CPR training in the community

Laypeople's activity for seeking telephone number of EMS before and during the COVID-19 outbreak: An analysis of web search data

Objective

To explore trends and patterns of laypeople's activity for seeking telephone number of emergency medical services (EMS) based on analysis of online search traffic, including changes of the search activity with onset of the coronavirus disease 2019 (COVID-19) outbreak, in five countries – the United States of America (USA), India, Brazil, the United Kingdom (UK) and Russia.

Methods

Google Trends (GT) country-level data on weekly relative search volumes (RSV) for top queries to seek EMS number were examined for January 2018–October 2021, including a comparison of RSVs between pre-COVID-19 period (January 2018–October 2019) and COVID-19 period (January 2020–October 2021), and evaluation of temporal associations of RSVs with weekly numbers of new COVID-19 cases.

Results

The countries demonstrated diverse patterns of the search activity with significantly different mean RSVs (the USA 1.76, India 10.20, Brazil 2.51, the UK 6.42, Russia 56.79; p < 0.001). For all countries excepting the USA mean RSVs of the COVID-19 period were significantly higher compared with the pre-COVID-19 ones (India +74%, Brazil +148%, the UK +22%, Russia +9%; p ≤ 0.034), and exhibited positive correlations with numbers of new COVID-19 cases, more pronounced for 2021 (India r_S = 0.538, Brazil 0.307, the UK 0.434, Russia 0.639; p ≤ 0.045).

Conclusion

Laypeople's activity for seeking EMS telephone number greatly varies between countries. It clearly responds to the spread of COVID-19 and could be reflective of public need for obtaining emergency help. Further studies are required to establish the role of GT for conducting real-time surveillance of population demand for EMS.

Incorporating cardiopulmonary resuscitation training into a cardiac rehabilitation programme: A feasibility study

Background:

Patients with a cardiac history are at future risk of cardiac events, including out-of-hospital cardiac arrest. Targeting cardiopulmonary resuscitation (CPR) training to family members of cardiac patients has long been advocated, but is an area in need of contemporary research evidence. An environment yet to be investigated for targeted training is cardiac rehabilitation.

Aim:

To evaluate the feasibility of providing CPR training in a cardiac rehabilitation programme among patients, their family members and staff.

Methods:

A prospective before and after study design was used. CPR training was delivered using video self-instruction CPR training kits, facilitated by a cardiac nurse. Data was collected pre-training, post-training and at one month.

Results:

Cardiac patient participation rates in CPR classes were high ( n = 56, 72.7% of eligible patients) with a further 27 family members attending training. Patients were predominantly male (60.2%), family members were predominantly female (81.5%), both with a mean age of 65 years. Confidence to perform CPR and willingness to use skills significantly increased post-training (both p<0.001). Post training participants demonstrated a mean compression rate of 112 beats/min and a mean depth of 48 mm. Training reach was doubled as participants shared the video self-instruction kit with a further 87 people. Patients, family members and cardiac rehabilitation staff had positive feedback about the training.

Conclusions:

We demonstrated that cardiac rehabilitation is an effective and feasible environment to provide CPR training. Using video self-instruction CPR training kits enabled further training reach to the target population.

Rates of cardiopulmonary resuscitation training in the United States

IMPORTANCE

Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted.

OBJECTIVES

To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties.

DESIGN, SETTING, AND PARTICIPANTS

We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a county's geographic, population, and health care characteristics.

EXPOSURE

Completion of CPR training.

MAIN OUTCOME AND MEASURES

Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute. RESULTS During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5-percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per $10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively).

CONCLUSIONS AND RELEVANCE

Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

Examining Self-Perceived First-aid Abilities After the Northridge Earthquake

Introduction:

This study examines those factors predictive of self-perceived first-aid abilities among a community-based sample after the 1994 Northridge earthquake.

Methods:

A probabilities-proportionate to-size (pps) sample of residents of Los Angeles County and 11 pre-selected zip codes from southeastern Ventura County was selected using computer-generated random digit-dialing (rdd) procedures 7–11 months after the earthquake. Data were collected from 506 individuals in 45 minute interviews. A unidimensional scale of self-perceived first-aid ability was created and represents the dependent variable in a causal path model.

Results:

In a causal path model, standardized path coefficients suggested that while reports of taking first-aid courses were the most influential factors in predicting higher self-perceived first-aid abilities, other factors including being white, younger, speaking English in the home, and lower income also predicted higher self-perceived first-aid abilities that were independent from taking formal first-aid courses.

