Elsevier

Resuscitation

Volume 84, Issue 4, April 2013, Pages 415-421
Resuscitation

Review article
How best to teach CPR to schoolchildren: A systematic review

https://doi.org/10.1016/j.resuscitation.2012.12.008Get rights and content

Abstract

Background

Training schoolchildren to perform cardiopulmonary resuscitation is one possible method of increasing bystander CPR rates. We reviewed available literature to identify what methods of training children have been successful.

Objectives and methods

This review sought to evaluate evidence addressing the following PICO question: (P) In schoolchildren, (I) what types of CPR, AED and first aid training (C) when compared to no training and to each other (O) lead to ability to perform life saving measures? Searches were conducted in Ovid MEDLINE (1946 – August 2012), Ovid EMBASE (1974 – August 2012) and Ebscohost Cinahl (1981 – August 2012). Database specific subject headings in all three databases (MeSH in MEDLINE, Emtree in EMBASE, Cinahl Headings) were selected for the concepts of cardiopulmonary resuscitation (CPR) and education. The combined results were then limited by age to include all school aged children. The search yielded 2620 articles. From titles, abstract and key words, 208 articles described CPR, AED and/or first aid training in schoolchildren and were eligible for review. These were obtained in full, were unavailable or not published in English. We reviewed articles for publication type and relevance. 48 studies were identified. One additional study was included as an extension of a study retrieved within the search.

Results

The studies found by the search were heterogeneous for study and training methodology. Findings regarding schoolchild age and physical factors, the role of practical training, use of self-instruction kits, use of computer based learning, reduced training time, trainer type, AED training are presented.

Conclusions

Evidence shows that cardiopulmonary training, delivered in various ways, is successful in a wide age range of children. While older children perform more successfully on testing, younger children are able to perform basic tasks well, including use of AEDs. Chest compression depth correlates with physical factors such as increasing weight, BMI and height. Instruction must include hands on practice to enable children to perform physical tasks. Repeated training improves performance and retention but the format and frequency of repeated training is yet to be fully determined. Types of training that may reduce the main obstacles to implementation of such training in schools include use of self-instruction kits, computer based learning and use of teacher and peer tutor trainers, but again, need further exploration. As starting points we recommend legislative and funded mandates to provide such training to schoolchildren, and production and use of a framework which will delineate longitudinal delivery of training over the school career. Further research should have some uniformity in terms of assessment methodology, look at longer outcomes, and ideally will evaluate areas that are currently poorly defined.

Introduction

The American Heart Association (AHA) published an advisory statement in 2011 which recommended that cardiopulmonary resuscitation (CPR) training for schoolchildren be mandatory.1 The ultimate aim of CPR training provision at school is to increase the rate of bystander CPR and survival after out of hospital cardiac arrest (OHCA). The annual incidence of adult sudden OHCA in the US is estimated at 55/100,000 people and survival is less than 10% across the US and Europe.2, 3 A cardiac arrest victim is 2–4 times more likely to survive a cardiac arrest with bystander CPR provision4 but rates of bystander CPR at cardiac arrests are consistently less than 20%.3, 5

Arguments for CPR training in schoolchildren include: training a large cohort of the population will, over time, increase the proportion of trained adults in the population; increasing awareness, interest and sense of importance of actions in OHCA to a wide audience early on in life6, 7, 8; training provision at a time when learning is already the main activity9; provision of life-saving knowledge and skills at a time of increased mobility outside of the home into public areas and increasing employment10; schoolchildren are likely to be sufficiently physically fit to provide CPR; potential automaticity of response in a cardiac arrest situation11; distribution of education and training across cultural and social groups; increased self-esteem and introduction of ideas of responsibility with provision of help in emergency situations a ‘normal’ response12; exposure of information and training materials to a second tier of learners at home.

Section snippets

PICO question

This review sought to evaluate evidence addressing the PICO question: (P) In schoolchildren, (I) what types of CPR, AED and first aid training (C) when compared to no training and to each other (O) lead to ability to perform life saving measures?

Search strategy

Searches were conducted in Ovid MEDLINE (1946 – August 2012), Ovid EMBASE (1974 – August 2012) and Ebscohost Cinahl (1981 – August 2012). Database specific subject headings in all three databases (MeSH in MEDLINE, Emtree in EMBASE, Cinahl Headings) were

Results

This search identified 2620 publications. After removal of 579 duplicates, 2041 publications were reviewed. Working from titles, abstracts or key words, 208 articles appeared relevant. 29 were unavailable in English. Of remaining articles, 48 were studies and fully reviewed. One additional study identified by and related to a search find was also included. This data is also presented in the PRISMA flow diagram below.

Study factors

Investigative methodology, training and reporting trends have varied and changed over the 50-year period in which relevant studies have been published, as mentioned above. In addition, the training objectives have had to keep pace with evolving life support recommendations.

