GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?

Objective: To determine whether physicians were aware of and had the skills to implement the American College of Critical Care Medicine/Pediatric Advanced Life Support Course septic shock protocol.
Design: A cross-sectional questionnaire survey.
Setting: Four academic institutions in Chennai, Manipal, Mangalore, and Trivandrum - cities representing the three southern states of Tamil Nadu, Karnataka, and Kerala, respectively, between February and April 2006.
Interventions: Pre and post lecture questions. They were evaluated using 11 questions testing knowledge and 10 questions testing their comfort level in performing interventions related to the initial resuscitation in septic shock.
Measurement and Main Result: The ACCM/PALS sepsis guidelines were taught during the PALS course conducted in the four academic institutions. A total of 118 delegates participated, of whom 114 (97%) were pediatricians and four (3%) were anaesthetists. The overall mean number of correct responses for the 11 questions testing knowledge before and after the lecture was 2.1 and 4.07, respectively P=0.001(paired t test). Although, 42% of the respondents (n=50) were aware of the ACCM guidelines, 88% (n=104) did not adhere to it in their practice. A total of 86% (n=101) and 66% (n=78) did not feel comfortable titrating inotropes or intubating in the ED; 78% (n=92) and 67% (n=78), respectively felt that central venous access (CVA) and arterial pressure (AP) monitoring were unimportant in the management of fluid refractory shock. Of the physicians, 20% (n=24) had never intubated a patient, 78% (n=92) had not introduced a central venous catheter, and 76% (n=90) had never introduced an intra-arterial catheter.
Conclusions: In view of the lack of skills and suboptimal knowledge, the ACCM/PALS sepsis guidelines may be inappropriate in its current format in the Indian setting. More emphasis needs to be placed on educating community pediatricians with a simpler clinical protocol, which has the potential to save many more children.

Keywords
Septic shock, recognition, children, emergency department, ACCM guidelines, PALS, knowledge barriers, critical illness