Conclusion:

First-aid training should be directed towards target segments of the population that are not likely to have had instruction in these basic skills. Those individuals who self-report high first-aid proficiency, independent of formal first-aid training, should be evaluated to assess their abilities to perform these skills.

Training rates and willingness to perform CPR in King County, Washington: a community survey

BACKGROUND

It has been hypothesized that high rates of cardiopulmonary resuscitation (CPR) training in a community will lead to improved survival for out-of-hospital cardiac arrest. However, factors to consider when designing a far-reaching community CPR training program are not well defined. We explored factors associated with receiving CPR training in the survey community and characteristics contributing to willingness to perform CPR in an emergency.

METHODS

A telephone survey was administered to 1001 randomly selected residents in September 2008 assessing CPR training history, demographics, and willingness to perform CPR. Characteristics of survey respondents were compared to examine factors that may be associated with reports of being trained compared to reports of never being trained. A stratified analysis compared characteristics of respondents who reported a high level of willingness to perform CPR in those trained compared to those never trained.

RESULTS

The survey response rate was 39%. Seventy-nine percent of survey respondents reported ever attending a CPR training class. A majority of people (53%) attended their most recent class more than five years ago. People who had never been trained in CPR were older, were more likely to be men and were less likely to have at least a 2-year college degree than those who had ever been trained. Among those who had been trained, younger age, male gender, time of last training and number of times trained were all significantly associated with willingness to perform CPR and none of these factors were associated with willingness in those who had not been trained.

CONCLUSIONS

Retraining rates, methods for reaching underserved populations and measures that will improve the likelihood that bystanders will perform CPR in an emergency should be considered when designing a community CPR education program.

Cardiac arrest in Stockholm with special reference to the ambulance organization

During a one-year period all patients with cardiac arrest (CA) taken care of by three ambulances were studied. An incidence of 110 cardiac arrests/100,000 inhabitants/year was found. The majority of CAs affected the elderly and occurred during the day in their homes. The majority of CAs were witnessed but cardiopulmonary resuscitation (CPR) had been initiated by bystanders in only a few cases. The ambulance arrived within a mean time of 7.7 +/- 4.0 min. Forty-eight per cent of the CA patients showed ventricular tachycardia or ventricular fibrillation (VT/VF) on ambulance arrival. Patients with a prolonged ambulance delay showed a lower incidence of VT/VF than patients with a short delay. Patients in whom CPR had been initiated by bystanders showed a significantly higher incidence of VT/VF (67%) than unattended patients (45%). Bystander CPR was furthermore associated with an increased incidence of VT/VF in patients with prolonged ambulance delay. VT/VF was present at the time when the ambulance arrived in 86% of the CA patients who had received CPR from a bystander and were reached within 8 min by the ambulance.

Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation

STUDY OBJECTIVE

Dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) instruction can increase the proportion of sudden cardiac arrest victims who receive bystander CPR and has been associated with improved survival. Most sudden cardiac arrest victims, however, do not receive bystander CPR. The study objective was to examine factors that may impede implementation of telephone CPR.

METHODS

We reviewed dispatcher audio recordings and emergency medical services reports for 404 cases of sudden cardiac arrest that occurred from July 1, 2000, to June 30, 2002, in the study county to assess the phase (1, instructions not offered; 2, instructions offered but declined; or 3, instructions offered and accepted but CPR not implemented) and specific factors within each phase that potentially impede telephone CPR.

RESULTS

Twenty-five percent (99/404) of victims received bystander CPR without dispatch assistance, 34% (139/404) received telephone CPR, and 41% (166/404) did not receive bystander CPR. Each phase of telephone CPR process impeded the implementation of CPR: (1) instructions not offered in 48% (80/166); (2) instructions offered but declined in 31% (52/166); and (3) instructions offered and accepted but CPR not implemented in 21% (34/166). During the first phase, telephone CPR was potentially impeded most frequently because the victim was reported to have signs of life (51/80, 64%); during the second and third phases, telephone CPR was most often impeded because of bystander physical limitation (32/86, 37%). Emotional distress, disease transmission, disagreeable victim characteristics, or medicolegal concerns uncommonly impeded telephone CPR (10/86, 12%).

CONCLUSION

Factors potentially impeding telephone CPR can be identified. Although many are logistically challenging, some may be addressable and hence provide opportunities to strengthen the chain of survival.

