basic life support education in secondary schools: a cross- · basic life support training in...

For peer review only

Basic Life Support Education in Secondary Schools: a cross-sectional survey in London, United Kingdom

Journal: BMJ Open

Manuscript ID bmjopen-2016-011436

Article Type: Research

Date Submitted by the Author: 03-Mar-2016

Complete List of Authors: Salciccioli, Justin; Imperial College London, Marshall, Dominic; Imperial College London Sykes, Mark; Imperial College London Wood, Alexander; Imperial College London Jopp, Stephanie; Imperial College London Sinha, Madhurima; Imperial College London Lim, Phang; Imperial College Healthcare NHS Trust

Primary Subject

Heading: Cardiovascular medicine

Secondary Subject Heading: Public health

Keywords: cardiopulmonary resuscitation, automatic external defibrillator, education, cardiac arrest

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Title:

Basic Life Support Education in Secondary Schools: a cross-sectional survey in London,

United Kingdom

Authors:

Justin D Salciccioli1, Dominic C Marshall1, Mark Sykes1, Alexander D Wood1, Stephanie

Joppa1, Madhurima Sinha1, P Boon Lim2

Affiliations:

1 – Imperial College London, London, UK

2 – Department of Cardiology, Hammersmith Hospital, London UK W12 0HS

Correspondence:

P Boon Lim

Consultant Cardiologist

Imperial College Healthcare NHS Trust

Hammersmith Hospital

Du Cane Road

London W12 0Hs

Email: [email protected]

Tel : 0203 313 4967

Fax: 0203 313 4095

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Abstract: Objectives

Basic life support training in schools is associated with improved outcomes from cardiac

arrest. International consensus statements have previously recommended universal BLS

training for school-aged children. The current practice of BLS training in London schools is

unknown. The aim of this study was to assess current practices of BLS training in London

secondary schools.

Setting, Population and Outcomes

A prospective audit of BLS training in London secondary schools was conducted. Schools

were contacted by email and a subsequent telephone interview was conducted with staff

familiar with local training practices. Response data were anonymised and captured

electronically. Universal training was defined as any programme which delivers BLS training

to all students in the school. Simple descriptive statistics were used to summarise the

results.

Results

A total of 65 schools completed the survey covering an estimated student population of

65,396 across 19 of 32 London boroughs. There were 5 (8%) schools that provide universal

training programs for students and an additional 31 (48%) offering training as part of an

extra-curricular program or chosen module. An AED was available in 18 (28%) schools,

unavailable in 40 (61%) and 7 (11%) reported their AED provision as unknown. The most

common reasons for not having a universal BLS training programme are the requirement for

additional class time (28%) and that funding is unavailable for such program (28%). There

were 5 students who died from sudden cardiac arrest over the period of the past 10 years.

Conclusion

BLS training rates in London secondary schools are low and the majority of schools do not

have an AED available in case of emergency. These data highlight an opportunity to improve

BLS training and to improve AEDs provision. Future studies should assess programmes

which are cost-effective and do not require significant amounts of additional class time.

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Key words: cardiopulmonary resuscitation, automatic external defibrillator, education,

cardiac arrest

Article Summary:

The strengths of this investigation are that data was collected prospectively from school

administrators who are responsible for BLS training at their institution. We used an electronic

data capture tool to with pre-specified variable responses, standardizing the data and

reducing inter-questioner variability. We were able to collect survey data from 65 secondary

schools from 19 boroughs across London, with responses reflecting practices as recent as

October 2014. A number of schools however are not represented in our data set. A further

limitation owes to the lack of external validation for the electronic data capture tool and

questionnaire. Finally, we collected data regarding the number school children who have

died on school premises of sudden cardiac death. This figure is inevitably subject to recall

bias.

Relatable points:

• Basic life support (BLS) training in schools improves outcomes in cardiac arrest

• BLS training in schools has been advocated by international councils

• BLS training rates in London schools is low

• Few London schools have an on-site automated external defibrillator (AED)

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Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health burden which poses

significant strain on healthcare systems [1] with approximately 420,000 arrests in the United

States [2] and 275,000 in Europe [3] annually. Basic life support (BLS) training is associated

with improved outcomes from cardiac arrest [4]. Rates of bystander cardiopulmonary

resuscitation (CPR) vary by location [5] a result which is thought to be the result of poor

training and education in CPR practices or the result of poor implementation of training

practices.

The chain of survival has been promoted broadly as a means to optimize the

community’s response to out-of-hospital cardiac arrest [6]. Previous investigations have

shown that BLS measures may be more important than advanced care in survival from out-

of-hospital cardiac arrest [7] and more recent evidence has provided further support for this

effect across healthcare systems [8].

