Introduction
World Health Organization (WHO) defined primary health care (PHC) as the following: “Primary health care is a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s need and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment” [1].
The Kingdom of Bahrain has 28 primary health centers with 375 physicians. These health centers are distributed around the governorates which serve more than 1,314,562 of the population [2]. It is the cornerstone of health service in the Kingdom, and it is the first point of contact for individuals in their quest for healthcare [3]. The total number of family physicians is 309, and the remaining are general practitioners (GPs) [2].
PHC provides a variety of services at the health centers which include curative services like family medicine, minor surgeries oral and dental care, preventive services like maternal and childcare, pre and postnatal examination, periodic checkup, and immunizations, rehabilitative services like physiotherapy. It also provides preemployment and premarital examination, school health, elderly care, home visits, health awareness, and promotion. It contains specialized clinics, and it also provides diagnostic radiology and laboratory services. It provides referrals to secondary health services as well as emergency [3].
Primary care physicians (PCPs) exposure to emergent conditions is reported globally. A study done by Fuchs et al. [4] about the prevalence of pediatric emergencies in office practice by 280 pediatricians and family practitioners, found that 62% of the responding physicians reported that they assessed more than one child each week who required hospitalization or urgent treatment in their offices [4]. Another study was done to compare the readiness of family physicians to deal with pediatric emergencies in comparison to pediatricians, which found that the average practice saw four or more pediatric emergencies in a year (family physicians 3.8 vs. pediatricians 4.9) and concluded that pediatric emergencies in the office are likely for either specialty [5]. Another study was done in Jeddah, Saudi Arabia in 2013, which found that 1,340,553 patients of varying ages visited the primary care centers in Jeddah. Of these, 70,284 were labeled as emergency cases. Thus, the prevalence of emergency cases attending primary care centers in Jeddah in 2013 was 5.2% with varying cases that included asthma exacerbation, anaphylaxis, myocardial infarction, and cardiac arrest [6].
There is more than one reason why it is not uncommon to encounter cases in PHC centers that need urgent intervention and resuscitation. There are a large number of health centers that are distributed in the Kingdom which makes them the first point of contact for a large number of populations.
Family physicians play a major role in managing emergency cases that present at primary care centers. Their role starts by recognizing urgent cases and initiating the management. Appropriate early management could improve patient outcomes. A study done by Eisenberg et al. [7] found that the decreased time from collapse to delivery of advanced emergency care accounted for the improved survival with paramedic services in out of hospital cardiac arrest. Another study done in Egypt in 2018 mentioned that a well-trained family physician who is qualified with basic life support (BLS), advanced trauma life support (ATLS), and advanced cardiac life support (ACLS) can handle up to 90% of cases seen in emergency room [8]. Moreover, the role of PCP is not limited to medical interventions, instead communicating with the patients, and relatives and addressing their concerns and clarifying their doubts as well as communicating with the receiving hospital is a vital role in the management. Also, they play a role in facilitating patients in need transfer to the receiving hospital to avoid delays in time sensitive management. On the other hand, PCPs should be able to differentiate between cases that need secondary care admission from cases that can be managed in primary care centers or outpatient settings [1]. Unfortunately, the data are lacking about Self-perceived competence in dealing with medical emergencies by family physicians and GPs in primary care in the Kingdom of Bahrain.
Aims
To set recommendations for emergency training courses based on physician’s reported Self-perceived levels of competence in managing medical emergencies in primary care health centers aiming to improve the level of knowledge and practical skills to optimize the quality of patient care provided in primary health centers.
Objectives
To assess the level of Self-perceived competence of PHC physicians working at PHC centers in Bahrain and being capable of handling medical emergencies and to identify the need of training.
Materials and Methods
Study design
Cross-sectional descriptive study with online data collection through anonymous self-administered questionnaire.
Study population
According to the Ministry of health database for 2020, 375 physicians are working in 28 PHC centers across the five health regions. All family physicians and GPs working in primary care health centers were included in the study.
