Our study clearly indicates that reevaluation of participants in ALSG courses is essential to promote retention of skills, as progressive limitation of theoretical knowledge was observed in our series. Moreover, indirect evidence supports the importance of subsequent training, which is per se acquired by all instructors. Instructors of the ALSG course possess in-depth knowledge of the skills which they teach in life support courses which they replenish at regular intervals.
Emergency life support training furnishes professionals with the skills to help someone in a life-threatening situation until further expert assistance arrives. Worryingly, Greece has one of the lowest proportion of professionals trained in emergency life support in Europe, despite the fact that a significant proportion of the general population may ultimately need cardiopulmonary resuscitation. This raise concerns concerning the diagnostic work-up and management of patients that present with medical emergency. The actual reasons that may underlie this effect remain to be elucidated, as there are no data to draw firm conclusions. It is believed, however, that in most cases physicians do not attend these courses due to lack of awareness concerning their existence and/or inability to access the organizing committees. A common misperception concerning emergency life support procedures is fear of legal allegations in cases that will ultimately develop severe morbidity and mortality. Structured programs aim at reducing this fear as they provide attendants the theoretical and practical background that ensures proper and efficacious handling of these patients [9].
Nevertheless, it is important to encourage participants to regularly refresh their skills by repeating courses every few years. In the longer term, the emergency services should work together to promote and deliver emergency life support training.
Life support courses in Greece are organized by scientific organizations and participation is voluntary. Certification renewal is offered every 3–5 years. In this study, as in others with similar endpoints, it has been proven that knowledge declines after an average time interval of six months [10]. Knowledge retention among adults participating in adult advanced life support (ALS) courses has been already reviewed by Yang et al in a systematic review that included 11 papers [11]. The authors of this paper observed a gradual decay in knowledge and skills which starts 6 months to 1 year following completion of training, with skill decay being faster compared to knowledge decay. Given this information we recommend that certification renewal should be offered at a shorter time interval that will allow proper revalidation of participants. In countries like Greece that face the problem of economic recession skill reassessment should ideally be done with an affordable economic fee and, if possible, with no charge at all.
The actual methodology that would help reduce knowledge and skill decay overtime has been recently reviewed by Au et al in the field of advance resuscitation training [12]. In their systematic review which included 16 studies and 1,192 participants the authors reported that simulation-based interventions, refresher courses and adjustments to the courses` content during re-evaluation and re-training of participants were of detrimental importance in retaining the required level of knowledge.
Taking this information into account we believe that the incorporation of a structured course of advanced gynecological life with re-evaluation of skill and knowledge retention within the first year is essential to increase physician and paramedical stuff awareness concerning current guidelines and algorithms in advanced life support [13, 14]. In this way, involved healthcare providers will be able to provide higher quality care in the field of gynecology, be able to incorporate such information into clinical practice and respond to emergencies with confidence. Adoption of algorithms to deal with gynecological and other emergencies, standardization of processes and continuous training of health personnel seems to be the correct strategy to improve CPR efficacy in cases of emergencies and to achieve high survival rates [13–15].
Strengths and limitations of our study
Our study presents for the first time in the international literature evidence concerning knowledge retention among participants that have attended an ALSG course and indicates the significance of revalidation of their knowledge. Nevertheless, its main limitation is the inability to include a control group that has already attended a second course of the program; hence, evaluating the potential beneficial effect of the latter in enhancing the understanding of participants. Moreover, data concerning the actual practical skills of involved providers remain, still, unknown; hence, application of theoretical knowledge remains unknown.
Directions for future research
The importance of advanced life support has been stressed in various medical fields. Knowledge retention remains, however, as previously stated, an important issue. Future research should study the usefulness of revalidation programs and determine the optimal interval between the first and sequential courses. It would be also useful to take in mind the actual involvement of participants in cases in real life and request their evaluation concerning the actual benefit of the course. Lastly, it is expected that the more courses a participant attends the more experience he gains; thus, determination of the least number of courses that is needed to gain long-term experience should be studied.