In order to improve the rate of early bystander CPR and early defibrillation the

International Liaison Committee on Resuscitation (ILCOR) recommended training in CPR

and familiarisation with Automated External Defibrillator (AED) as part of secondary school

curricula [9]. BLS training has since become a requirement for graduation in multiple states

throughout the United States (http://tinyurl.com/o8hmvwb). However, the requirement for

BLS training is not part of the educational curriculum in the United Kingdom (UK) and the

current practice of BLS training in schools throughout the UK is unknown.

We sought to investigate the current practices relating to BLS training in London

secondary schools. The primary aim of this study was to identify the rate of universal student

training programs. In order to identify such programs, we performed a cross-sectional survey

to ascertain current training practices for students in London secondary schools.

Methods

Study Design and Setting

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A registered audit was conducted as a cross-sectional survey of BLS and AED

training in London secondary schools between June 2014 and October 2014. The project

was approved as an audit at Hammersmith Hospital, Imperial College Healthcare Trust

(Registration number 1673). Interviewers received preliminary training in survey details and

appropriate administration of the telephone interviews. All schools were contacted by email

initially and a subsequent telephone interview was conducted with school staff familiar with

local training practices. Response data were anonymised and captured electronically in a

standardized electronic database.

Survey Design and Data Collection

The survey was developed in two phases. First, a preliminary survey was created

and school administrators in three pre-specified London boroughs were contacted to

complete the survey. Interviewers were responsible for recording survey results data as well

as recording aspects of the survey tool which requiring additional clarification. Second, the

survey tool was updated to incorporate suggestions from the initial series of telephone

interviews and data collection.

Response data were collected and managed using an electronic data capture tool

which provided pre-specified variable responses and missing value-response alerts to

minimize incomplete responses. During the course of the telephone interview data were

captured directly into the standardized web-based survey tool.

Outcomes and Analysis

The primary outcome of interest was a current universal training program which

delivers BLS training to all students in the school. Secondary outcomes of interest included

the presence of an AED in the school and the perceived barriers to implementation of a

universal student training program. The survey also included a single question to estimate

the rate of death in school children during the 10-year period prior to the current

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investigation. Simple descriptive statistics including means or medians and frequencies with

percentages were used to summarise the results, as appropriate.

Post-Hoc Analysis

We performed a single post-hoc analysis to estimate the cost to treat a single case of

student cardiac arrest. During the course of the data collection period, the UK Department of

Education issued a public statement which recommends placement of AEDs in all UK

primary and secondary schools [10]. The DoE statement supports purchasing of AEDs by

the NHS Supply Chain and with this program, the cost per AED would be £452.78 [10]. For

this analysis, we used reported incidence of student sudden cardiac arrest as a single case

of cardiac arrest and computed the rate of cardiac arrest per secondary school surveyed.

Results

Characteristics

Surveys were completed in 19 (52%) of the 32 London boroughs. Of 449 schools,

representatives from 71 (16%) schools were contacted successfully and a total of 65 (15%)

completed the survey. There were 6 schools which refused to participate (8%). The student

population from the surveyed schools completed covers an estimated population of 65,396

students between the ages of 11 and 19 years. In this sample, the earliest that students are

exposed to BLS training is in Year 7 (approximately 11 years of age). Specialist First Aid and

CPR educators from outside organizations (eg. St. John’s Ambulance, British Heart

Foundation, etc.) are most commonly responsible for providing educational programs and

training for students (15%).

Primary and Secondary Outcomes

There were 5 (8%) schools that provide universal training programs for students and

an additional 31 (48%) offered training as part of an extra-curricular program or chosen

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module. The most common reasons for not having a universal BLS training program is the

requirement for additional class time (28%) and that funding is unavailable for such program

(28%). An AED was available in 18 (28%) schools, unavailable in 40 (61%) and 7 (11%)

reported their AED provision as unknown. There were 5 students who died from sudden

cardiac arrest over the period of the past 10 years. However, the administrator reporting 1 of

the 5 cases was unable to confirm whether the sudden cardiac arrest happened at the

school or away from school premises.

Cost Analysis

Of the 65 schools surveyed there were at least 5 sudden cardiac arrests reported

during the preceding 10-year period. As such, an AED would need to be placed in 13

secondary schools in order to provide the opportunity to treat at least 1 sudden cardiac

arrest within a 10-year period. The NHS Supply Chain will provide AEDs in schools

throughout the UK for £452.78 and for a total of 3628 state funded secondary schools this

would amount to a cost of £1,642,685.84 in order to place one AED in every secondary

school in England.[11]

Discussion

In this prospective audit of London secondary schools there were overall low rates of

universal BLS training programmes for students. Specifically, fewer than half the schools

surveyed offer some form of optional BLS training for students with only 8% offering a

universal BLS training program. The most common reasons stated for not having universal

BLS training were the requirement for additional class time and the lack of funding to support

such programs. Further, we found less than a third of schools had an AED on the school

premises available in case of emergency. Although small, the estimated number of students

suffering sudden cardiac arrest while on school premises (5) in the preceding decade

highlights the importance of current government and public health campaigns to equip

schools with AEDs and to improve the rate of CPR training in schools. We estimate that an

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AED placed in a minimum of 13 schools would be required in order to treat a single case of a

child with sudden cardiac arrest.