Sample size
All physicians working in health centers were included. The sample size with a total number of physicians between 250 and 300 was calculated based on the registry of a total number of physicians in the 28 health centers in the 5 health regions with a confidence interval of 99% with a sampling margin of error of 4.74%.
Sampling technique
Adapted [9], anonymous and self-administered seven-item electronic questionnaires were sent to family physicians and GPs, from January 2022 to February 2022. Physicians were invited to participate through direct email which was sent by primary investigators. The email included information about the study and objectives with a link that provided detailed information about the study and participants were ensured that answers will be anonymous. Physicians have had access to the questionnaire after agreeing to terms of participation by clicking on the “Approve” box.
Inclusion criteria
1. All PCPs including family physicians and GPs working in primary care health centers in the Kingdom of Bahrain agreed to participate during the period from January 2022 to February 2022.
Exclusion criteria
1. Trainees.
Settings
Electronic data collection was held over a period of 30 days, from January 2022 to February 2022 using the SurveyMonkey platform which was emailed to all family physicians and GPs working in primary care health centers.
Tools
A systematically adapted self-administered anonymous questionnaire was used in the study. It was designed by the research team to attain the aims and objectives of the study. The principal investigators developed the questionnaire elements based on the objectives of the study and a literature review of similar studies. Survey questions were adapted from other studies to serve the research purposes primarily.
To ensure reliability, a group of consultant family physicians subspecialized in emergency medicine were invited to assess the questionnaire for relevance and to provide a critique of the content of the questionnaire. Then a pilot was conducted in a sample of 10 physicians to assess the face validity of the questionnaire and the time spent to answer the questions was measured. The results of the pilot were not included in the final analysis of the results.
The questionnaire encompassed seven items on: (1) physician’s demographic data; age, sex, the health center of practice, years in practice, specialty; (2) most recent training in emergency courses BLS, ACLS, ATLS, and pediatric advanced life support (PALS); (3) attitude of physicians towards emergency medical services provided at their respective PHC centers; (4) Self-perceived level of competency in managing emergency cases; (5) Self-perceived level of competency in performing skills; (6) emergency training in topics, courses and skills identified by PHC physicians; and (7) preferred method for training in emergency medicine.
Outcomes
The primary outcome is to assess the level of confidence and competency in managing medical emergencies at PHC centers.
Ethical consideration
The study was conducted with adherence to the fundamental ethical principles consent was taken from the participants and approval was granted by the ethical committee. The data were kept private and analyzed anonymously.
Plan of analysis
Statistical analysis was performed using the Statistical Package for Social Sciences version 26.0 (IBM Corp. ARMONK, USA) and the statistical significance was tested at a 5% level. The continuous characteristics like age and years of experience were summarized in terms of mean, standard deviation, and median, while gender, specialty, and various course attendance by participants were expressed in terms of frequencies and percentages. The association of participant characteristics with comfort level, willingness, and competence to treat emergency cases was evaluated using Spearman’s rank correlation coefficient. The association between specialty and the above factors was determined using Cramer’s V coefficient. Moreover, the association between the comfort level of handling different types of emergency cases and the characteristics of participants was obtained using Spearman’s rank correlation. The association between various emergency skills and participant characteristics was also studied using Spearman’s rank correlation as well as Cramer’s V association.
Results
Of the 375 eligible family physicians and GPs, 184 (45.5%) responded and returned answered questionnaires. It is worth mentioning that some participants did not answer all the survey elements as none of them were obligatory, that’s why some tables will have missing or incomplete data.
Table 1 provides a description of the various characteristics of participants. The mean age was 38.71 (SD: 9.00) years with a median of 35 years. There was female preponderance with 117 (83.6%) as compared to 23 (16.4%) males. The mean years of experience of participants was 11.66 (SD: 8.69) years. Majorly, of the participants were family physicians [67 (47.9%)], followed by consultant family physicians [55 (39.3%)]. The total number of GP participants was [18 (12.8%)]. The description of different courses attended by participants within the last 2 years is given in the table. A total of 82 (48.24%) physicians attended the BLS course in the past 2 years, on the other hand, only four participants (14.28%) attended the PALS while only 2 (8.69%) attended the ATLS course.