Dispatcher-assisted cardiopulmonary resuscitation. An evaluation of efficacy amongst elderly

Bystander cardiopulmonary resuscitation (CPR) increases survival rates. The largest group of cardiac arrest patients are men over the age of 60 in the home, and the most probable potential CPR provider is an older woman who is not likely to have received CPR training. One method to increase the percentage of bystander-initiated CPR in this setting is for CPR instruction to be provided by nurse dispatchers via telephone. Two male and 18 female volunteers with a median age of 78 years and no previous CPR experience performed 9 min of telephone assisted CPR on a manikin. They were randomised to receive telephone instructions in chest compressions alone or standard CPR including mouth-to-mouth ventilation. Variables were registered by a recording manikin, visual observations, and video and audiotape recordings. The median period from dispatcher contact until continuous CPR was significantly longer for standard instructions than for compression only, 4.9 versus 3.4 min, and fewer chest compressions were provided during the 9 min test period, median 124 versus 334 compressions. In both groups the overall CPR performance was of very poor quality, and unlikely to have affected outcome in a real situation. Other telephone assisted CPR scripts should be tested in this potential bystander group.

Knowledge of the national emergency telephone number and prevalence and characteristics of those trained in CPR in Queensland: baseline information for targeted training interventions

Members of the community contribute to survival from out-of-hospital cardiac arrest by contacting emergency medical services and performing cardiopulmonary resuscitation (CPR) prior to the arrival of an ambulance. In Australia there is a paucity of information of the extent that community members know the emergency telephone number and are trained in CPR. A survey of Queensland adults (n=4490) was conducted to ascertain current knowledge and training levels and to target CPR training. Although most respondents (88.3%) could state the Australian emergency telephone number correctly, significant age differences were apparent (P<0.001). One in five respondents aged 60 years and older could not state the emergency number correctly. While just over half the respondents (53.9%) had completed some form of CPR training, only 12.1% had recent training. Older people were more likely to have never had CPR training than young adults. Additional demographic and socio-economic differences were found between those never trained in CPR and those who were. The results emphasise the need to increase CPR training in those aged 40 and over, particularly females, and to increase the awareness of the emergency telephone number amongst older people.

Factors associated with CPR certification within an elderly community

OBJECTIVE

To determine the frequency of CPR certification amongst residents living within a predominantly elderly community and examine the perceived barriers to learning basic CPR and factors associated with intent to become certified.

METHODS

A household survey was sent with a community newsletter to each home of a non-gated elderly community that requires one member of each household to be at least 55 years of age. The community consists of 2488 homes (approximately 4000 residents). Thirteen Yes/No questions were asked in a skip-pattern based upon the question: "Are you CPR certified?" Data analysis included univariate, bivariate, and logistic regression.

RESULTS

947 participants with a mean age of 69 completed and returned the survey. Forty-eight percent of the participants had received prior training in CPR. Eighty-four percent were not currently certified in CPR, and top reasons cited were: 'don't know why' (36%), 'lack of interest' (20%), 'concerned about health risks' (17%). Forty-six percent of those not certified desired certification. Increasing age was inversely associated with CPR certification status and the desire to be certified.

CONCLUSION

Almost half of the residents in this predominantly elderly community had received prior training in CPR, although most were not currently certified and cite significant specific and non-specific reasons and obstacles. Improved survival requires targeted interventions to achieve higher proportions of CPR-competent individuals in such high-risk communities.

Geographical distribution of cardiac arrest in Nottinghamshire

BACKGROUND

to analyse the incidence of out-of-hospital cardiac arrest in Nottinghamshire; to ascertain its geographical distribution; and to determine whether the geography of coronary heart disease mortality and out-of-hospital cardiac arrest are the same.

METHODS AND RESULTS

population based, retrospective study in the County of Nottinghamshire with a total population of 993,914 in an area of 2183 km2 divided into 191 electoral areas. In the 4 years from 1 January, 1991 to 31 December, 1994, 1634 patients sustained a cardiac arrest attributed to a cardiac cause (International Classification of Diseases codes 390-414 and 420-429) and were attended by the Nottinghamshire Ambulance Service. The overall crude mean incidence rate of community cardiac arrest per electoral area was 40.2 per 100,000 population (range 0-121.2). Thirteen electoral areas, relatively deprived according to the Townsend score, had a significantly greater than expected incidence rate of cardiac arrest (median of 75.6/100,000 per electoral area; interquartile range (IQR) 65.3, 83.8). Twelve relatively affluent electoral areas had a significantly lower than expected incidence rate (median of 18.5/100,000 per area (IQR 13.0, 28.7). After adjusting for deprivation index, there were no differences in coronary heart disease (CHD) mortality and community cardiac arrest in urban and rural electoral areas. Apart from response times by ambulance crews, the events that follow the cardiac arrest such as bystander resuscitation, ventricular fibrillation found as the presenting rhythm and survival were similar in all electoral areas.

