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Resuscitation training in school curricula

Cardiac arrest is a leading cause of death and neurocognitive impairment worldwide. To improve survival and neurological outcome, early initiation of cardiopulmonary resuscitation is essential

Daniel C Schroeder MD
Hannes Ecker MD
Hugo Van Aken MD FRCA FANZA 
Department of Anaesthesiology, 
Intensive Care Medicine and Pain Therapy, 
University Hospital of Muenster
Bernd W Böttiger MD DEAA FESC FERC 
Professor and Head of the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne 
In 2015, the European Resuscitation Council (ERC) guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care abundantly recommend education of school children in CPR to sustainably increase bystander CPR rates.1 While annually 350,000 people die from cardiac arrest (CA) in Europe, rates of survival to hospital discharge still average 6–9%.2 A scientific body of evidence indicates an improvement of survival by the factor 2–4 and significantly advanced neurological outcome by early initiation of CPR.3
There is scientific evidence that lay resuscitation improves survival at 30 days and one year after CA.1 However, only 20–30% of bystanders initiate CPR in the field, although 60% of cardiac arrests are being observed. As shown on the example of Norway, which implemented CPR training in school curricula in 1961, bystander CPR rates may increase to 70% within a decade.4,5
Extrapolating the data from Norway, 200,000 lives could potentially be saved worldwide. Therefore, several national and international resuscitation associations released the “Kids Save Lives” statement, which has recently been endorsed by the World Health Organization (WHO). Here, a comprehensive implementation of CPR training in school curricula is suggested in every country.4
The objective of this review article is i) to elucidate educational aspects of teaching school children, ii) to summarise campaigns in different countries worldwide and iii) to have a glance into future issues to be pursued to sustainably increase lay resuscitation rates. 
CPR training in school children is effective and serves as multiplier
To date, neither mandatory nor voluntary Basic Life Support (BLS) training for the adult public can reach a comprehensive coverage of lay resuscitation in most European countries. Although in Germany for example approximately 79% of persons over the age of 14 participate in CPR training at least once in their life,6 the estimated percentage of 15% adequately teached lay-rescuers, which is required to improve outcomes after OHCA, cannot be achieved.5
In a situation of cardiac arrest, scientific evidence points towards a retention strategy of lay persons in fear of making mistakes potentially deteriorating the patient’s situation. However, given that Advanced Cardiac Life Support (ACLS) by professionals on average starts 8–12 minutes after collapse, lay resuscitation is utterly needed to decrease the brain damage that is triggered by hypoxia 3–5 minutes after cardiac arrest.7 Accordingly, the latest CPR guidelines emphasise the (thoracic) “compression-only strategy” during BLS to simplify the procedures and reduce reluctance of lay persons.1,7 Oxygen still abounded in lungs and blood can be supplied to the brain by thoracic compressions only and sufficiently save brain tissue within the first minutes after collapse.
To date, there is a scientific gap of knowledge related to the frequency of refresher training children need to maintain CPR skills. Although most studies verified a loss of CPR skills within a period of 3–6 months after initial training,8 it is not proven that biannual CPR training is advantageous.9 Nevertheless, a scientific body of evidence recommends mandatory repetitive training to preserve capabilities related to CPR. 
In fact, at least one CPR training a year is needed to preserve particular capabilities related to CPR, which is easily implemented in schools and also highly effective.1,3,8 It is also known that repetitive BLS training of school children increases their willingness and CPR skills.3,4,7
Additionally, children have an open approach to CPR training before puberty and often serve as multipliers when teaching relatives and friends at home.10 Particular Scandinavian data undeniably supports CPR training in school children. In Norway that implemented mandatory CPR trainings in school curricula in 1961, bystander CPR rates reach 70%.5,10 In 2010, five years after implementation of mandatory BLS training in school curricula in Denmark, lay resuscitation rates doubled. Ten years after implementation survival after out-of-hospital cardiac arrest increased threefold.10
CPR training is recommended from the age of 12
A body of scientific evidence clearly showed that the quality of CPR increases by the age of the performing child. Indeed, age, sex and physical factors including body mass index also influence the quality of CPR as recently shown by Abelairas-Gomez.11 As a result, the 2015 guidelines recommend 12 years as the minimum age to perform a CPR to reach similar quality to an adult.1,8
However, from the authors’ perspective, training in school children younger than 12 years may also be reasonable since a long-term effect with continuous improvement is also considered for younger children. In fact, pre-puberty children usually develop a positive attitude towards CPR training and reveal a promising approach to sustainably improve bystander CPR rates. 
Practical training is important to develop CPR skills
Several training possibilities are available and were scientifically developed including online- or computer-based training, instruction videos and self-instruction kits. Reder et al. showed that children who underwent practical training conduct CPR significantly better than theoretical training only.10,12 Therefore, many CPR programmes for school children use self-instruction kits that contain a simplified resuscitation mannequin as well as a defibrillator and handy dummies depending on the manufacturer. 