Table 2 summarizes the PHC physicians’ level of comfort, willingness, and competency in association with age, years of practice, specialty, and the attended course. 47 participants (33.57%) were not sure about their comfort level in dealing with emergency cases in their health centers. Approximately one third of participants (35.71%) N=50 reported agreeing on their willingness to treat emergency cases at PHC centers. Regarding feeling competent in dealing with emergency cases in primary care centers, we found that the number of participants who agreed or were not sure was equal. The specialty had statistically significant association with overall comfort level with coefficient 0.263 (p=0.001). GPs or GPs with diploma were more comfortable in dealing with emergency cases than family physicians or consulting family physicians. All other associations described in the table were statistically nonsignificant.
Table 1.
Description of characteristics of participants.
| Characteristic | Level | Statistic N (%) |
|---|---|---|
| Age in years (mean ± SD; median) | 38.71 ± 9.00; 35.00 | |
| Gender [n (%)] | Female | 117 (83.6) |
| Male | 23 (16.4) | |
| Experience in years (mean ± SD; median) | 11.66 ± 8.69; 9.50 | |
| Specialty [n (%)] | Consultant family physician | 55 (39.3) |
| Family physician | 67 (47.9) | |
| GP/GP + diploma/others | 18 (12.8) | |
| Attended—BLS [n (%)] | ≤2 years | 82 (48.24) |
| >2 years | 88 (51.76) | |
| Attended—ACLS [n (%)] | ≤2 years | 41 (27.15) |
| >2 years | 110 (72.85) | |
| Attended—ATLS [n (%)] | ≤2 years | 2 (8.69) |
| >2 years | 21 (91.31) | |
| Attended—PALS [n (%)] | ≤2 years | 4 (14.28) |
| >2 years | 24 (85.72) | |
| Attended—Emergency course in family medicine [n (%)] | ≤2 years | 44 (36.3) |
| >2 years | 77 (63.7) |
Table 3 assess the Self-perceived level of comfort among participants in dealing with emergency cases in adults and pediatrics age group in PHC centers. The highest level of reported comfort was equally observed in both acute bronchial asthma and hypoglycemia management in adults age group at which 66 participants (47.14%) felt very comfortable in managing such cases. On the other hand, the highest number of participants not feeling comfortable was observed in dealing with major and multiple traumas in adults (67, 47.86%) and pediatrics (63, 45%), followed by cardiac arrest in pediatrics (55, 39.29%). There was a difference in the perceived level of comfort among participants in dealing with shock and cardiac arrest in adults in comparison to pediatrics. It was found that 36.43% of participants were feeling moderately comfortable in dealing with shock in adult patients, while most participants reported not feeling comfortable in dealing with shock in the pediatric age group 36.43%. The same finding was noticed in dealing with cardiac arrest in adults in comparison to pediatrics, as it was found that 35% of the participants were feeling moderately comfortable in adults while 39.29% of participants were not feeling comfortable.
Table 2.
The attitude of physicians toward emergency medical services provided at their PHC centers and association of participant characteristics with comfort, willingness, and competence to treat emergency cases.
| Perceived level of competence | Score [% (n)] | Correlation; p-value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | Age in yearsa | Years of practicea | Specialityb | Attended coursesb | ||||
| BLS | ACLS | ATLS | PALS | |||||||||
| I feel comfortable in dealing with emergency cases at PHC | 8.57% (12) | 32.86% (46) | 33.57% (47) | 19.29% (27) | 5.71% (8) | 0.017; 0.840 | 0.006; 0.940 | 0.263; 0.001 | 0.231; 0.112 | 0.176; 0.362 | 0.250; 0.068 | 0.115; 0.762 |
| I am willing to treat emergency cases at PHC center | 20.71% (29) | 35.71% (50) | 19.29% (27) | 15.71% (22) | 8.57% (12) | 0.017; 0.840 | -0.129; 0.129 | 0.212; 0.068 | 0.223; 0.138 | 0.192; 0.269 | 0.123; 0.716 | 0.127; 0.686 |
| I feel competent in dealing with emergency cases at PHC level | 6.3% (10) | 37.5% (59) | 37.5% (59) | 12.1% (19) | 6.3% (10) | -0.059; 0.486 | -0.063; 0.462 | 0.216; 0.053 | 0.181; 0.334 | 0.218; 0.156 | 0.127; 0.691 | 0.081; 0.920 |
aUsing Spearman rank correlation.
bUsing Cramer’V coefficient of association.
