Basic Life Support Education in Secondary Schools: a cross- · Basic life support training in...
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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
<b>Primary Subject
Heading</b>: Cardiovascular medicine
Secondary Subject Heading: Public health
Keywords: cardiopulmonary resuscitation, automatic external defibrillator, education, cardiac arrest
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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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Basic Life Support Education in Secondary Schools: a cross-sectional survey in London, United Kingdom
Journal: BMJ Open
Manuscript ID bmjopen-2016-011436.R1
Article Type: Research
Date Submitted by the Author: 14-Jun-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
<b>Primary Subject
Heading</b>: Cardiovascular medicine
Secondary Subject Heading: Public health
Keywords: cardiopulmonary resuscitation, automatic external defibrillator, education, cardiac arrest
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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 (BLS) in schools is associated with improved outcomes from
cardiac arrest. International consensus statements have 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 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
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
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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.
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 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:
• 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 are 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.
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 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
Study Design and Setting
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. 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.
Response data were collected and managed using an electronic data capture tool
which provided pre-specified variable responses and missing value-response alerts to
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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
investigation. Simple descriptive statistics including 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 (DoE) issued a public statement which recommends placement of AEDs in all UK
primary and secondary schools [11]. The DoE statement supports purchasing of AEDs by
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%).
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
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.[12]
Discussion
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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
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 [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.
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
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
Department of Education has recently published guidance for schools to equip the institution
with an AED [11] 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
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improvement in neurologically intact survival with onsite AEDs compared to AEDs which
have been dispatched via emergency services [20]. 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.
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.
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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
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 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.
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.
13 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.
14 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.
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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17 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.
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
20 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).
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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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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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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Basic Life Support Education in Secondary Schools: a cross-sectional survey in London, United Kingdom
Journal: BMJ Open
Manuscript ID bmjopen-2016-011436.R2
Article Type: Research
Date Submitted by the Author: 20-Aug-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
<b>Primary Subject
Heading</b>: Cardiovascular medicine
Secondary Subject Heading: Public health
Keywords: cardiopulmonary resuscitation, automatic external defibrillator, education, cardiac arrest
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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 (BLS) training in schools is associated with improved outcomes from
cardiac arrest. International consensus statements have 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 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
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
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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.
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 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:
• 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 are 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.
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 [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
unanswered is whether legislation to require schools to teach BLS will improve outcomes for
patients suffering cardiac arrest.
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 [11]. BLS training has since become a requirement for graduation in multiple states
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.
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 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 [15].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
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
Study Design and Setting
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). 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.
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. The final survey tool (see Supplementary files) was brief,
included fewer than 20 response elements, and could typically be completed over the
telephone in less than 10 minutes.
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
investigation. Simple descriptive statistics including frequencies with percentages were used
to summarise the results, as appropriate.
Post-Hoc Analysis
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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 (DoE) issued a public statement which recommends placement of AEDs in all UK
primary and secondary schools [18]. The DoE statement supports purchasing of AEDs by
the UK National Health Service (NHS) Supply Chain and with this program, the cost per AED
would be £452.78 [18]. 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%).
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
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%)
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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.[19]
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
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.
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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
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].
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 [27]. 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 [28]. Although below the threshold
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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 will further increase awareness and familiarity with AEDs amongst school
children. 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 [18] 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 [29]. 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.
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
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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
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
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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 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.
8 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.
9 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.
10 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.
11 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
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.
15 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.
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
18 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).
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
21 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.
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.
24 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.
25 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.
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
28 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
29 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).
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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Basic Life Support Education in Secondary Schools: a cross-sectional survey in London, United Kingdom
Journal: BMJ Open
Manuscript ID bmjopen-2016-011436.R3
Article Type: Research
Date Submitted by the Author: 21-Sep-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
<b>Primary Subject
Heading</b>: Cardiovascular medicine
Secondary Subject Heading: Public health
Keywords: cardiopulmonary resuscitation, automatic external defibrillator, education, cardiac arrest
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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 (BLS) training in schools is associated with improved outcomes from
cardiac arrest. International consensus statements have 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. 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 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
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 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:
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:
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 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
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.
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 [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
unanswered is whether legislation to require schools to teach BLS will improve outcomes for
patients suffering cardiac arrest.
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 [11]. BLS training has since become a requirement for graduation in multiple states
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.
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 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 [15].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
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
Study Design and Setting
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). 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.
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. The final survey tool (see Supplementary files) was brief,
included fewer than 20 response elements, and could typically be completed over the
telephone in less than 10 minutes.
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
investigation. Simple descriptive statistics including frequencies with percentages were used
to summarise the results, as appropriate.
Post-Hoc Analysis
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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 (DoE) issued a public statement which recommends placement of AEDs in all UK
primary and secondary schools [18]. The DoE statement supports purchasing of AEDs by
the UK National Health Service (NHS) Supply Chain and with this program, the cost per AED
would be £452.78 [18]. 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%).
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
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%)
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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.[19]
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
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.
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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
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].
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 [27]. 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 [28]. Although below the threshold
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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 will further increase awareness and familiarity with AEDs amongst school
children. 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 [18] 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 [29]. 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.
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
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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
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
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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 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.
8 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.
9 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.
10 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.
11 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
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.
15 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.
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
18 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).
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
21 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.
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.
24 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.
25 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.
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
28 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
29 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).
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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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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