mean were categorized as having poor ACLS practice. Table 3 shows the respondents’ practice question scores in terms of both number and percentage, with correct answer percent- ages ranging from 34.8% to 69.4%. Notably, about 102 (69.4%) participants answered the question of how to administer CPR to adult victims correctly. Additionally, the questions related to “the proper steps for operating an AED” and “how to manage an imme- diately obstructed airway” were the most correctly answered prac- tice questions, with percentages of 61.5% and 57.1%, respectively. Conversely, 65.2% of participants answered questions about “how to perform CPR for a child” incorrectly. The correct steps in “man- agement of a shock” and “emergency care after witnessing a car- diac arrest” received correct responses from 63.9% and 60.8% of participants, respectively. Less than half of the respondents cor- rectly answered the practice questions marked “witnessing an adult unresponsive victim who has been submerged in fresh water and just removed from it” and “treating an individual who presented in ventricular fibrillation after CPR and one-time attempt at defibril- lation, then his new rhythm is third-degree AV block”, with correct response rates of 41.4% and 45.6%, respectively. When assessing the overall practice levels of respondents based on their profes- sions, a notable difference was found: 55.1% of nurses and 9.5% of GPs had poor practice (Figure 2). Article Table 2. Responses of participants to advanced cardiac life support knowledge questions at selected primary public hospitals in Ethiopia (2023). Knowledge Correct response Incorrect response N (147) % N (147) % Definition of ACLS 59 39.9 88 60.1 The site of electrical impulse for normal cardiac activity 63 42.6 84 57.4 The correct sequence of normal sinus rhythm and electrical heart activity 58 39.2 89 60.8 The first drug of choice during cardiac arrest 80 54 67 46 Abbreviation AED stands for 96 65.5 51 34.5 The proper pairing regarding CPR for an adult: 64 43.3 83 56.7 The critical characteristics of high-quality CPR include 91 62 56 38 Criteria to stop CPR 78 53 69 47 Position of pregnant women during CPR 62 41.9 85 58.1 The location for CRP in adult 80 54 67 46 You have just administered a drug to an individual in supraventricular tachycardia. 65 43.9 82 56.1 She complains of flushing and chest heaviness. The drug most likely caused this complains is, An individual presents with symptomatic bradycardia. Her heart rate is 32. 78 52.7 69 47.3 The initial drug used for this case. The location for chest compression in infants 65 44.3 82 55.7 The role of 2nd rescuer during CPR 62 42.2 85 57.8 The patient comes in the ER with ECG interpretations of ventricular fibrillation, 75 51 72 49 what is your Immediate response to fix problems? ACLS, advanced cardiac life support; AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; ER, emergency room. [page 55] [Emergency Care Journal 2023; 19:12036] Figure 1. Overall knowledge level of respondents based on their profession at selected primary public hospitals, Ethiopia, 2023. Non -co mmerc ial us e o nly Factors associated with the knowledge of advanced cardiac life support The unadjusted binary logistic regression analysis revealed nine variables that contributed to the understanding of ACLS. Six of these variables, with p-values less than 0.25, showed a signifi- cant correlation with knowledge of ACLS. Comparing male and female respondents, the former showed 7.83 times greater knowl- edge [COR 7.83, 95% CI (1.72-35.53)]. Compared to those with a diploma, participants with a bachelor’s degree had higher odds of having good knowledge [COR = 10.84, 95% CI: 3.4-34.25]. Compared to individuals without ACLS training, those who received it had a tenfold higher likelihood of having good knowl- edge [COR=10, 95% CI (2.86-34.8)]. Compared to respondents assigned to the outpatient department, those assigned to the ED had higher odds of having good knowledge [COR=5.41, 95% CI: 1.35-21.61]. Work experience showed an inverse association with participants’ ACLS knowledge [COR=0.71, 95% CI: 0.60-0.85], suggesting that knowledge levels tended to decline with increasing work experience. Moreover, participants who worked in areas with easy access to emergency medications and equipment showed higher levels of knowledge than those who worked in less- equipped areas [COR=4.81, 95% CI: 1.20-19.12] (Table 4). In the multivariable logistic regression analysis, sex, level of education, availability of equipment, and years of experience were found to be significantly associated with ACLS knowledge at a p-value of less than 0.05. Compared to female respondents, males were 3.8 times more likely to have good knowledge [AOR=3.84, 95% CI: (1.005-14.717)]. Compared to diploma nurses, GPs and degree- holding nurses exhibited significantly higher knowledge [AOR=13.4, 95% CI: (1.83-97.74)]. The odds of having good knowledge decreased by 32% for each extra year of experience [AOR=0.67, 95% CI: (0.54-0.85)]. Study participants who worked in areas with emergency medication and well-equipped work- places had 5.3 times higher odds of having good knowledge than those who worked in places with fewer resources [AOR=5.32, 95% CI: (1.44-19.67)] (Table 4). Factors associated with the practice of advanced cardiac life support In the unadjusted binary logistic regression analysis, sex, work experience, training, assigned workplace, and exposure to cases of cardiac arrest showed associations with ACLS practice, with p-val- ues less than 0.25. Male respondents had 9.9 times higher odds of practicing ACLS compared to female respondents [COR=9.92, 95% CI: 1.23-17.90]. Compared to participants who did not receive ACLS training, those who did receive ACLS training had a 5.5-fold higher likelihood of practicing ACLS [COR=5.57, 95% CI: (1.43-21.54)]. With each additional year of work experience, the likelihood of good practice in ACLS increased by 1.2 times [COR 1.23, 95% CI: 1.03-1.48]. Nurses and GPs working in the emergency area were 5.4 times more likely to practice ACLS com- pared to others working in other wards [COR=5.4, 95% CI: (1.35- 21.61)]. Participants with more exposure to cases of cardiac arrest were 9.7 times more likely to perform ACLS practice compared to those with no exposure [COR=9.71, 95% CI: (2.56-37.21)] (Table 5). In the multivariable logistic regression analysis, assigned work- place, training, exposure to cases of cardiac arrest, and work expe- rience were found to be significantly (P-value less than 0.05) asso- ciated with the practice of ACLS. Participants working in the ED were 4.9 times more likely to practice ACLS than those working in another workplace [AOR=4.87, 95% CI: 1.11-21.30]. For each additional year of work experience, the odds of demonstrating good practice in ACLS increased by 1.44 times [AOR=1.44, 95% Article Table 3.Responses of study participants to advanced cardiac life support practice questions at selected primary public hospitals in Ethiopia (2023). Practice Correct response Incorrect response N (147) % N (147) % The correct step for Emergency care 61 39.2 86 60.8 You are transporting an individual who goes into cardiac arrest. IV access is unsuccessful, the next step is 77 52.4 70 47.6 In the primary survey if you suspect the patient's way is obstructed, what is the initial management 84 57.1 63 42.9 Steps to perform CPR for adult victims 102 69.4 45 30.6 Step in the management of a shock 53 36.1 94 63.9 Baby “X “who is 4 years old, comes to the ER with loss of consciousness, and agonal breathing. 51 34.8 96 65.2 There is no pulse, technique to perform CPR for this child You are treating an individual who presented with ventricular fibrillation. 67 45.6 80 54.4 After CPR and one attempt at defibrillation, his new rhythm is a third-degree AV block. The next step is You are witnessing an adult unresponsive victim who has been submerged in fresh water 58 41.4 89 58.5 and just removed from it, he has spontaneous breathing but he is unresponsive. The next step is The proper steps for operating an AED are 90 61.5 57 38.5 AED, automated external defibrillator; AV, atrioventricular; CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; ER, emergency room; IV, intravenous. Figure 2. Overall practice levels of respondents based on their pro- fessions at selected primary public hospitals in Ethiopia (2023). [Emergency Care Journal 2023; 19:12036] [page 56] Non -co mmerc ial us e o nly CI: 1.08-1.91]. Participants who received ACLS training were 13.6 times more likely to practice ACLS compared to those who did not undergo the training [AOR=13.63, 95% CI: 2.66 - 65.74]. Those who had previously witnessed a case of cardiac arrest were 14 times more likely to practice ACLS than people