Bold values indicate significant association of two attributes.
To what extent do you agree or disagree with the following statements? 1=strongly agree; 2=agree; 3=Not sure; 4=disagree; 5=strongly disagree.
Table 3.
Selfassessed comfort in managing emergency cases in adults and pediatrics.
| Emergency case | Self-perceived level of comfort | ||||
|---|---|---|---|---|---|
| Very comfortable % (n) | Moderately comfortable % (n) | Mildly comfortable % (n) | Not comfortable % (n) | ||
| Acute asthma | Adults | 47.14 (66) | 37.86 (53) | 8.57 (12) | 6.43 (9) |
| Pediatrics | 19.29 (27) | 47.14 (66) | 27.14 (38) | 6.43 (9) | |
| Respiratory arrest / Asphyxia | Adults | 4.29 (6) | 41.43 (58) | 29.29 (41) | 25 (35) |
| Pediatrics | 3.57 (5) | 26.43 (37) | 38.57 (54) | 31.43 (44) | |
| Shock | Adults | 11.43 (16) | 36.43 (51) | 25.71 (36) | 26.43 (37) |
| Pediatrics | 6.43 (9) | 22.14 (31) | 35 (49) | 36.43 (51) | |
| Cardiac arrest | Adults | 15.71 (22) | 35 (49) | 24.29 (34) | 25 (35) |
| Pediatrics | 7.86 (11) | 21.43 (30) | 31.43 (44) | 39.29 (55) | |
| Acute chest pain | Adults | 35.71 (50) | 42.14 (59) | 16.43 (23) | 5.71 (8) |
| Pediatrics | 10 (14) | 30.71 (43) | 35.71 (50) | 23.57 (33) | |
| Hypoglycemia | Adults | 47.14 (66) | 41.43 (58) | 6.43 (9) | 5 (7) |
| Pediatrics | 22.86 (32) | 44.29 (62) | 21.43 (30) | 11.43 (16) | |
| Diabetic ketoacidosis | Adults | 28.57 (40) | 42.86 (60) | 18.57 (26) | 10 (14) |
| Pediatrics | 19.29 (27) | 32.14 (45) | 32.14 (45) | 16.43 (23) | |
| Convulsion | Adults | 15.71 (22) | 47.14 (66) | 31.43 (44) | 5.71 (8) |
| Pediatrics | 17.86 (25) | 33.57 (47) | 35 (49) | 13.57 (19) | |
| Impaired consciousness | Adults | 7.14 (10) | 36.43 (51) | 40 (56) | 16.43 (23) |
| Pediatrics | 4.29 (6) | 25 (35) | 40 (56) | 30.71 (43) | |
| Major/multiple trauma | Adults | 6.43 (9) | 17.14 (24) | 28.57 (40) | 47.86 (67) |
| Pediatrics | 6.43 (9) | 15.71 (22) | 32.86 (46) | 45 (63) | |
To what extent do you feel yourself being comfortable in managing the following emergency cases in adults and pediatrics? 1=very comfortable; 2=moderately comfortable; 3=mildly comfortable; 4=not comfortable.
Table 4.
