Introduction

Cardiopulmonary Resuscitation (CPR) was introduced in the United States in 1966 when the National Academy of Sciences National Research Center (NAS NRC) Conference on CPR recommended training of medical, allied health, and other professional medical personnel in theapplication of external chest compression techniques in accordance with the standards of the American Heart Association (AHA). ₂ The public at large was furnished with training in Basic Life Support (BLS) in 1973. The first adult Advanced Cardiac Life Support (ACLS) course was organized in 1974. Other courses in Advanced Life Support, such as pediatric and neonatal, were introduced later. Mortality due to cardiovascular causes decreased in the United States following the implementation of CPR techniques. ₃ Two decades later, CPR was introduced into the Kingdom of Saudi Arabia (KSA). The start was modest. In 1979, CPR (BCLS and ACLS) instruction was provided to undergraduate medical students using audiovisual aids. The principal instructor (MAS) earned his BLS Instructor's certificate from the AHA in 1982. At the same time, limited activities of CPR (Basic only) were organized in a very dosed community. In the summer of 1983 the author contacted the headquarters of the American Heart Association and invited them to hold in the spring of 1984 the first CPR instructor courses. This invitation was made by the College of Medicine, King Saud University (KSU).d the first CPR instructor's courses in BCLS and ACLS in the KSA. Twenty four physicians of different specialities from various hospitals in the KSA enrolled in this course 18 candidates were certified as instructors, two of them were faculty members of the College of Medicine and were selected as Associate Faculty to the AHA. ₄ Thus, the Postgraduate Center, College of Medicine, King Saud University became responsible for organizing and conducting all different courses in BCLS and ACLS for medical and non medical personnel throughout the Kingdom. These educational activities started immediately following the first AHA instructor level course and continued until the Saudi Heart Association (SHA) was established and recognized in 1985. Since that time, the SHA has become solely responsible for these activities as well as for initiating other activities, such as conferences, research, journals, etc. Two additional courses were organized in 1987 and 1993 respectively, in order to update the faculty members of the SHA with the new guidelines in CPR and Emergency Cardiac Care (ECC).` In the three courses conducted by the AHA in Saudi Arabia the instructors were senior faculties and the chairmen of the AHA.

The SHA appointed the principal author as the Chairman of the National CPR Committee. The Committee's main responsibility has been to continue and establish plans to expand CPR educational activities throughout the Kingdom for medical and non medical personnel in both the Arabic and English languages. The members of the National CPR Committee were selected from all regions of Saudi Arabia and from different backgrounds of medicine. The committee decided to organize and conduct only adult CPR courses (Provider and Instructor) for BCLS and ACLS. These courses were divided as follows:

1. BLS (for medical and medical personnel);

2. ACLS (for medical, Emergency Medical Service (EMS) personnel, and nurses in critical care areas). These courses have been provided either separately or combined.

Methods

Data for 21 years were abstracted and analysed. Regularly, data from each Center were received and filed. The National Heart Committee (NHC), provide separate file for each center, thus record of activities, of each center is intact. This ultimately maksing the annual statistics easier to produce. Analysis of the activities of each center was carried out to produce statistics of different regions or hospitals beside the NHC of the SHA and the Department of Anaesthesia, College of Medicine, KSU. The NHC alone managed to organise and conduct varieties of courses including provider and instructor for BLS and ACLS and is the sole body responsible to establish accredited training centers in the Kingdom and the surrounding states Recently the activities of the NHC was limited to a program only of instructor courses and establishing new accredited centers at the same time giving the chance to other big centers such as KFSH & RC and NGH, al-Mashura skills training center, etc. This move was recently initiated and given to some certain facilities who have potentials to expand on their activities throughout the kingdom by organizing and conducting provider courses only. As the years passed, the hospital accreditation system was enforced throughout the following steps

1. Long-term policy of the SHA which illustrates that all hospitals must have an accredited BLS training center, while regions must have accredited ACLS training centers. This was achieved totally with the other government hospitals, to some extent with hospitals of the private sector and to a lesser extent in the hospitals of the M.O.H.

2. In 2001 the SHA introduced fees for training centers and stipulated rules and regulations for it which included the duties of the center and the duties of the SHA. An informative booklet on CPR in the kingdom was produced and recently has been revised, updated and upgraded. These two measures helped a great deal in maintaining quality of work of the training centers regular statistics and supervision by the DHA.

3. ARAMCO Medical Complex requirement from all private hospitals in the Kingdom of Saudi Arabia and the Gulf states dealing with them must have all their staff be certified in CPR and the hospital must be accredited and affiliated with Saudi and American Heart Associations.