who had not [AOR=14.11, 95% CI: 2.9- 48.05)] (Table 5). Discussion Among the 147 respondents of this study, 51.03% were female, aligning with studies conducted in Ethiopia, which reported pro- portions of 54.9% and 52.9%.19 However, a study conducted at Wollo University showed a different trend, with 57.2% of the par- ticipants being male,20 which can be attributed to the study location difference. In line with a study done in Addis Ababa, where 90.2% of study participants had a BSc degree, the majority of study par- ticipants (90.4%) had one.19 In terms of profession, 25.85% were GPs, which is similar to the 26.61% of general practitioners report- ed in an Ethiopian study.20 Of the respondents, only 38.05% under- went ACLS training; this was done through on-the-job training. Similar findings were reported in a study conducted in Karela, India, where 38.6% of the participants had received ACLS train- ing.21 However, the percentage in this study was higher than in a study done in hospitals in the Amhara Region (31.4%),15 and lower than in studies done at Jazan University in Saudi Arabia (47.7%), where training was obtained.22 The differences in the findings across these studies can be attributed to variations in the accessi- bility of training programs and training preparedness. In our study, 39.5% (95% CI: 32.3-47.7) of the participants showed good knowledge. These results align with a study conduct- ed in Ethiopia and a South Indian study, which reported scores of 40.5% and 41.6%, respectively.16,23 These findings, however, are not as high as those obtained from research carried out in Saudi Arabia, North Kerala, Turkey, and 65%, 76%, and 87% of the pop- ulation, respectively.21,24,25 The differences in ACLS knowledge levels observed in various studies point to potential differences in the usefulness and accessibility of ACLS training courses and readiness initiatives. These disparities may also be related to dif- ferences in training program quality, differences in professional knowledge, differences in resource availability, and differences in healthcare infrastructure. The results of the multivariable logistic regression analysis showed that the availability of emergency supplies and medication, experience, sex, and educational attainment were all highly corre- lated with ACLS knowledge. This result is consistent with a study conducted in Pakistan, where educational level and experience were also identified as significant factors.26 Male respondents were 3.84 times more likely than female responders to have good knowledge compared to female respondents. This is in line with a study from Sains Malaysia that found that males were 5.43 times more likely than females to have good knowledge.27 The disparity in ACLS knowledge concerning sex can be explained by a higher proportion of males (54%) being assigned to the ED, which increases the likelihood of encountering cases of cardiac arrest. Training may also be a contributing factor, as a majority of males Article Table 4. Bivariate and multivariable analysis of factors associated with study participants' knowledge of advanced cardiac life support at selected primary public hospitals in Ethiopia, 2023 (N=147). Variables Knowledge COR p AOR p Good (%) Poor (%) Sex Male 45(30.6) 27(18.37) 7.83(1.72-35.53) 0.008*** 3.84(1.05-14.71) 0.049** Female 13(8.85) 61(42.18) 1 1 Age 58(39.5) 89(60.5) 3.33(.15-70.91) 0.44 Educational level Diploma 1(0.7) 13(8.8) 1 1 Degree 57(39.5) 75(51) 10.84(3.43-34.25) 0.000*** 13.4(1.84-97.74) 0.010** Profession Nurses 39(26.53) 70(47.6) 1 GP 19(12.97) 19(12.9) 1.79(.27-11.98) 0.851 Assigned workplaces Emergency 30(20.44) 40(27.21) 5.4(1.35-21.61) 0.017** 1.45(.65-3.26) 0.357 MW 6(4.08) 23(15.65) 2.5(.50-12.46) 0.264 OPD 10(6.8) 12(8.16) 1.875(.41-8.43) 0.413 PW 5(3.4) 6(4.08) 1 SW 4(2.7) 6(4.08) 1 OR 3(2.04) 2(1.36) 1 Training on ACLS Yes 40(27.2) 16(10.9) 10 (2.86-34.8) 0.000*** 2.54(.706-9.142) 0.153 No 18(12.3) 73(49.6) 1 1 Exposure to cardiac arrest case Yes 55(37.4) 80(54.4) .49 (.06-4.01) 0.511 No 3(2.1) 9(6.1) 1 Availability of Equipment Yes 16(10.88) 13(8.84) 4.8 (1.20-19.12) 0.026** 5.32(1.44-19.67) 0.012** No 42(28.57) 76(51.7) 1 1 Experiences 58(39.5) 89(60.5) .718(.60-.85) 0.000*** .678 (.54-.85) 0.001*** AOR, adjusted odds ratio; COR, crude odds ratio; MW, medical ward; OPD, outpatient department; OR, operating room; PW, pediatric