Advances in cardiac arrest care have, since it was first described in 1991, focused on

improving performance in the chain of survival [6]. While the past decade has significant

improvement in the advanced care of the post-arrest patient, multiple recent investigations

have demonstrated in large populations of patients the overall importance of improving the

early links in the chain of survival, namely early identification of cardiopulmonary arrest and

early initiation of bystander CPR efforts via large-scale educational programs [12,13]. Two

recent reports have shown that CPR prior to emergency medical service arrival in OHCA is

associated with improved survival [8], and that this basic intervention may be as effective or

better than pre-hospital advanced life support [7]. However, one area that remains

unanswered is whether legislation to require schools to teach BLS will improve outcomes for

patients suffering cardiac arrest.

The primary aim of this investigation was to appreciate the current practices of CPR

and AED training in school-aged children in London. Our hypothesis that there would be a

small proportion of London secondary schools currently offering universal BLS training

programs was based primarily on previous reports which have suggested low rates of BLS

training in the UK compared to European countries [14]. This hypothesis was made despite

consensus statements from local and international professional resuscitation bodies. These

data are relevant as they highlight potential areas for significant improvement in public health

initiatives. Since the 2011 ILCOR consensus statement recommending CPR training in

secondary schools, a number of political bodies in jurisdictions outside the UK have made

CPR training a legal requirement for graduation from secondary school, a measure which

has not been adopted in the UK. To the best of our knowledge this investigation is the only

study to have assessed the rate of BLS training in London secondary schools since these

consensus statements have been made.

Our results demonstrate the significant room for improvement in student training in

schools. We identified a small proportion (8%) of schools which provide CPR training for all

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students while 48% of schools offer some optional training for students. These results are in

line with a recent investigation from Toronto, Canada, which found that 51% of secondary

schools provide CPR training for students although it is unclear whether CPR training

programs were required for all students in the institution or whether these were optional

programs [15]. There are important differences relating to the legislation between the two

locations that raise the issue of making CPR training a requirement of school curriculum.

While the government of Ontario, Canada has made it mandatory for students to

demonstrate an understanding of cardiopulmonary resuscitation in order to obtain their

secondary school diploma the UK government has yet to make such a change to curriculum

requirements. It is unclear, therefore, what effect legislation has on the overall rate for

students receiving CPR training. Despite this difference one recent report has also shown a

temporal trend toward improving outcomes from OHCA in Denmark since instituting

mandatory resuscitation training programs in elementary schools [13].

In the UK, where legislation for BLS training in schools has not been written, the

Department of Education has recently published guidance for schools to equip the institution

with an AED [10] and offer financial support for purchasing an AED. As financial

requirements were cited as one of the most common reasons for not having BLS training

programs, such additional financial support should help improve public access AEDs in

schools. Other campaigns such as the “Defib in schools” campaign, by the Arrhythmia

Alliance (http://www.defibssavelives.org/defibs-in-schools), and the British Heart Foundation

“Nation of Lifesavers” community campaign to support AED installation in schools can help

to increase public awareness and improve AED installation rates. Such campaigns are

important especially in light of the fact that previous investigations have shown a significant

improvement in neurologically intact survival with onsite AEDs compared to AEDs which

have been dispatched via emergency services [16]. In the absence of legislation for BLS and

AED training, local champions have been able to significantly increase rates of BLS and

AED training and such endeavours should be encouraged, with successful local frameworks

for provision of training adopted and implemented nationally.

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The strengths of this investigation are that data were collected prospectively from

school administrators who were responsible with BLS training practices at each of the

institutions. We used an electronic data capture tool with pre-specified variable responses

and error-response elements to minimize incomplete responses. A number of limitations

should also be considered when interpreting the results of this investigation. While we were

able to capture survey results data on a large number of London secondary schools there

are a number of schools which are not represented. We have however collected complete

survey data from 65 secondary schools from 19 boroughs across London which represents a

large estimated student population with responses reflecting practices as recent as October

2014. One further limitation is that the survey tool that was used for the investigation has not

been validated in a separate population. We attempted to mitigate this weakness with a pilot

phase of the survey during which time respondents were able to provide feedback about the

questionnaire. Finally, as we have attempted to obtain an estimate of the number of school

children which have died as a result of cardiac arrest this data is inevitably limited by recall

bias and larger population studies would be necessary to confirm our findings.

Conclusion

BLS training rates in London secondary schools are low and the majority of schools

do not have an AED available in case of emergency. As a number of international health and

resuscitation organizations are attempting to improve overall training rates these data

highlight an opportunity to vastly improve training in schools throughout the United Kingdom.