4. Saudi Council for Health Specialties recent enforcement of obtaining BCLS and ACLS through different specialties or through the SHA. The request of 90 credit hours for renewal of permit to practice in the Kingdom must have 16 credit hours of CPR. This is applied on Doctors, Dentists, Pharmacists, Critical Care Nurses and Paramedics while only basic for all categories of medical personnel working in the health care delivery system in Saudi Arabia.

5. The CPR national committee produced two issues of CPR in the kingdom of Saudi Arabia and the Gulf States. The book contains information in 48 pages on development of training center, annual fees to the SHA, price list of courses and educational materials plus other relevant matters. The second issue was recently produced and contains more elaborate and detailed information in 140 pages on new information pertinent to CPR in the Kingdom and the Gulf States in order to control the quality of the training and the certification provided.

Development and accreditation of Training Centers

The NHC was established in accordance with the criteria of the AHA. ₁,₂,₄ The same policy and procedures were maintained for any new center to be established. Furthermore, regular supervision by newly established faculty chosen according to a new criteria formulated by the SHA.These steps helped to maintain type, number and quality of CPR coursess (Table 1).

Figure 1

Table 1: Basic and Advanced CPR courses conducted up to 2005

The essential requirements that needed to establish a accredited training center are:

1. Educational facilities such as lecture halls, four stations and audiovisual aids.

2. Mannequins for teaching basic and/or advanced cardiac life support courses.

3. several Instructors with valid certificates by SHA or AHA. Olternative is to have a provider and/or instructor course either for BLS and/or ACLS is conducted by the SHA.

4. Handout material the SHA provides its own approved BLS and ACLS provider books also Arabic version of BLS proviver and instructor books while using the AHA's books for BLS and ACLS instructor courses.These education materials at cost, without profit.

5. Supporting facilities such secretarial and other essential office facilities that help to continue, maintain, and expand these educational activities.

6. A CPR coordinator who is responsible to organise and conduct aschedual training programmes and sending regularely the statistic of their center to the NHC.

7. CPR committee who will responsible for establishing the CPR activities including collecting data, reviewal of the existing CPR policy and procedures, communicating with the SHA etc.

Once the above requirements are fulfilled, the center can be Accredited and begin to organise and conduct CPR courses. Supervision of the activities of any center is carried out by a faculty member especially for the first few courses.

Results

Up to the end of 2005, the CPR Committee of the SHA was able to establish 90 Centers in the Kingdom. All can provide BLS courses and only 34 Centers can provide combined BLS and ACLS courses. These centers are widely distributed through different hospitals in the Kingdom of Saudi Arabia. The health care system is divided into three categories, mainly the M.O.H. which provides 60% of the health care in the Kingdom while the other 40% is shared by the private sector and other government hospitals. The total number of hospitals in the M.O.H. is 212. The private sector has 83 hospitals while the other government has only 39. The accredited training centers was increased in other government hospitals and, to a lesser extent in the private sector hospitals, while the the number of the M.O.H. hospitals is still low. In the early stages of development, the majority of courses were organized in Riyadh City at the NHC, but in the last decade more and more courses have been conducted outside of the capital, even the activities of CPR were extended to the Gulf states.

The total number of certificates issued up to date exceeds 288,000. In the first 13 years the certificates issued was approximately 85,000 while the last 8 years has shown a tremendous increase in the certificates issued. The figure is rising year by year as shown in Table 2.

Figure 2

Table 2: The last 8 years annual certificates issued

Figure 3

Table 3: 2005 Annual figures of certificates issued in Saudi Arabia and the Gulf Regions.

The above table shows the 2005 annuals figures of various BLS and ACLS certificates which issued by different accredited training centers in the Kingdom of Saudi Arabia and the Gulf region. We are considered to be the second highest country after the U.S.A. that certifies medical personnel plus a limited number of citizens. The table also shows that Riyadh region still certifies more than 40 %.

Figure 4

Table 4: Achievements of various active Centres

The number of active Centers of BLS and ACLS in the Kingdom is 90. About 16 have ceased their activities. The majority were in the M.O.H. and some private institutions. This is mainly due to lack of human and financial support and dedication are the main reasons for the cessation of the activities of these Centers.Unless the MOH provides all the means to support CPR activities, the majority of medical personnel will not be certified, and eventually, the survival rate from cardiac arrest in their hospitals will be at a lower level than other hospitals. The figures in table 3 prove our point. Their active centers only certified 17% of the total figures of 2005 shown in that table.