ward; SW, surgical ward; *significant at p<0.25, **significant at p<0.05, ***signifi- cant at p<0.01. [page 57] [Emergency Care Journal 2023; 19:12036] Non -co mmerc ial us e o nly (55.3%) underwent ACLS training. Moreover, the access that peo- ple have to education and training can be influenced by gender roles and societal expectations. It is also possible that men are more likely to be inspired, encouraged, or to undergo ACLS train- ing. This variation may also be caused by differences in the will- ingness to pursue training or take ACLS courses. The participants’ knowledge of ACLS was found to be negatively correlated with their work experience. This may be explained by the progressive loss of theoretical knowledge that occurs with increasing work experience. Degree holders among the study participants were found to be 13.4 times more knowledgeable compared to diploma nurses. This odds ratio is higher than what research done in Amhara has shown.15 This result is not surprising because individuals usually gain more knowledge as they progress in their academic programs, and advanced degrees frequently offer a deeper and more thorough understanding of medical practices and procedures. Individuals who worked in areas well-equipped with emergen- cy medication and equipment had a 5.3-fold higher likelihood of knowing ACLS than people who worked in locations without such resources. This result is consistent with a study conducted at Felege Hiwot Hospital. The result underscores the critical role of access to emergency resources in healthcare settings. Adequate access to emergency medication and equipment can make a sub- stantial difference in the preparedness and knowledge of health- care professionals. When resources are readily available, health- care professionals have the tools and materials necessary to recog- nize protocols. In our study, only 35.37% (95% CI: 28.68-43.8) of participants demonstrated good practice in ACLS, while the majority of partic- ipants demonstrated poor practice. This finding is in line with a study from Tabuk universities, where over half of the participants had poor practice in ACLS.28 However, it is higher than the find- ings of a study carried out in Bhutan, which reported that only 25% of participants had good practice skills.29 These differences could be influenced by factors such as the quality of training programs, the availability of resources, and the level of experience among healthcare professionals. In the multivariable logistic regression results, assigned work- place, training, exposure to cases of cardiac arrest, and experience were significantly associated with ACLS practice (P<0.05). Furthermore, our study revealed that there was no discernible vari- ation in the profession’s level of practice. This finding is in con- trast to research from Nigeria,30 where GPs demonstrated better practice compared to nurses. Additionally, our findings contradict a study conducted in Jamaican universities, that found a negative correlation between practicing ACLS and being a doctor.18 The dis- crepancy between these findings was attributed to various factors, including differences in the study setting, healthcare systems, and the timing of the research. It is possible that the training and roles of healthcare professionals vary across regions and may be influ- enced by local healthcare practices and policies. In our study, participants who had received ACLS training had 13.6 times higher odds of having good practice compared to those who had not. This suggests that training is an effective way to improve psychomotor skills and that practicing with someone who Article Table 5. Bivariate and multivariable analysis of factors associated with study participants' practice of advanced cardiac life support at selected primary public hospitals in Ethiopia, 2023 (N=147) Variables Practice COR p AOR p Good (%) Poor (%) Male 50(34) 22(14.9) 9.9 (1.23-17.904) 0.031** 1.914(.55-6.7) 0.309 Female 14(9.5) 61(41.6) 1 1 Age 52(35.37) 95(64.63) 1.018(.936-1.108) 0.667 Educational level Diploma 2(1.36) 12(8.15) 1 1 Degree 50(34) 83(56.4) 3.6(.83-15.18) 0.088 * 2.722(.27-27.92) 0.399 Profession Nurses 28(19.04) 81(55.1) 1 1 GP 24(16.3) 14(9.5) 2.027(.99-3.22) 0.001*** 7.024(1.27-38.78) 0.025** Assigned workplaces Emergency 33(22.45) 37(25.17) 5.41(1.35-21.61) 0.017** 4.879(1.12-21.31) 0.035** MW 5(3.4) 24(16.32) OPD 7(4.76) 