Acknowledgements

The authors are grateful for the illustration prepared by Will Mower. This work is supported

by the National Institute for Health Research Biomedical Research Centre based at Imperial

College Healthcare NHS Trust and Imperial College London. The views expressed in this

publication are those of the author(s) and not necessarily those of the NHS, the National

Institute for Health Research or the Department of Health

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Contributions

JDS and PBL were responsible for project design and survey development. ADW was

responsible for acquiring survey contact information. DCM, MCS, SJ and MS were

responsible for primary survey data collection. JDS, DCM and MCS were responsible for

data analysis and PBL for interpretation of results. All authors contributed to the first draft of

the manuscript and have reviewed the final version before submission.

Competing Interests

The authors have no competing interests to declare. The corresponding author affirms that

the manuscript is an honest, accurate, and transparent account of the study being reported

and that no important aspects of the study have been omitted.

Data Sharing

No additional data available.

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References

1 Berdowski J, Berg RA, Tijssen JGP, et al. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479–87.

2 Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation 2014;129:e28.

3 Atwood C, Eisenberg MS, Herlitz J, et al. Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 2005;67:75–80.

4 Stiell IG, Wells GA, DeMaio VJ, et al. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase I results. Ann Emerg Med 1999;33:44–50.

5 Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. Jama 2008;300:1423–31.

6 Cummins RO, Ornato JP, Thies WH, et al. Improving survival from sudden cardiac arrest: the ‘chain of survival’ concept. Circulation 1991;83:1832–47.

7 Sanghavi P, Jena AB, Newhouse JP, et al. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med 2015;175:196–204.

8 Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307–15.

9 Cave DM, Aufderheide TP, Beeson J, et al. Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association. Circulation 2011;123:691–706. doi:10.1161/CIR.0b013e31820b5328

10 UK Department of Education. Health and Safety in Schools. Automated external defibrillators (AEDs) in schools. 2014.https://www.gov.uk/government/publications/automated-external-defibrillators-aeds-in-schools (accessed 2 Aug2015).

11 UK Department of Education. Number of secondary schools and their size in student numbers. 2014.https://www.gov.uk/government/publications/number-of-secondary-schools-and-their-size-in-student-numbers (accessed 2 Aug2015).

12 Lund-Kordahl I, Olasveengen TM, Lorem T, et al. Improving outcome after out-of-hospital cardiac arrest by strengthening weak links of the local Chain of Survival; quality of advanced life support and post-resuscitation care. Resuscitation 2010;81:422–6.

13 Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. Jama 2013;310:1377–84.

14 Garcia-Barbero M, Caturla-Such J. What are we doing in cardiopulmonary resuscitation training in Europe? An analysis of a survey. Resuscitation 1999;41:225–36.

15 Hart D, Flores-Medrano O, Brooks S, et al. Cardiopulmonary resuscitation and automatic external defibrillator training in schools:‘Is anyone learning how to save a life?’ CJEM 2013;15:270–8.

16 Berdowski J, Blom MT, Bardai A, et al. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation 2011;124:2225–32.

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Figures Figure 1: Map of London boroughs. Colors represent boroughs with surveys completed from

all secondary schools within the borough (green), from a proportion but not all of the

secondary schools (blue), or borough without completed survey data (grey).

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Map of London boroughs. Colors represent boroughs with surveys completed from all secondary schools within the borough (green), from a proportion but not all of the secondary schools (blue), or borough

without completed survey data (grey).

722x581mm (72 x 72 DPI)

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Journal: BMJ Open

Manuscript ID bmjopen-2016-011436.R1


Date Submitted by the Author: 14-Jun-2016


Primary Subject





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Title:


United Kingdom

Authors:



Affiliations:



Correspondence:

P Boon Lim




Du Cane Road

London W12 0Hs


Tel : 0203 313 4967

Fax: 0203 313 4095

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Basic life support training (BLS) in schools is associated with improved outcomes from

cardiac arrest. International consensus statements have recommended universal BLS



secondary schools.







results.

Results




extra-curricular program or chosen module. An Automated External Defibrillator (AED) was

available in 18 (28%) schools, unavailable in 40 (61%) and 7 (11%) reported their AED

provision as unknown. The most common reasons for not having a universal BLS training

programme are the requirement for additional class time (28%) and that funding is

unavailable for such program (28%). There were 5 students who died from sudden cardiac

arrest over the period of the past 10 years.

Conclusion



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BLS training and AEDs provision. Future studies should assess programmes which are cost-

effective and do not require significant amounts of additional class time.


cardiac arrest

Article Summary:


administrators who are responsible for Basic Life Support training at their institution. We

used an electronic data capture tool to with pre-specified variable responses, standardizing

the data and reducing inter-questioner variability. We were able to collect survey data from

65 secondary schools from 19 boroughs across London, with responses reflecting practices

as recent as October 2014. A number of schools however are not represented in our data

set. Finally, we collected data regarding the number school children who have died on

school premises of sudden cardiac death. This figure is inevitably subject to recall bias.

Relatable points:



• BLS training rates in London schools are low


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Introduction







practices.

