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Mandatory CPR Training in US High Schools

      Abbreviations and Acronyms:

      CPR (cardiopulmonary resuscitation)
      The number of US states mandating cardiopulmonary resuscitation (CPR) training as a requirement for graduation from high school is rapidly increasing (Table).

      American Heart Association. CPR in schools. American Heart Association website. www.heart.org/cprinschools. Accessed January 28, 2015.

      Such requisite CPR training in high school now involves 21 states and more than 1 million high school students annually.

      American Heart Association. Over 1 million students to learn lifesaving CPR skills each year. American Heart Association website. http://blog.heart.org/over-1-million-students-to-learn-lifesaving-cpr-skills-each-year/. Published May 30, 2014. Accessed January 28, 2015.

      Although students may opt out, parental consent is required to do so, compelling the majority of high school students to learn the basic techniques of CPR. We believe this widespread implementation of CPR training has many benefits to high school students and the broader US public. High school students are well positioned to improve rates of bystander CPR initiation in the United States,
      • Nichol G.
      • Thomas E.
      • Callaway C.W.
      • et al.
      Resuscitation Outcomes Consortium Investigators
      Regional variation in out-of-hospital cardiac arrest incidence and outcome.
      and their engagement could reduce deep disparities in regional rates of survival of out-of-hospital cardiac arrest through early initiation of bystander CPR. Imagine what could happen if CPR training was required in all of the more than 37,000 high schools in the United States.
      TableUS States With a Law Requiring Cardiopulmonary Resuscitation Training Before High School Graduation
      Data from the American Heart Association.

      American Heart Association. CPR in schools. American Heart Association website. www.heart.org/cprinschools. Accessed January 28, 2015.

      StateYear/school year put into effect
      Alabama1984
      Arkansas2014-2015
      Delaware2014-2015
      Georgia2013-2014
      Idaho2015-2016
      Illinois2014-2015
      Iowa2008
      Louisiana2014-2015
      Maryland2014-2015
      Minnesota2014-2015
      Mississippi2014
      New Jersey2014-2015
      North Carolina2014-2015
      Oklahoma2015-2016
      Rhode Island2013
      Tennessee2012
      Texas2014-2015
      Utah2014-2015
      Vermont2012
      Virginia2016-2017
      Washington2014-2015
      Cardiovascular disease is the leading cause of death in the United States, and each day, more than 1000 people experience a sudden, out-of-hospital cardiac arrest.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
      Before the adoption of CPR in communities, the survival following out-of-hospital cardiac arrest approximated less than 5%.
      • Ritter G.
      • Wolfe R.A.
      • Goldstein S.
      • et al.
      The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims.
      One estimate suggests that the number needed to treat for one person to survive out-of-hospital cardiac arrest due to the initiation of bystander CPR is between 24 and 36.
      • Sasson C.
      • Rogers M.A.
      • Dahl J.
      • Kellermann A.L.
      Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis.
      However, only about 1 in 3 witnessed out-of-hospital cardiac arrests involve early bystander CPR initiation.
      • Nichol G.
      • Thomas E.
      • Callaway C.W.
      • et al.
      Resuscitation Outcomes Consortium Investigators
      Regional variation in out-of-hospital cardiac arrest incidence and outcome.
      • Swor R.
      • Khan I.
      • Domeier R.
      • Honeycutt L.
      • Chu K.
      • Compton S.
      CPR training and CPR performance: do CPR-trained bystanders perform CPR?.
      It is often assumed that the fear of mouth-to-mouth resuscitation is the major barrier to bystanders performing CPR, but panic and discomfort of the bystander are in fact the most common reasons why CPR is not initiated during a witnessed cardiac arrest.
      • Swor R.
      • Khan I.
      • Domeier R.
      • Honeycutt L.
      • Chu K.
      • Compton S.
      CPR training and CPR performance: do CPR-trained bystanders perform CPR?.
      A bystander trained in CPR is the strongest predictor of a victim receiving CPR (odds ratio, 6.6; 95% CI, 3.5-12.5), stronger than a public location of the cardiac arrest, a bystander-witnessed event, and the bystander’s overall educational level.
      • Swor R.
      • Khan I.
      • Domeier R.
      • Honeycutt L.
      • Chu K.
      • Compton S.
      CPR training and CPR performance: do CPR-trained bystanders perform CPR?.
      Although not proven, it is likely that bystanders trained in CPR are more likely to act and act competently, for example, with the appropriate depth of chest compressions and with less hesitation.
      Initially, the CPR in Schools campaign sponsored by the American Heart Association aimed to train school teachers.
      • Cave D.M.
      • Aufderheide T.P.
      • Beeson J.
      • et al.
      American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Advocacy Coordinating Committee
      Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association.
      However, several examples of students successfully performing CPR on adults led to a wider campaign to include students as potential CPR providers. Similarly, tragic missed opportunities for CPR in cases of bystander-witnessed events have prompted the desire to train high school students whenever possible. Although proponents cite the number of lives that may be saved with minimal investment, critics focus on the lack of funding for such initiatives in school districts, the limited time in the high school curriculum, and the uncertain benefits of a minimalist approach of just a few hours of CPR training.
      The success of mandatory high school CPR training programs is the result of advocacy by several stakeholders including students, out-of-hospital cardiac arrest survivors, and family members of out-of-hospital cardiac arrest victims. Today, the rules for CPR training in high schools are variable across states, ranging from mere recognition of the steps of the “chain of survival” to formal American Heart Association–endorsed in-person training on automated external defibrillator use and CPR.
      • Cave D.M.
      • Aufderheide T.P.
      • Beeson J.
      • et al.
      American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Advocacy Coordinating Committee
      Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association.
      State laws represent a growing recognition that behavioral change for health at the high school level may truly save lives. In cases of automated external defibrillator use, the training may be more intense but of higher benefit if an out-of-hospital cardiac arrest is witnessed in a public place.
      Advocates of mandatory CPR training of high school students emphasize that students are more likely to encounter out-of-hospital cardiac arrest victims in shopping malls or among family members at home than to encounter a high school student experiencing out-of-hospital cardiac arrest. Thus, learning CPR is mostly a selfless act both for the individual high school student and for high school students as a group. Unlike most safety and public health laws, mandatory CPR training encourages people to help others in need but does not lead directly to improved health outcomes for the learner. The implication of altruism suggests that uptake of training may be less vulnerable to student nonparticipation and lack of parental consent than other high school level health initiatives, such as universal vaccination. This factor could make CPR education one of the most widely accepted health programs implemented in high schools.
      US legislation regarding CPR is admirable in the rapidity of uptake and its growing national reach. Training in CPR is but one of many important, beneficial health behaviors that can be taught to high school students. Other valuable health priorities include road and traffic safety and alcohol and drug awareness. Surprisingly, mandatory education on these other health issues was seldom required of students who graduated before 2015. The choice of CPR training as requisite among all of these competing health care education priorities is influenced by such factors as the epidemiology of a disease, the efficacy of an intervention, the financial and time investment of a participant or institution, the likelihood of an intervention actually being needed, and the appropriateness of enforcing training. There are also key influences of timing, patient advocacy, and the political will to enact change.
      Ideally, the mandatory nature of CPR training in high schools—the last time many Americans will interface with formal education