Generally, these activities depend on dedication, enthusiasm, the number of instructors to organize and conduct courses with the possibilites of expanding, the administrative and financial support and finally the availability of other courses than CPR. Analysis of the activities of all Centers indicates that some Centers are more active than are others, such as the King Saud University, (National Heart Center, Department of Anaesthesia, College of Medicine, KKUH, and KKAUH), ARAMCO, King Faisal Specialist Hospital and Research Center, Riyadh (KFSH&RC), King Abdulaziz Medical City (National Guard), Riyadh, Makkah al-mukarramah training center, Al Qassim. region Al-ansar hospital medinah al-munawarrah, KFSH & RC. Jeddah, and KAMC (National Guard), Jeddah, military Hospital, Al-Mashura Health Skills Training Center respectively.

Instructor Certification

Community CPR

Reasons For Failure

The authors classified the reasons for failure into two important stages. They are:

STAGE I (1984 to 2000)

STAGE II: (2000- 2005). The era of success

This stage is considered to be the golden era of the SHA, where the goals of expanding its activities were achieved within the Kingdom and even extended to the Gulf region. The following measures helped tremendously in reaching this level. They are:

International training organization (ITO):

This scheme was developed which allowed for the overseas organizations to be affiliated with the AHA. The first agreement was signed in 1999 between AHA and SHA indicating that the SHA is the sole body responsible for all CPR activities in the kingdom. A second agreement was signed in 2003. Recently the activities of the SHA extending into the Gulf region was recognized and blessed by the AHA. Over the past five years our figures have increased steadily and we are now the second highest after the USA. The total number of certificates issued is now over 200,000. In the first 15 years just over 85,000 certificates were issued while in the last five years alone over 125,000 have been issued. As new centers are established it is expected that activities will increased.

Booklet of information:

Early Production of rules and regulations “CPR in The Kingdom of Saudi Arabia” booklet (40 pages), establishment of centers rules for annual fees and other relevant matters. An updated version was issued in 2005 (140 pages)

Reforming the national CPR committee:

The reformation of the CPR National committee in 2000 was achieved. The committee members gathered from all regions of the Kingdom. These were the team who helped to provide and supervise the expansion of the services. Members of the committee are:

Figure 5

ARAMCO:

The recent affiliation of ARAMCO hospitals to the SHA and their mandatory requirement for private hospitals in the kingdom who wish to receive their patients must have CPR facilities and certified staff. This ruling was a blessing in disguise that majority of private hospitals requested the SHA to organise and conduct CPR courses and at the same time affiliated to SHA as CPR recognised training centers. After 2000 the number increased substantially from to .

Ministry of Health:

M.O.H. Recognition and requesting from all hospitals to have a center for training and required that those centers must be affiliated to and recognised by SHA. The M.O.H. recently started to require that all medical personnel working during the pilgrimage season must be holders of a valid certificate in CPR. This was followed with even better future plans to arrange to have an agreement with the SHA to certify 5000 various medical staff in BLS and 1000 physicians and critical care personnel in ACLS over one year. We hope that this endeavour will be extended to a larger number of their medical personnel.

Gulf / Arab resuscitation Council:

One of the objectives of the National CPR Committee is to explore the idea of establishing an Arab or Gulf resuscitation council. Professors Takrouri and Seraj made the effort, using the internet, and put forward a proposal to establish an Arab resuscitation council. This effort was not welcomed favourably by the Arab world within the medical personnel for the same reasons that have been mentioned earlier about the lack of enthusiasm within the medical individuals in the KSA. The same happened with the Gulf States as a group but our approach was successful with individual countries. The main reasons for being unsuccessful are, lack of finance to purchase the equipment, establish training center and purchase educational materials and affiliation with the SHA, etc. In this regard Dr. Khalid Abu Haimed and I presented a lecture on stages which the SHA went through for the past almost two decades, its financial budget and income and finally emphasizing the advantages of having such training centers that can and will produce regular activities based on the actual cost of establishing the training center and its requirement. The center will be able to retain all expenses and be self- supporting. Both presenters point out that long term plan will generate enough income and even produce a surplus to the establishment. This effort had a great impact and helped in Bahrain, Dubai, Oman and Yemen, etc. Several others neighbouring countries are considering to follow suit e.g. Kuwait, Pakistan.

Future Recommendations

The SHA will succeed if it aims to answer all of the questions asked above. The following recommendations should he adopted for the next five to ten year plan. They are:

National recognition of CPR:

Health care professionals:

Red Crecent personnel:

Security forces:

The Youth Welfare Presidency:

Saudi Arabian Airlines ( Saudia):

The Ministry of Education:

Security personnel:

Driving licence:

Educational and promotional Campaign:

Public at large

Research