The chain of survival has been promoted broadly as a means to optimize the

community’s response to out-of-hospital cardiac arrest [6]. Previous investigations have

shown that BLS measures may be more important than advanced care in survival from out-

of-hospital cardiac arrest [7] and more recent evidence has provided further support for this

effect across healthcare systems [8]. In order to improve the rate of early bystander CPR

and early defibrillation the International Liaison Committee on Resuscitation (ILCOR)

recommended training in CPR and familiarisation with Automated External Defibrillator

(AED) as part of secondary school curricula [9]. BLS training has since become a

requirement for graduation in multiple states throughout the United States

(http://tinyurl.com/o8hmvwb). However, the requirement for BLS training is not part of the

educational curriculum in the United Kingdom (UK) and the current practice of BLS training

in schools throughout the UK is unknown.


and AED training in school-aged children in London. Our hypothesis was that, despite

consensus statements from local and international professional resuscitation bodies, there

would be a small proportion of London secondary schools currently offering universal BLS

training programs. This was based primarily on previous reports which have suggested low

rates of BLS training in the UK compared to European countries [10].These data are relevant

as they may highlight potential areas for improvement in public health initiatives. In order to

identify training programs, we performed a cross-sectional survey to ascertain current

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training practices for students in London secondary schools. To the best of our knowledge

this investigation is the only study to have assessed the rate of BLS training in London

secondary schools since these consensus statements have been made.

Methods





(Registration number 1673). Interviewers received preliminary training in survey details and

appropriate administration of the telephone interviews. All schools were contacted by email

initially and a subsequent telephone interview was conducted with school staff familiar with

local training practices. Response data were anonymised and captured electronically in a

standardized electronic database.







interviews and data collection. The final survey tool (see Supplemental files) was brief,

included fewer than 20 response elements, and could typically be completed over the

telephone in less than 10 minutes.



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investigation. Simple descriptive statistics including frequencies with percentages were used

to summarise the results, as appropriate.

Post-Hoc Analysis



Education (DoE) issued a public statement which recommends placement of AEDs in all UK


the UK National Health Service (NHS) Supply Chain and with this program, the cost per AED

would be £452.78 [11]. For this analysis, we used reported incidence of student sudden

cardiac arrest as a single case of cardiac arrest and computed the rate of cardiac arrest per

secondary school surveyed.

Results

Characteristics

Surveys were completed in 19 (52%) of the 32 London boroughs (Figure 1). Of 449

schools, representatives from 71 (16%) schools were contacted successfully and a total of

65 (15%) completed the survey. There were 6 schools which refused to participate (8%).

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The student population from the surveyed schools completed covers an estimated

population of 65,396 students between the ages of 11 and 19 years. In this sample, the

earliest that students are exposed to BLS training is in Year 7 (approximately 11 years of

age). Specialist First Aid and CPR educators from outside organizations (eg. St. John’s

Ambulance, British Heart Foundation, etc.) are most commonly responsible for providing

educational programs and training for students (15%).











Cost Analysis








Discussion

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early initiation of bystander CPR efforts via large-scale educational programs [13,14]. Two

recent reports have shown that CPR prior to emergency medical service arrival in OHCA is

associated with improved survival [8], and that this basic intervention may be as effective or

better than pre-hospital advanced life support [7]. While two recent randomized studies have

demonstrated that trained teachers are able to provide adequate training in for resuscitation

in schools[15,16] , one area that remains unanswered is whether legislation to require

schools to teach BLS will improve outcomes for patients suffering cardiac arrest.



students while 48% of schools offer some optional training for students. These results are in

line with a recent investigation from Toronto, Canada, which found that 51% of secondary

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schools provide CPR training for students although it is unclear whether CPR training

programs were required for all students in the institution or whether these were optional

programs [17]. There are important differences relating to the legislation between the two

locations that raise the issue of making CPR training a requirement of school curriculum.

While the government of Ontario, Canada has made it mandatory for students to

demonstrate an understanding of cardiopulmonary resuscitation in order to obtain their

secondary school diploma the UK government has yet to make such a change to curriculum

requirements. It is unclear, therefore, what effect legislation has on the overall rate for

students receiving CPR training. Despite this difference one recent report has also shown a

temporal trend toward improving outcomes from OHCA in Denmark since instituting

mandatory resuscitation training programs in elementary schools [14].

Our findings would suggest a rate of approximately one cardiac arrest per 130 school

years (0.04 per 5 years), a similar rate to previous reports in the United States [18]. Based

on current evidence ERC guidelines support the cost-effectiveness of placement of AEDS in

public areas where there is one cardiac arrest per 5 years [19]. Although below the threshold

for cost-effectiveness recommended by the ERC, placement of an AED in schools may fall

within the acceptable cost per QALY recommended by the National Institute of Clinical

Excellence and further will increase awareness and familiarity with AEDs amongst school

children. In the UK, where legislation for BLS training in schools has not been written, the










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Conclusion





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Acknowledgements






Contributions






Competing Interests




Data Sharing


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References











11 UK Department of Education: Health and Safety in Schools. Automated external defibrillators (AEDs) in schools. 2014.

12 UK Department of Education. Number of secondary schools and their size in student numbers. 2014.



15 Lukas R-P, Van Aken H, Mölhoff T, et al. Kids save lives: a six-year longitudinal study of schoolchildren learning cardiopulmonary resuscitation: Who should do the teaching and will the effects last? Resuscitation 2016;101:35–40.