CONCLUSIONS

increasing level of deprivation is associated with areas of increased incidence of out-of-hospital cardiac arrest in Nottinghamshire, and the effect is apparently different from that on CHD mortality. There is scope for reducing incidence rates of community cardiac arrest and to introduce strategies to improve survival in areas identified as having high rates of community cardiac arrest.

Attitudes towards CPR training and performance in family members of patients with heart disease

Considering that heart patients may be at higher risk for cardiac arrest, this study was conducted to evaluate the preparedness and willingness of cardiac patient family members to perform cardiopulmonary resuscitation (CPR). A cross-sectional survey of 100 family members of cardiac patients was conducted at a tertiary care emergency department over a 1.5-month period. Response rate was 95%. While 49% reported prior CPR training, only 7% trained within the past year. The majority received training (59%) because of a school or job requirement with only 8% trained because of 'concern for a family member.' The most frequent reasons for not being trained were 'never thought about it' or 'not interested' (57%). However, 49% of the untrained group did report an interest in future training. While 2% of respondents recalled a healthcare professional suggesting such training, 58% stated they would be influenced positively by such a recommendation. The most frequently reported barriers to performing CPR included fear of harming the patient or a lack of knowledge and skill to help. Despite a presumed higher risk for sudden cardiac death, most family members of cardiac patients do not maintain skills in basic CPR. Healthcare professionals may have the ability to significantly alter this concerning statistic through education and routine recommendations to patients' families.

Attitudes of trained Swedish lay rescuers toward CPR performance in an emergency. A survey of 1012 recently trained CPR rescuers

59 years old. Only 1% had attended the course because of their own or a relative's cardiac disease. Ninety-four per cent believed there was a minor to major risk of serious disease transmission while performing CPR. When predicting their willingness to perform CPR in six scenarios, 17% would not start CPR on a young drug addict, 7% would not perform CPR on an unkempt man, while 97% were sure about starting CPR on a relative and 91% on a known person. In four of six scenarios, respondents from rural areas were significantly more positive than respondents from metropolitan areas about starting CPR. In conclusion, readiness to perform CPR on a known person is high among trained CPR rescuers, while hesitation about performing CPR on a stranger is evident. Respondents from rural areas are more frequently positive about starting CPR than those from metropolitan areas.

The impact of television public service announcements on the rate of bystander CPR

OBJECTIVE

To determine whether televised public service announcements (PSAs) demonstrating the fundamentals of CPR were effective in increasing the rate of layperson bystander-initiated CPR.

METHODS

Two 30-second PSAs were shown 597 times from September 8, 1996, through April 12, 1997. In each, CPR was given to one member of an older couple by the other in the home. The authors measured rates of bystander CPR in communities that were exposed to the PSA and in communities that were not exposed in two time periods, a before-airing period, January 1, 1993, through September 7, 1996, and a during-airing period, September 8, 1996, through April 12, 1997. A case was defined as a patient with a nontraumatic cardiac arrest that occurred before arrival of EMS personnel, and for whom CPR was initiated by EMS personnel or lay bystanders.

RESULTS

There were 1,786 cardiac arrests in the "before" period and 289 in the "during" period. The rate of bystander CPR increased from 43% to 55% (p<0.05) in the intervention community and remained the same in the comparison community (33%).

CONCLUSION

Airing of the PSA was accompanied by an increase in the rate of bystander CPR, though the increase may be attributable to a secular trend.

Neighborhoods matter: a population-based study of provision of cardiopulmonary resuscitation

STUDY OBJECTIVE

Cardiorespiratory resuscitation (CPR) nonprovision-the failure of bystanders to provide CPR to cardiac arrest victims-remains a well-documented public health problem associated with significant mortality. Multivariate data on failure to provide CPR are limited. Given the established independent contributions of neighborhoods to explaining many behaviors, we asked the following questions: Do neighborhood characteristics affect the likelihood of CPR nonprovision? In particular, we sought to identify the characteristics of areas that have had the most success in providing CPR.

