The Missing Link in the Chain of Survival: The Case for Structured, Localized In-Hospital Resuscitation Training and a National Resuscitation Council in Pakistan

Abstract

In-hospital cardiac arrest (IHCA) remains a common and recurring emergency in Pakistani hospitals, yet survival outcomes have shown remarkably little improvement over the past two decades. Unlike out-of-hospital cardiac arrest, where bystander response largely determines the early chain of survival, the first responder to IHCA is almost always a member of the hospital workforce—a house officer, staff nurse, resident, or on-call physician. Consequently, the resuscitation competence of frontline ward staff, rather than that of a designated code team alone, represents the single most modifiable determinant of patient survival. International experience consistently demonstrates that structured, mandatory resuscitation training substantially improves outcomes, increasing return of spontaneous circulation (ROSC) from 27.1% to 43.9% [1] while maintaining survival-to-discharge rates of 21–30% [2,3]. Pakistan, however, continues to lag behind these benchmarks. A 383-patient study conducted in Karachi between 1998 and 2003 reported an ROSC rate of 72%, yet only 19% of patients survived to hospital discharge [4]. More than two decades later, a contemporary study from Aga Khan University Hospital (2021–2023) reported an adult survival-to-discharge rate of only 18.9% [5], indicating that despite advances in critical care and resuscitation science, meaningful improvements in ultimate patient survival have remained elusive. This persistent gap is mirrored by substantial deficiencies in resuscitation knowledge and certification among healthcare professionals. A cross-sectional survey of 420 doctors, dentists, and nurses in Karachi found that 58.3% possessed inadequate knowledge of basic life support (BLS) [6]. Although 83.9% of physicians at a tertiary-care hospital had previously attended a BLS course, 65.6% were unable to identify the currently recommended chest compression rate [7]. At another tertiary hospital in Karachi, only 26.8% of 400 healthcare workers correctly identified the first action to be taken for an unconscious patient, despite 80% correctly recognizing the abbreviation "BLS" [8]. Similarly, only 46% of healthcare professionals in Chitral correctly identified the appropriate indication for initiating cardiopulmonary resuscitation (CPR) [9]. Even among cardiologists at Pakistan's National Institute of Cardiovascular Diseases, only 75.3% held formal resuscitation certification, while the mean knowledge score was only 50.9% [10]. Likewise, among 201 healthcare professionals in Peshawar, merely 16.4% demonstrated good BLS knowledge, despite nearly two-thirds expressing a positive attitude towards resuscitation training [11]. Collectively, these findings suggest that attendance at isolated training courses alone is insufficient to ensure sustained competency without regular certification, refresher training, and institutional reinforcement. Existing resuscitation training opportunities within Pakistan remain fragmented. The Advanced Cardiac Life Support (ACLS) programme offered by the College of Physicians and Surgeons Pakistan and several tertiary-centre initiatives have undoubtedly expanded educational opportunities [12–14]. Nevertheless, these programmes remain predominantly fee-based, English-medium, and largely accessible to postgraduate trainees working in major urban centres. They have yet to evolve into a standardized national system capable of providing universal competency-based training across all levels of healthcare delivery. An equally important deficiency is the absence of a national in-hospital cardiac arrest registry. High-income countries have demonstrated the value of registries such as the American Heart Association's Get With The Guidelines®–Resuscitation programme in benchmarking performance, monitoring adherence to guidelines, identifying quality gaps, and driving continuous improvement [15]. Pakistan currently lacks an equivalent national database for IHCA, despite successful implementation of Utstein-based methodology for out-of-hospital cardiac arrest surveillance in Karachi [16]. Developing a standardized national IHCA registry would provide an essential foundation for measuring patient outcomes, monitoring institutional performance, tracking certification status, and evaluating the impact of future educational interventions. The disconnect between policy and practice is particularly striking. Since 2010, the Pakistan Medical and Dental Council (PMDC) has mandated BLS certification for house officers. Yet the consistently poor knowledge demonstrated across multiple studies—including the finding that only 58.3% of healthcare professionals possessed adequate BLS knowledge [6]—suggests that implementation, maintenance of competency, and periodic recertification remain inadequate. Certification requirements alone cannot improve outcomes unless accompanied by structured training programmes, objective competency assessments, institutional accountability, and ongoing quality assurance. Pakistan has previously attempted to establish a national coordinating body for resuscitation education. The Pakistan Resuscitation Society, established in 1999, and the proposed National Resuscitation Council of Pakistan in 2013 both failed to achieve sustainability because of insufficient institutional and governmental support [13]. International experience demonstrates that such organizations can become major drivers of healthcare quality improvement. Singapore established its National Resuscitation Council after more than 15 years of coordinated training efforts and has successfully developed nationally standardized education and certification systems [17]. Similarly, India's Resuscitation Council developed Compression-Only Life Support (COLS), a simplified hands-only resuscitation protocol specifically designed for low-resource settings, illustrating how international guidelines can be effectively adapted to local healthcare realities [18]. Encouragingly, Pakistan has recently renewed this agenda. In January 2024, the Ministry of National Health Services established a Federal Technical Working Group tasked with developing Pakistan's own national resuscitation guidelines and locally relevant training programmes [19]. This initiative represents an important opportunity to establish a sustainable national framework for resuscitation education. However, guidelines alone will not be sufficient. Their implementation should occur alongside the creation of a National Resuscitation Council, mandatory competency-based certification and recertification programmes for all healthcare workers involved in patient care, standardized instructor development pathways, and a national Utstein-based IHCA registry capable of monitoring outcomes and informing continuous quality improvement. After more than twenty years during which approximately only one in five Pakistani patients experiencing in-hospital cardiac arrest survives to hospital discharge [4,5], the evidence clearly indicates that the missing link in Pakistan's chain of survival is not merely updated clinical guidelines but a coordinated national system that integrates education, certification, surveillance, quality improvement, and accountability. Establishing a National Resuscitation Council, supported by localized training programmes and a comprehensive national cardiac arrest registry, would represent one of the most achievable and potentially transformative interventions for improving resuscitation outcomes across the country. Acknowledgment: None. Funding: No specific grant for this research from any public, commercial, or not-for-profit funding agency References Kapoor MC. Assessing outcomes of resuscitation training in hospitals. Indian J Anaesth. 2018;62(5):327-9. DOI: 10.4103/ija.IJA_313_18 Cooper S, Cade J. Predicting survival, in-hospital cardiac arrests: resuscitation survival variables and training effectiveness. Resuscitation. 1997;35(1):17-22. DOI: 10.1016/S0300-9572(97)00020-8 Fuchs A, Käser D, Theiler L, Greif R, Knapp J, Berger-Estilita J. Survival and long-term outcomes following in-hospital cardiac arrest in a Swiss university hospital: a prospective observational study. 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