Finally, self-instruction kits can be taken home, which offers the opportunity to repeat newly learned abilities and transmit them to others such as siblings and friends.10,12 Thus, all classes of age and social origin can be reached. Corrado et al. showed that one pupil trained in CPR in turn trains 1.77 relatives or friends. Surprisingly, boys (1.45±1.01 persons per pupil) showed a significantly lower multiplier effect compared to girls (2.26±1.89 persons per pupil).13
Undeniably, theoretical training only including online training or instructional video is disadvantageous compared to practical training but plays a major role in the younger generation today.10,12 Therefore, online-based training opportunities are widely provided by manufacturers of resuscitation mannequins, government bodies and school authorities. Today, both American Heart Association (AHA) and ERC include online and classroom components in their trainings, leveraging the “flipping the classroom” trend. 
In conclusion, both theoretical and practical training opportunities scientifically evaluated have shown improvement of learning experience; combination of both may offer the best possible effect to school children. 
Teaching provided by school teachers is more effective compared to healthcare professionals 
As recently shown by a six-year longitudinal study school children reveal significantly better knowledge in CPR skills as well as a better ventilation rate when trained by school teachers compared to emergency physicians. However, chest compression rate, depth, ventilation volume and self-efficacy did not differ in both groups.14 Interestingly, results by Beck et al. even point towards a feasible BLS training by schoolmates as suitable instructors.15 In conclusion, each type of teacher may be regarded as suitable instructor as long as chest compressions are the main focus in lay CPR.
Chest compressions and calling for help are the main focus 
School children’s CPR programmes are oriented towards the recommendations of BLS guidelines provided by the International Liaison Committee on Resuscitation (ILCOR). Since the requirements of BLS training tremendously vary according to the characteristics of the participants, the optimal duration of BLS training is not determined in the guidelines. Consequently, since most school curricula include two hours BLS per year, some key issues definitively needed to be emphasised in BLS training of school children. 
General key issues are usually i) the correct detection of a cardiac arrest, ii) a correctly performed call for help, and iii) the initiation of adequate thoracic compressions with a potential mouth-to-mouth ventilation. Again, a reduction of stress and reluctance related to the primary initiation of thoracic compressions are the main focus of both general and school children BLS training today. 
Generally, BLS training progressively pursues the message “the only wrong thing would be to do nothing”. Teaching the assessment of an Automatic External Defibrillator (AED) is potential and mainly depends on the particular school respectively the responsible teaching organisation.
Implementation of CPR training in school curricula is now endorsed by the World Health Organization (WHO) 
As several studies have shown, CPR-rates in many European countries are alarmingly low.3–5 In Europe, Scandinavia impressively shows lay resuscitation rates of more than 60%, while Germany (16%), Poland (27%) and Romania (6%) have a large demand for lay resuscitation programmes.16
In the United States lay resuscitation is provided in approximately 30–40%.10 Therefore, several campaigns that emphasise the need for early initiation of cardiopulmonary resuscitation including a “the Medical Emergency Response Plan for Schools” initiated by the AHA, the “European Restart a Heart Day” initiated by the ERC, or “ein-leben-retten” (“save one life”) initiated by the German Society of Anaesthesiology and Intensive Medicine, were initiated in both Europe and United States. Recently, the German Resuscitation council published particular curricula for education of school children in CPR ( 
Consequently, 35 of the 52 US states regulated mandatory BLS training in high schools per law. In Europe, the “Kids save Lives” statement of the European Patient Safety Foundation (EuPSF), the European Resuscitation Council (ERC), the International Liaison Committee on Resuscitation (ILCOR), and the World Federation of Societies of Anaesthesiologists (WFSA) also consistently recommended an implementation of theoretical and practical CPR skills in school curricula. 
Accordingly, on 13 January 2015 the World Health Organization (WHO) granted their approval and endorsed the statement that school children from the age of 12 or younger should be trained in CPR for two hours per year worldwide.4,10
Prescription of mandatory BLS training is the next step to sustainably increase lay resuscitation rates
Despite strong nationwide recommendations for BLS training in school children, neither Europe nor United States prescribed mandatory BLS training in school children yet. Principally, mandatory BLS training in school children is accompanied by some costs. However, satisfactory neurological outcome from CA, which is predominantly dependent on the early initiation of CPR, significantly decreases hospital expenditures. 
Presumably, repetitive BLS training in school children could decrease costs for post-hospital care. Unfortunately, in most European countries healthcare costs and educational costs are differently accounted. Thus, a link between survival and education is not always obvious. Explanation of this link is a key issue and highly important in the future. A common strategy between educational and health authorities may promote mandatory BLS training in school children. 
Repetitive BLS training of the younger generation is of crucial importance to sustainably increase lay resuscitation rates in the population and thus, improve survival after cardiac arrest. Conduction of BLS training in schools is cheap and easy. Recently, the World Health Organization recommended training in CPR for two hours per year worldwide. 
Children from the age of 12 are highly motivated to learn CPR and transfer their skills to relatives. Practical training is mostly appropriate to enhance CPR performance. Self-instruction kits are suitable for training since practical CPR skills can be repeated at home. 
Training sessions can be held by a trained teacher, medical professionals and medical students. Online training and instructional videos seem to play a major role in the younger generation. Mandatory CPR training for school children is lacking worldwide and legislative action is needed. 
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