16 Beck S, Issleib M, Daubmann A, et al. Peer education for BLS-training in schools? Results of a randomized-controlled, noninferiority trial. Resuscitation 2015;94:85–90.

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18 Lotfi K, White L, Rea T, et al. Cardiac Arrest in Schools. Circ 2007;116 :1374–9. doi:10.1161/CIRCULATIONAHA.107.698282

19 Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99. doi:10.1016/j.resuscitation.2015.07.015


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209x148mm (300 x 300 DPI)

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Title: Basic Life Support Education in Secondary Schools: a cross-sectional survey in London, United Kingdom

Supplementary Appendix

Table of Contents: Survey Instrument …………………………………………………………………………… 2

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2

Survey Instrument

1. Borough: drop down list a. Barking and Dagenham, Barnet, Brexley, Brent, Bromley, Camden, City of

London, Croydon, Ealing, Enfield, Greenwich, Hackney, Hammersmith and Fulham, Haringey, Harrow, Havering, Hillingdon, Hounslow, Islington, Kensington and Chelsea, Kingston, Lambeth, Lewisham, Merton, Newham, Redbridge, Richmond on Thames, Southward, Sutton, Tower Hamlets, Waltham Forest, Wandsworth, Westminster

2. School ID 3. What is the current enrollment (number of pupils) in this school? 4. What is the maximum age and minimum age of pupils in this school? (Give

range, e.g. 8-14) 5. Is there currently any universal CPR education or training program for students in

place in this institution, i.e. will ALL students at some point receive? (Y/N) a. If yes, continue to Q6 b. If no, continue to Q10

6. In which year(s) are students introduced universally to CPR and AED training? Provide earliest year in which students are exposed to CPR training.

a. Year 7 b. Year 8 c. Year 9 d. Year 10 e. Year 11 f. Year 12 (lower 6th) g. Year 13 (upper 6th) h. Other (specify)

7. Are students exposed to CPR training at any other time? If so, in which years? Choose one.

a. No follow-up training program in place b. Year 7 c. Year 8 d. Year 9 e. Year 10 f. Year 12 (lower 6th) g. Year 13 (upper 6th) h. Other (specify)

8. Who is responsible for providing CPR training / education for these students? Choose one.

a. Teachers b. Specialist first aid/CPR educators employed at the institution c. Specialist first aid/CPR educators from an outside organization (e.g. St.

John’s ambulance, British Heart Foundation, etc.) d. Other (specify)

9. What has been the biggest challenge to maintain universal CPR training in this institution? Choose one.

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3

a. Instructor training or scheduling b. Class scheduling c. Initial purchase of equipment d. Maintenance of equipment e. Other (specify)

10. Is there any non-universal CPR training program for students at this institution? (Y/N)

a. If yes, continue to Q13 b. If no, continue to Q11

11. For schools without current CPR training/education programs: a. What do you perceive to be the biggest barrier to student training?

Choose one. i. Requirement for additional class time ii. Funding unavailable for these programs iii. Cost of purchasing and/or maintaining equipment is prohibitive iv. School population is too small to be cost effective v. School population is too large to offer training to everyone vi. No perceived need for this training vii. Other (specify)

12. Other CPR training programs a. Are teachers or staff members required to have CPR training (Y/N)

i. If yes, is this training optional or a requirement? Choose one.p 1. Required for all teachers in this institution 2. Required for select teachers in this institution 3. Other (specify)

b. Who is responsible for providing CPR training/education for these individuals?

i. Teachers ii. Specialist first aid/CPR educators employed at the institution iii. Specialist first aid/CPR educators from an outside organization

(e.g. St Johns ambulance, British Heart Foundation, etc.) iv. Other (specify)

c. With what frequency, if any, do these individuals complete their CPR training? Choose one.

i. Annually ii. Every second year iii. Every third year iv. Less than once every third year v. Never vi. Other

13. Non-universal CPR training for Students a. How might students be exposed to CPR training at this institution?

Choose one. i. As part of Duke in Edinburgh scheme ii. Physical education classes iii. Social health and wellness class

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4

iv. Other scheduled class time v. Other (specify)

b. Who is responsible for providing CPR training/education for these students? Choose one.