Schoolchild age

Studies assessing success of training courses demonstrate significant improvements in performance after training, compared to baseline, in children of all ages, from 4 to 20 years. While most studies have looked at training in teenagers, children of 4–5 years have been able to assess consciousness and breathing, remember the emergency number, give sufficient information by telephone, put a patient into recovery position and open the airway when tested 2 months after training.14 On assessment on

Effectiveness of CPR training in general

Traditional CPR training incorporates video and/or instructor demonstration, and hands-on manikin-based instruction and practice, accompanied by a manual. Testing is written and/or practical, although studies show poor correlation between the two in children.21, 26, 32

Despite significant overall improvements after training, the quality of CPR on testing can still be poor. Despite good outcomes in other tested areas one study demonstrated that 29% of chest compressions by American children in

Discussion

Some areas in the world have been able to improve their outcomes after OHCA by implementation of community-wide campaigns including training of schoolchildren in CPR. The US community of Seattle and King County have one of the best OHCA survival rates in the world. CPR was initiated by bystanders in 52% of OHCA cases in 2011 with 21% overall survival. Of patients suffering OHCA in a shockable rhythm prior to EMS arrival, 45% survived. This compares to under 5% survival in other US states.59 In

Conclusion

Studies performed over a wide time period and looking at a variety of approaches to training schoolchildren in CPR and associated skills show that all training interventions are successful within a short time scale in increasing knowledge and skills of children when tested. Training should start at an early age and be repeated at regular intervals over the school career. Training interventions should be age-appropriate and practical and should both reinforce core ideas and sequentially

Conflict of interest statement

No funding was formally allocated to undertaking this review.

References (69)

  • C. Sherif et al.

    Effectiveness of mouth-to-mouth resuscitation performed by young adolescents on a mannequin

    Am J Emerg Med

    (2005)
  • A. Bohn et al.

    Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four-year prospective cohort study

    Resuscitation

    (2012)
  • C. Lester et al.

    Teaching schoolchildren cardiopulmonary resuscitation

    Resuscitation

    (1996)
  • K. Frederick et al.

    Will changing the emphasis from ‘pulseless’ to ‘no signs of circulation’ improve the recall scores for effective life support skills in children?

    Resuscitation

    (2002)
  • P. Toner et al.

    Teaching basic life support to school children using medical students and teachers in a ‘peer-training’ model – results of the ‘ABC for life’ programme

    Resuscitation

    (2007)
  • T. Rosafio et al.

    Chain of survival: differences in early access and early CPR between policemen and high-school students

    Resuscitation

    (2001)
  • S. Reder et al.

    Comparison of three instructional methods for teaching cardiopulmonary resuscitation and use of an automatic external defibrillator to high school students

    Resuscitation

    (2006)
  • P.J. Moore et al.

    A study of school students’ long term retention of expired air resuscitation knowledge and skills

    Resuscitation

    (1992)
  • S. Younas et al.

    An evaluation of the effectiveness of the opportunities for resuscitation and citizen safety (ORCS) defibrillator training programme designed for older school children

    Resuscitation

    (2006)
  • G. Teague et al.

    Online resuscitation training. Does it improve high school students’ ability to perform cardiopulmonary resuscitation in a simulated environment?

    Resuscitation

    (2006)
  • T. Lorem et al.

    Impact of a self-instruction CPR kit on 7th graders’ and adults’ skills and CPR performance

    Resuscitation

    (2008)
  • T. Lorem et al.

    High school students as ambassadors of CPR – a model for reaching the most appropriate target population?

    Resuscitation

    (2010)
  • J. Kelley et al.

    Eighth grade students become proficient at CPR and use of an AED following a condensed training programme

    Resuscitation

    (2006)
  • P. Paal et al.

    Comparison of mouth-to-mouth, mouth-to-mask and mouth-to-face-shield ventilation by lay persons

    Resuscitation

    (2006)
  • M. Connolly et al.

    The ‘ABC for life’ programme – teaching basic life support in schools

    Resuscitation

    (2007)
  • D. McCluskey et al.

    Teaching CPR in secondary education: the opinions of head teachers in one region of the UK

    Resuscitation

    (2010)
  • J. Breckwoldt et al.

    Medical students teaching basic life support to school children as a required element of medical education: a randomised controlled study comparing three different approaches to fifth year medical training in emergency medicine

    Resuscitation

    (2007)
  • L. Lawson et al.

    Automated external defibrillation by very young, untrained children

    Prehosp Emerg Care

    (2002)
  • T.W. Lindner et al.

    Good outcome in every fourth resuscitation attempt is achievable – an Utstein template report from the Stavanger region

    Resuscitation

    (2011)
  • P. Eisenburger et al.

    Life supporting first aid training of the public – review and recommendations

    Resuscitation

    (1999)
  • J. Soar et al.

    Part 12: Education, implementation, and teams: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

    Resuscitation

    (2010)
  • P. Chehardy et al.

    Cardiopulmonary resuscitation and emergency cardiovascular care. Education

    Ann Emerg Med

    (2001)
  • S. Reder et al.

    Cardiopulmonary resuscitation training in Washington state public high schools

    Resuscitation

    (2003)
  • D.M. Cave 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)
  • Cited by (198)

    View all citing articles on Scopus

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.12.008.

    View full text