Assessment of Confidence, Guideline Adherence, and Resuscitation Challenges Following Advanced Cardiovascular Life Support Certification Among Postgraduate Residents: A Cross-Sectional Study

Background: Cardiac arrest remains a leading cause of mortality worldwide. Advanced Cardiovascular Life Support (ACLS) training is designed to equip postgraduate (PG) residents with the competencies required for effective resuscitation. However, gaps in skill retention, electrocardiogram (ECG) interpretation, and utilization of physiological monitoring tools such as end-tidal carbon dioxide (EtCO₂) monitoring and real-time cardiopulmonary resuscitation (CPR) feedback devices continue to impede resuscitation quality in clinical practice. Aim: The aim of the study is to assess post-training confidence, perceived clinical competence, and guideline adherence among PG residents and to identify challenges encountered during live in-hospital cardiac arrest resuscitations. Methods: A cross-sectional, feedback-based study was conducted at a tertiary care, American Heart Association (AHA)-accredited teaching hospital in South India over six months. A total of 187 PG residents from 32 departments who had completed ACLS training and participated in at least one in-hospital cardiac arrest resuscitation were enrolled. A validated, structured 24-item questionnaire (Cronbach’s α = 0.814) was administered electronically. This study was reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for cross-sectional studies. Statistical analysis included descriptive statistics, Mann-Whitney U test, Spearman correlation, and multiple linear regression. Results: Mean confidence and perceived competence scores were 9.75 ± 1.33 (95% confidence interval (CI): 9.55-9.94) and 22.83 ± 3.29 (95% CI: 22.35-23.31), respectively (all values self-reported). Significant gaps in monitoring tool utilization were identified, including non-use of real-time CPR feedback devices, absence of EtCO₂ monitoring, and difficulties with ECG rhythm interpretation during live resuscitations. Specifically, 43.5% (n = 80) of participants did not use real-time CPR feedback devices, and 48.9% (n = 89) did not utilize EtCO₂ monitoring during resuscitation. The most prevalent resuscitation challenge was ECG rhythm interpretation, reported by 34.2% (n = 64; 95% CI: 27.3%-41.9%) of participants. ACLS training quality was rated as excellent by 73% (n = 137; 95% CI: 65.8%-79.3%) of participants. No significant intergroup differences were found between clinicians and non-clinicians (p > 0.05). Confidence was the only significant predictor of perceived clinical competence (β = 0.724, p < 0.001; R² = 0.527). Conclusion: Participants reported high levels of confidence and perceived clinical competence following ACLS training, suggesting the program provides a solid foundation for emergency cardiovascular care. Nonetheless, persistent deficiencies in ECG interpretation, feedback device utilization, and EtCO₂ monitoring adherence warrant targeted curricular interventions, including structured ECG modules, biannual simulation-based refresher training, and mandatory integration of physiological monitoring tools. Future multicenter studies with objective performance metrics are recommended.