1. Teachers 2. Specialist First Aid / CPR educators employed at the institution 3. Specialist First Aid / CPR educators from an outside organization

(eg St. John’s ambulance, British Heart Foundation, etc.) 4. Other (specify)

14. Is there an automated external defibrillator in case of emergency? (Y/N/unknown) 15. To the best of your knowledge, in the past 10 years, have any students passed

away from sudden cardiac arrest (SCA)? Y/N/unknown a. If yes, what number of students have passed away from SCA (Total # of

students within the last 10 years) 16. We are planning to survey a number of secondary schools in order to better

understand CPR training practices across London. Would you be interested in receiving a summary of the results of this survey in the coming months? (This question is optional as a response here may remove anonymity in the survey. We do not plan to use this information for any other purposes) Y/N

17. Are you interested in learning more about the possibility of having student volunteers into your school to teach CPR and First Aid?

18. Can you provide the best email address to contact you about the above? (Record this information on the hardcopy list of schools provided)

19. Date/Time questionnaire completed a. Month, day, year, hour, min, AM/PM

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Journal: BMJ Open



Date Submitted by the Author: 20-Aug-2016


Primary Subject





BMJ Open on A


http://bmjopen.bm

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BM



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Title:


United Kingdom

Authors:



Affiliations:



Correspondence:

P Boon Lim




Du Cane Road

London W12 0Hs


Tel : 0203 313 4967

Fax: 0203 313 4095

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Basic life support (BLS) training in schools is associated with improved outcomes from




secondary schools.







results.

Results










Conclusion



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cardiac arrest

Article Summary:


administrators who are responsible for Basic Life Support training at their institution. We

used an electronic data capture tool to with pre-specified variable responses, standardizing

the data and reducing inter-questioner variability. We were able to collect survey data from

65 secondary schools from 19 boroughs across London, with responses reflecting practices

as recent as October 2014. A number of schools however are not represented in our data

set. Finally, we collected data regarding the number school children who have died on

school premises of sudden cardiac death. This figure is inevitably subject to recall bias.

Relatable points:



• BLS training rates in London schools are low


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Introduction







practices.






early initiation of bystander CPR efforts via large-scale educational programs [7,8]. Previous

investigations have shown that BLS measures may be more important than advanced care

in survival from out-of-hospital cardiac arrest [9] and more recent evidence has provided

further support for this effect across healthcare systems [10]. One area that remains







throughout the United States [12]. Recent efforts have been made globally to train children in

CPR and the World Health Organization has endorsed the ‘Kids Save Lives’ statement from

the European Resuscitation Council to further improve training for school-aged children

[13,14]. However, within Europe variation exists between countries regarding the methods

used to train and how much time is spent training children, the general public and healthcare

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professionals alike [15–17]. While the requirement for BLS training is not part of the

educational curriculum in the United Kingdom (UK) and the current practice of BLS training

in schools throughout the UK is unknown.












Methods





(Registration number 1673). A total of eight interviewers administered the survey during the

course of two afternoon sessions (24/09/2014 and 01/10/2014). Prior to each session

interviewers received via lecture presentation preliminary training in survey details and

delivery for appropriate administration of the telephone interviews. All schools were

contacted by email initially and a subsequent telephone interview was conducted with school

staff familiar with local training practices. Response data were anonymised and captured

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electronically in a standardized electronic database. In order to ensure standardisation of

response data the database contained pre-specified variable responses as described below.







interviews and data collection. The final survey tool (see Supplementary files) was brief,















Post-Hoc Analysis

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Results

Characteristics
















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Cost Analysis








Discussion













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students while 48% of schools offer some optional training for students. Our findings reflect

the results of a similar survey of schools in Yorkshire, England which found only three of the

fourteen schools delivered universal training[20].Our results are further in line with a recent

investigation from Toronto, Canada, which found that 51% of secondary schools provide

CPR training for students although it is unclear whether CPR training programs were

required for all students in the institution or whether these were optional programs [21].

There are important differences relating to the legislation between the two locations that

raise the issue of making CPR training a requirement of school curriculum. While the

government of Ontario, Canada has made it mandatory for students to demonstrate an

understanding of cardiopulmonary resuscitation in order to obtain their secondary school

diploma the UK government has yet to make such a change to curriculum requirements. It is

unclear, therefore, what effect legislation has on the overall rate for students receiving CPR

training. Despite this difference one recent report has also shown a temporal trend toward

improving outcomes from OHCA in Denmark since instituting mandatory resuscitation

training programs in elementary schools [8]. A recent report from Denmark assessed which

factors school leaders and teachers value in the aim to train school children in BLS [22]. It is

important to note that other investigations have demonstrated that effective BLS training is

possible in the absence of trained or experienced BLS instructors [23]. Further, while two

randomized studies have demonstrated that trained teachers are able to provide adequate

training in for resuscitation in schools and a systematic review has summarised the methods

to best teach CPR to children [24–26].