      National Center for Education Statistics. Fast facts. http://nces.ed.gov/fastfacts/display.asp?id=98. Accessed April 28, 2015.

      —will enable the American health care system to remediate deep disparities in survival following out-of-hospital cardiac arrest. Perhaps surprisingly, the range of survival prevalence following out-of-hospital cardiac arrest is among the highest survival disparities of any disease in the United States, ranging from 0% (Detroit) and 3% (Chicago) to 46% (King County, Washington, and Olmsted County, Minnesota), with a median of approximately 15%.
      • Eisenberg M.
      • White R.D.
      The unacceptable disparity in cardiac arrest survival among American communities.
      Where you live is the most important predictor of whether you will survive a cardiac arrest in the United States today. If learning CPR and cardiac defibrillation remains optional, it is likely that students in wealthier schools and neighborhoods will continue to be taught CPR and those in poorer schools and districts will be less able to participate. It is precisely in large, inner-city neighborhoods and poorer US counties where the impact of cardiac disease is disproportionately felt and in these same populations where CPR should be prioritized.
      On the basis of the dramatic improvement in survival when CPR is initiated quickly and our society’s basic principles to help each other, it is our opinion that CPR training should become mandated by law in all states before graduation from high school. We also advocate for the initiation of systematically designed databases to understand the number of students trained and the range of curricula employed in various locations as states roll out mandatory CPR training. The number and outcomes of cardiac arrests attended by students and people who were last trained in CPR in high school is currently unrecorded. This lack of quantification of the effect of high school CPR training represents missed opportunities for evaluation of program effectiveness. Although CPR training in high schools is almost certainly beneficial, it is imperative to quantify its effects. In this way, the ultimate objective value of CPR training in high schools may be confirmed.

      References

      1. American Heart Association. CPR in schools. American Heart Association website. www.heart.org/cprinschools. Accessed January 28, 2015.

      2. American Heart Association. Over 1 million students to learn lifesaving CPR skills each year. American Heart Association website. http://blog.heart.org/over-1-million-students-to-learn-lifesaving-cpr-skills-each-year/. Published May 30, 2014. Accessed January 28, 2015.

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