The COVID-19 pandemic is a global threat and an international public health emergency. As of October 30, 2021, more than 2.4 millions Malaysians were infected with COVID-19, with 28,832 deaths recorded [1]. According to the statistics, 66% of those who died were unvaccinated, 22.4% were partially vaccinated, and 11.6% were completely vaccinated [1]. Patients with older age (≥51 years), underlying comorbidities such as chronic kidney disease and chronic pulmonary disease, and unvaccinated were more likely to be severely affected by COVID-19 [2]. Currently, unvaccinated individuals account for nearly 95% of COVID-19-infected critically ill patients [3]. The utilization rate of intensive care unit (ICU) beds across the country had reached 80%, and hospitals are accepting more patients with moderate to severe COVID-19 complications who require resuscitation [4].

COVID-19 is transmitted directly through respiratory droplets or indirectly through contact with contaminated surfaces [[5], [6]]. Airborne transmission may occur in medical institutions during aerosol-generating procedures (AGP) [[7], [8], [9]]. COVID-19 can be spread by particles suspended in the air and may be inhaled by health care workers (HCW) within the vicinity [6]. For a variety of reasons, resuscitation poses significant risks to emergency HCW. Firstly, cardiopulmonary resuscitation (CPR) entails numerous AGP such as chest compressions, assisted ventilation, and tracheal intubation [[7], [8], [9]]. Secondly, resuscitation creates a stressful atmosphere that may contribute to the breaching of infection control measures such as improper donning or doffing of personal protective equipment (PPE) [7]. Thirdly, resuscitation procedures necessitate emergency HCW working in close proximity to one another and patients [7]. Poor adherence to infection control measures may negatively impact the workforce dynamics due to the need for exposed HCW to be quarantined, further reducing an already depleted workforce [7]. As of August 17, 2021, a total of 7,599 (3.05%) of HCW were infected with COVID-19, in which 5,135 (67.6%), had completed their vaccination. About 2,446 (32.2%) were asymptomatic, 10 had moderate illness, 4 had severe illness, and only 3 were severely ill [10]. The main source of infection among HCW was from nosocomial acquisition, further emphasizing the need to implement COVID-19 resuscitation guidelines [11].

Previous resuscitation guidelines did not emphasize the provision of care in biohazard scenarios such as COVID-19. To rectify this, the European Resuscitation Council (ERC) has published COVID-19 resuscitation guidelines highlighting infection control measures [8]. Emergency HCW are the first point of contact with COVID-19 patients and are at the highest risk of occupational exposure due to AGP during resuscitation [[9], [12]]. Previous studies have evaluated HCW knowledge on COVID-19 infection control [[13], [14], [15], [16]]. Bhagavathula et al. found a disparity of knowledge and attitude between doctors and allied heatlh personnel on COVID-19 transmission and disease prevention [13]. Hossain et al. demonstrated that despite 99% of HCW had adequate knowledge on PPE, they had poor practice in correct usage of PPE [14]. Abd Samat et al. had reported 68.9% of emergency HCW had good knowledge, but poor confidence regarding intubation strategies in COVID-19 patients and the risk of viral exposure [15]. However, these studies were focused on infection control measures [[13], [14], [16]] or airway management [15] and COVID-19 resuscitation was not explicitly explored.

Given the COVID-19 nosocomial exposure among emergency HCW, assessing their readiness to comply with the ERC guidelines is crucial to prevent viral transmission. The purpose of this study is to address the gap in the levels of knowledge, attitude, and practice (KAP) towards the ERC COVID-19 resuscitation guidelines among emergency HCW.