15(10.2) 8.75(.91-8.394) 0.060* 1 PW 4(2.72) 7(4.76) 1 SW 3(2.04) 7(4.76) 1 OR 2(1.36) 3(2.04) 1 Training on ACLS/BLS Yes 35(23.8) 21(14.28) 5.57(1.43-21.54) 0.013** 13.6(2.66-65.74) 0.010** No 17(11.56) 74(50.34) 1 1 Exposure to cardiac arrest case Yes 49(33.3) 86(58.5) 9.7(2.56-37.21) 0.001*** 14.11(2.9- 48.05) 0.002*** No 3(2.04) 9(6.12) 1 1 Availability of Equipment Yes 17(11.56) 12(8.16) .45(.10-1.93) 0.288 No 35(23.8) 83(56.46) 1 Experiences 52(35.37) 95(64.63) 1.23(1.03- 1.48) 0.022 ** 1.44(1.08-1.91) 0.006*** AOR, adjusted odds ratio; ACLS, advanced cardiac life support; BLS, basic life support; COR, crude odds ratio; GP, general practitioner; MW, medical ward; OPD, outpatient department; OR, operating room; PW, pedi- atric ward; SW, surgical ward; *significant at p<0.25, **significant at p<0.05, ***significant at p<0.01. [Emergency Care Journal 2023; 19:12036] [page 58] Non -co mmerc ial us e o nly has received training can greatly boost their competency and capa- bility. The result is higher than the study conducted in Gonder (AOR: 1.74, 95% CI 1.42 to 3.53).18 Work experience shows a strong association with participants’ practice toward ACLS (AOR: 1.44, 95% CI 1.08-1.91). One possi- ble explanation is that practice performance gets better with expe- rience. Previous exposure to cases of cardiac arrest significantly influenced the ACLS practice. Healthcare professionals who had been exposed to cardiac arrest cases exhibited superior BLS/ACLS practice compared to those who had not, as reported in Amhara region referral hospitals.18 This finding may be reasonable by the fact healthcare professionals who have encountered cases of car- diac arrest during their work have had the chance to use ACLS pro- cedures and interventions in actual clinical settings. Compared to study participants in other departments, those assigned to the ED had a 4.9-fold higher likelihood of practicing ACLS. This could be explained by the fact that patients who come to the ED frequently have severe conditions that require ACLS interventions for them to survive, giving medical personnel practice opportunities. This finding is well-supported by the American Heart Association guidelines, which state that staff in critical care and emergency medicine may possess more advanced resuscitation knowledge and skills than those in their typical clinical roles.2 Methodological consideration The study has several strengths. After conducting a survey, we were able to derive important conclusions and offer suggestions for enhancements. The findings also served as inspiration for subse- quent studies and further exploration. Additionally, the transparen- cy and clarity exhibited in the reporting of methods, research pro- cesses, and results contribute to the credibility of the study. This study’s limitation stems from the fact that it was a survey assess- ment, meaning there might not have been much correlation between survey respondents’ real-world behavior and their responses. Conclusions Our study highlights a significant gap in both knowledge and practice of ACLS among nurses and GPs. If regular and effective ACLS training is not provided, this gap may hurt patient survival rates during cardiac arrests. The multivariable logistic regression analysis identified several variables, including sex, educational status, experience, and the availability of emergency equipment and medication, that are related to one’s knowledge of ACLS. Similarly, the assigned workplace, training, exposure to cases of cardiac arrest, and working experience were significantly associat- ed with ACLS practice. These findings emphasize the importance of addressing these factors to improve knowledge and practice in ACLS. Since primary and district hospitals serve as the first line and core areas for immediate patient resuscitation, this study high- lights the need for targeted, regular, in-service ACLS training to bridge the knowledge and practice gap among healthcare workers. Simulation-based education and training, incorporating tangible procedures, should be employed to acquire effective ACLS tech- niques. Based on these results, we advise including ACLS proto- cols in health students’ formal education. References 1. Tintinalli JE, Stapczynski JS, Ma OJ, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw Hill Education; 2016. 2. 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