METHODS

We performed multivariable logistic regression analysis of a prospectively collected cohort of 4,379 cardiac arrests linked at an individual level to neighborhood data from the US Census. These arrests represent all out-of-hospital cardiac arrests in the City of Chicago in 1987 and 1988.

RESULTS

In multivariate analysis, patients who had cardiac arrests who lived in neighborhoods where cardiac arrests were more common were significantly more likely to receive CPR. Patients with arrests in racially integrated neighborhoods were most likely to be provided with CPR, followed by those in predominately white neighborhoods, with the lowest rates of CPR provision in predominately black neighborhoods. Neither the socioeconomic status, number of elderly, nor the occupational characteristics of the neighborhood appeared to influence CPR provision. At the individual level, in-home arrests and arrests among middle-aged black residents (relative to older black and all white residents) were less likely to receive CPR.

CONCLUSION

Substantial variation in rates of CPR nonprovision exists between neighborhoods; the variation is associated with neighborhood characteristics. Combining individual and neighborhood data allows identification of important factors associated with the failure to provide CPR.

What can you teach about cardiopulmonary resuscitation (CPR) in 30 seconds? Evaluation of a television campaign

This study evaluated an 8-month media campaign, implemented in western Washington, to educate people on the basic steps of cardiopulmonary resuscitation (CPR) for cardiac arrest. A telephone survey was conducted with a total of 384 adults randomly selected from two towns, one that had been exposed to the campaign (intervention town) and one that had not been exposed to the campaign (comparison town). Results showed that respondents in the intervention town were more likely than respondents in the comparison town to report (a) having heard messages on CPR in the past month, (b) having seen the CPR media campaign, and (c) knowing the three basic steps of CPR. Respondents who had seen the campaign evaluated it very favorably. There were no differences between respondent groups in self-reported CPR training or intentions to perform CPR, suggesting that the campaign had a greater impact on knowledge and awareness than on intentions and behavior.

Resuscitation from out-of-hospital cardiac arrest: is survival dependent on who is available at the scene?

OBJECTIVE

To determine whether survival from out-of-hospital cardiac arrest is influenced by the on-scene availability of different grades of ambulance personnel and other health professionals.

DESIGN

Population based, retrospective, observational study.

SETTING

County of Nottinghamshire with a population of one million.

SUBJECTS

All 2094 patients who had resuscitation attempted by Nottinghamshire Ambulance Service crew from 1991 to 1994; study of 1547 patients whose arrest were of cardiac aetiology.

MAIN OUTCOME MEASURES

Survival to hospital admission and survival to hospital discharge.

RESULTS

Overall survival from out-of-hospital cardiac arrest remains poor: 221 patients (14.3%) survived to reach hospital alive and only 94 (6.1%) survived to be discharged from hospital. Multivariate logistic regression analysis showed that the chances of those resuscitated by technician crew reaching hospital alive were poor but were greater when paramedic crew were either called to assist technicians or dealt with the arrest themselves (odds ratio 6.9 (95% confidence interval 3.92 to 26.61)). Compared to technician crew, survival to hospital discharge was only significantly improved with paramedic crew (3.55 (1.62 to 7.79)) and further improved when paramedics were assisted by either a health professional (9.91 (3.12 to 26.61)) or a medical practitioner (20.88 (6.72 to 64.94)).

CONCLUSIONS

Survival from out-of-hospital cardiac arrest remains poor despite attendance at the scene of the arrest by ambulance crew and other health professionals. Patients resuscitated by a paramedic from out-of-hospital cardiac arrest caused by cardiac disease were more likely to survive to hospital discharge than when resuscitation was provided by an ambulance technician. Resuscitation by a paramedic assisted by a medical practitioner offers a patient the best chances of surviving the event.