Distribution of participants according to level of emergency skills in handling cases.
| Emergency skills | 1 | 2 | 3 | 4 | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Recognition and diagnosis of emergencies | 22 | 15.7% | 28 | 20.0% | 46 | 32.9% | 44 | 31.4% |
| ECG rhythm recognition | 15 | 10.7% | 31 | 22.1% | 64 | 45.7% | 30 | 21.4% |
| External cardiac compression | 26 | 18.6% | 22 | 15.7% | 33 | 23.6% | 59 | 42.1% |
| Cardioversion | 34 | 24.3% | 51 | 36.4% | 38 | 27.1% | 17 | 12.1% |
| Transcutaneous pacing TCP | 67 | 47.9% | 28 | 20.0% | 21 | 15.0% | 24 | 17.1% |
| Oxygen therapy | 25 | 17.9% | 29 | 20.7% | 38 | 27.1% | 48 | 34.3% |
| Cannulation | 33 | 23.6% | 37 | 26.4% | 31 | 22.1% | 39 | 27.9% |
| Administering emergency drugs | 17 | 12.1% | 41 | 29.3% | 57 | 40.7% | 25 | 17.9% |
| Nasogastric tube (NGT) Insertion | 42 | 30.0% | 43 | 30.7% | 23 | 16.4% | 32 | 22.9% |
| Urinary catheter insertion | 35 | 25.0% | 34 | 24.3% | 30 | 21.4% | 41 | 29.3% |
To what extent do you feel yourself being competent in performing the following emergency skills? 1=wouldn’t know where to start; 2=would do one only if no-one else was available; 3=would attempt in most cases (perceived competence=reasonable); 4=would attempt in most/all cases (perceived competence=good/high).
Table 4 presents the Self-perceived level of competence in performing emergency skills among PHC physicians. It shows less than half of family physicians have a good to high level of competency in the recognition and diagnosis of medical emergencies (31.4%). The majority of physicians reported good to a high level of competence in performing external cardiac compression 42.1%, oxygen therapy 34.3%, cannulation 27.9%, and urinary catheter insertion 29.3%. Most of the physicians wouldn’t know how to start transcutaneous pacing 47.9%, while 36.4% would perform cardioversion or NGT insertion 30.7% only if no-one else was available.
Figure 1 shows that the majority of participants 137 (97.9%) think that they need training in emergencies.
The right side of Figure 2 is showing the areas of emergency medicine the participants need to be trained. Pediatric emergencies and major trauma showed the highest number among participants that needed training with 113 (80.7%) and 106 (75.7%), respectively. This is followed by respiratory arrest 92 (65.7%) and impaired consciousness 91 (65%). On the other hand, only 38 (27.14%) participants need training in managing hypoglycemia, and 40 (28.57%) in managing acute asthma. The left side of the bar chart shows the participants responses regarding emergency medicine skills they need to be trained in. Cardioversion, transcutaneous pacing, and ECG rhythm recognition were the most common skills the participants suggested training in with numbers 93 (66.4%), 80 (57.14%), and 68 (48.57%), respectively. On the other hand, only 31 (22.14%) participants suggested training needs in cannulation and 34 (24.28%) in oxygen therapy.
Figure 1.
Pie chart showing the distribution of participants suggesting the need for training.
Figure 3 showed the participant’s responses when asked about the emergency medicine courses they need to be trained in. Most of the participants (70%) suggested training needs in ACLS, followed by ATLS (65%), while only (42.9%) suggested training needs in BLS.
Figure 2.
Horizontal bar chart showing a number of participants suggesting various areas of training and skills.
Figure 3.
Column chart showing a number of participants suggesting training needs on various courses.
Figure 4.
Column chart showing a number of participants suggesting various practical training needs.
Note, although pediatric emergencies and major trauma showed the highest number among participants that needed training, the proportion of participants who suggested training in ACLS was more than PALS and ATLS.
Figure 4 shows the preferred method for training in emergency medicine among participants. The majority of the participants 122 (87.1%) prefer practical training in PHC centers by a qualified person, followed by hospital rotation training in emergency department 49 (35%). On the other hand, printed materials and webinars were the least preferred methods of training among the participants with number of 19 (13.6%) and 27 (19.3%), respectively.