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Excellence and will further increase awareness and familiarity with AEDs amongst school

























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Conclusion





Acknowledgements






Contributions






Competing Interests

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Data Sharing


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References












12 CPR in Schools Legislation Map. http://cpr.heart.org/AHAECC/CPRAndECC/Programs/CPRInSchools/UCM_475820_CPR-in-Schools-Legislation-Map.jsp

13 Böttiger BW, Van Aken H. Kids save lives –. Resuscitation 2015;94:A5–7.

14 https://www.resus.org.uk/EasySiteWeb/GatewayLink.aspx?alId=1219tle.


16 Jäntti H, Silfvast T, Turpeinen A, et al. Nationwide survey of resuscitation education in Finland. Resuscitation 2009;80:1043–6. doi:10.1016/j.resuscitation.2009.05.027

17 Miró O, Jiménez-Fábrega X, Espigol G, et al. Teaching basic life support to 12-16 year olds in Barcelona schools: views of head teachers. Resuscitation 2006;70:107–16. doi:10.1016/j.resuscitation.2005.11.015


19 UK Department of Education. Number of secondary schools and their size in student numbers. 2014.https://www.gov.uk/government/publications/number-of-secondary-schools-and-their-

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size-in-student-numbers (accessed 2 Aug2015).

20 Lockey AS, Barton K, Yoxall H. Opportunities and barriers to cardiopulmonary resuscitation training in English secondary schools. Eur J Emerg Med Published Online First: 11 August 2015. doi:10.1097/MEJ.0000000000000307


22 Zinckernagel L, Malta Hansen C, Rod MH, et al. What are the barriers to implementation of cardiopulmonary resuscitation training in secondary schools? A qualitative study. BMJ Open 2016;6:e010481. doi:10.1136/bmjopen-2015-010481

23 Iserbyt P, Mols L, Charlier N, et al. Reciprocal learning with task cards for teaching Basic Life Support (BLS): investigating effectiveness and the effect of instructor expertise on learning outcomes. A randomized controlled trial. J Emerg Med 2014;46:85–94.



26 Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review. Resuscitation 2013;84:415–21. doi:10.1016/j.resuscitation.2012.12.008

27 Lotfi K, White L, Rea T, et al. Cardiac Arrest in Schools. Circ 2007;116:1374–9. doi:10.1161/CIRCULATIONAHA.107.698282



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209x148mm (300 x 300 DPI)

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2

Survey Instrument














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3















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4












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Journal: BMJ Open



Date Submitted by the Author: 21-Sep-2016


Primary Subject





BMJ Open on A


http://bmjopen.bm

j.com/

BM



nloaded from


Title:


United Kingdom

Authors:



Affiliations:



Correspondence:

P Boon Lim




Du Cane Road

London W12 0Hs


Tel : 0203 313 4967

Fax: 0203 313 4095

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Basic life support (BLS) training in schools is associated with improved outcomes from




secondary schools.






to all students in the school. Descriptive statistics were used to summarise the results.

Results










Conclusion





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cardiac arrest

Article Summary:

Article Focus:

International health and resuscitation committees have recommended training in CPR and

familiarisation with Automated External Defibrillator (AED) as part of secondary school

curricula and recent efforts have been made globally to train children in CPR. However, the

requirement for BLS training is not a part of the educational curriculum in the United

Kingdom (UK).

Key Messages:


have an AED available in case of emergency. These data highlight an opportunity to vastly

improve training in schools throughout the United Kingdom

Strengths and Limitations:

Strengths include data collected prospectively from secondary schools across London, with

responses reflecting practices as recent as October 2014. A number of schools, however,

are not represented in our data set. Recall bias limits our ability to generalize our findings

relating to the number school children who have died on school premises of sudden cardiac

death.

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Introduction







practices.






early initiation of bystander CPR efforts via large-scale educational programs [7,8]. Previous

investigations have shown that BLS measures may be more important than advanced care

in survival from out-of-hospital cardiac arrest [9] and more recent evidence has provided

further support for this effect across healthcare systems [10]. One area that remains







throughout the United States [12]. Recent efforts have been made globally to train children in

CPR and the World Health Organization has endorsed the ‘Kids Save Lives’ statement from

the European Resuscitation Council to further improve training for school-aged children

[13,14]. However, within Europe variation exists between countries regarding the methods

used to train and how much time is spent training children, the general public and healthcare

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professionals alike [15–17]. The requirement for BLS training is not part of the educational

curriculum in the United Kingdom (UK) and the current practice of BLS training in schools

throughout the UK is unknown.












Methods





(Registration number 1673). A total of eight interviewers administered the survey during the

course of two afternoon sessions. Prior to each session interviewers received via lecture

presentation preliminary training in survey details and delivery for appropriate administration

of the telephone interviews. All schools were contacted by email initially and a subsequent

telephone interview was conducted with school staff familiar with local training practices.

Response data were anonymised and captured electronically in a standardized electronic

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database. In order to ensure standardisation of response data the database contained pre-

specified variable responses as described below.







interviews and data collection. The final survey tool (see Supplementary files) was brief,















Post-Hoc Analysis

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/B

MJ O


ownloaded from