Discussion
The aim of this study was to evaluate the Self-perceived competence of PHC physicians in managing medical emergencies in health centers in the Kingdom of Bahrain and to determine the factors contributing to it. Many studies have shown that emergency cases are to be encountered in the PHC setting and this necessitate that every medical doctor should be competent to perform the basic resuscitation skills [6,10].
In our study, it was found that GPs were more comfortable in dealing with emergency cases than family physicians or consultant family physicians which could be explained by encountering more emergency cases, full time work status, the experience of practicing in a nonmetropolitan area, and due to the fact, that performing emergency skills on regular basis enables them to feel more comfortable [10,11]. These findings were supported by another study which found that the level of competence in dealing with emergencies was better among physicians with diplomas in family medicine and GPs with MBBS than Arab Board-qualified physicians [12].
In our study, there was no statistically significant correlation between the attended emergency courses and with perceived level of competence. A similar finding was found in a study done in Jeddah in which physician`s attended courses of BLS, ATLS, and ACLS were not significantly associated with the score of perceived level of competence in performing emergency skills [6]. On the other hand, a study done in South Africa found that current or expired certification in PALS courses increased perceived competence. It also found that current certification in advanced life support courses had a positive impact on trainees’ Self-perceived levels of competence in emergency skills [10]. The nonsignificant correlation in our study could be explained by the fact that the majority of PHC physicians attended the emergency courses within more than 2 years’ timeframe which could lead to a decline in skills retention which could compromise performance [13]. A study done in Jazan found that competence in clinical emergencies was less in those who did ATLS and BLS more than 2 years’ timeframe in comparison to those who did it in less than 12 months [12].
Regarding selfassessed comfort in managing emergency cases, we found acute bronchial asthma and hypoglycemia management in adults were among the highest reported levels (47.14%). A similar finding was reported among GPs in Queensland in which the highest level of comfort was for managing acute asthma and hypoglycemia [11]. Greater comfort level in dealing with such cases could be explained by their higher prevalence and being among the most common medical emergencies encountered in PHC centers [6].
The overall comfort level in our study was lowest in dealing with major and multiple traumas in adults (47.86%) as well as pediatrics (45%). Also, the participants reported not feeling comfortable when dealing with cardiac arrest (39.29%) and shock (36.43%) in pediatrics more than adults (25%, 26.43%), respectively. A study done by Dufourqn et al. [10] found that resuscitation in children was underperformed as cardiac arrest occurs less frequently in this age group, which creates anxiety, avoidance of resuscitation, and less confidence. These findings could be attributed to the fact that the lower prevalence of these cases in primary care centers in comparison to secondary care results in lower exposure and fewer opportunities to experience how to deal with them [6]. This can also explain the low Self-perceived level of competence in performing some of the emergency skills like transcutaneous pacing (47.9%), NGT insertion (30.7%), and cardioversion (36.4%). The reported low level of confidence in performing emergency skills could be due to the delay in getting the opportunity to practice the skills they learned on real cases [6]. Past training in emergency skills was associated with the increased perceived level of competence [11]. However, some of the training was limited to observation without hands on practice which could impair the mastery of the skills.
Strength and Limitations
Strength
This is considered the first study in the Kingdom of Bahrain that addresses this topic. In addition, it is an important subject as it addresses the perceived level of competence in dealing with emergency cases in PHC and it has the potential to advance the quality of care provided by exploring the areas that need improvements.
Limitations
This study might have some recall bias or inaccuracy as some family physicians and GPs answered the questions based on their memory and experience. Also, it recruited a small number of respondents. The questionnaire is not an objective method to assess competency and the answers may not necessarily correlate with the actual performance.
Conclusion
The present study showed that up to 37.5% of PHC physicians were not sure if they felt competent in managing emergencies in primary care. Pediatric emergencies, trauma, and cardiovascular skills namely cardioversion, transcutaneous pacing, and ECG rhythm recognition were highest among PCPs that need training. The majority of physicians reported their need for further training in dealing with emergencies, preferably through practical training in health centers by qualified staff. We suggest conducting further studies to evaluate the physician’s competency, training needs, and how to best prepare the PHC centers to deal with medical emergencies.