Cardiopulmonary resuscitation training for family members of patients on cardiac rehabilitation programmes in Scotland

Existing cardiopulmonary resuscitation (CPR) training programmes have failed to reach those most likely to witness a cardiac arrest, such as families of cardiac patients. In 1993, the Scottish Health Service Advisory Committee suggested that CPR training could be offered as part of cardiac rehabilitation programmes. A survey was carried out to identify the current extent and nature of such training and factors influencing its provision. Questionnaires were mailed to all the 45 Scottish cardiac rehabilitation programmes on the British Heart Foundation's register. A 93% response rate was achieved. Only 37% of programmes provided information to families about attending a CPR course and 37% actually provided CPR training The numbers trained by these programmes were very small. Hospital programmes were significantly more likely than community programmes to provide CPR training (chi2 = 6.65, P < 0.01) as were those which included an exercise component (chi2 = 7.63, P < 0.01). Reasons for not providing training ranged from lack of resources and lack of staff training, to not having considered it. CPR training is provided as part of cardiac rehabilitation programmes to a limited extent. Ways of recruiting and increasing the number of family members of cardiac patients who are trained in CPR need to be found.

Evaluating CPR performance in basic life support: the VIDRAP protocol

This paper presents the second part of the validated Cardiff test for one rescuer basic life support skills, based on observation of video recording combined with the Recording Resusci Anne printout (VIDRAP). The authors believe that this is a robust evaluation tool which is capable of assessing the potential value to a casualty of a simulated resuscitation. The adoption of a widely accepted test methodology would facilitate comparison of research in different centres, which is not possible at present.

Assessing with CARE: an innovative method of testing the approach and casualty assessment components of basic life support, using video recording

The resuscitation community is now moving towards a set of basic life support guidelines but different countries and training centres have their own individual methods of instruction. It would be advantageous if a universal testing method were available to facilitate intercentre comparison. This could lead to an international course which had been rigorously assessed and evaluated. Taking this as a starting point, the Cardiff Assessment of Response and Evaluation (CARE) was developed. CARE is an innovative assessment technique using video recording for testing the preliminary steps of life support as outlined by the European Resuscitation Council. The assessment was validated by testing 67 members of the public who had been trained in cardiopulmonary resuscitation, 27 shortly after instruction and 40 between 6 and 18 months after instruction. All subjects were tested without prior warning and video recorded for independent scoring by two researchers and a paramedic training officer. Scores were compared using the k correlation which showed a high level of agreement between observers. Video recording and marking using the CARE schedule and guidelines is a reliable method for assessing the preliminary steps in life support.

Ethnicity and proficiency in English as factors affecting community cardiopulmonary resuscitation (CPR) class attendance

Communities with a high prevalence of cardiopulmonary resuscitation (CPR) knowledge have a greater out of hospital cardiac arrest survival rate. Within metropolitan Adelaide, 12.4% of the community is from a non-English speaking country and 20.3% of these have a poor proficiency in English. The purpose of this study was to examine the effect of ethnicity (specifically, Southern European born (SEB) and South East Asian born (SEAB)) and a poor proficiency in English (PENG) on CPR skill acquisition. Population Census postcode data were compared to postcode student CPR classes attendance. Results showed a negative correlation between SEB (-0.44), SEAB (-0.36), PENG (-0.42) with CPR class attendance. Postcodes with a less than community average of SEB, SEAB and PENG had an average proportion of CPR class attendees of 2.64% (C.I. 2.43, 2.85), 2.54% (C.I. 2.35, 2.73) and 2.65% (C.I. 2.35, 2.73), respectively, whilst those postcodes with a greater than community average had 2.03% (C.I. 1.90, 2.16), 2.07% (C.I. 1.90, 2.24) and 2.04% (C.I. 1.90, 2.18) proportion of CPR class attendees. The difference for each category was significant to a P < 0.001. This study points to SEB, SEAB, and PENG as factors associated with fewer CPR class attendances. Future CPR classes should specifically target and cater for ethnic groups from non-English speaking countries with poor English skills if CPR skills are to be widely disseminated throughout the entire community.

The need for wider dissemination of CPR skills: are schools the answer?

The value of instructing members of the public in CPR is now widely recognised, but community training schemes which rely largely on volunteers may fail to reach their targets. CPR training for lay people is often a once only activity and it has been shown that, without revision, skills deteriorate rapidly. By teaching CPR in secondary schools all social classes and ethnic groups could be reached, and retention of skills improved by regular revision. Health education has shown that it may be beneficial to use older pupils as instruction assistants.

Emergencies in the school setting: are public school teachers adequately trained to respond?

INTRODUCTION

This study attempted to determine the extent of training and emergency care knowledge of public school teachers in midwestern states. A secondary purpose was to assess the frequency of injury and illness in the school setting requiring the teacher to first-respond.

METHOD

A questionnaire and 14-item, scenario-based, emergency medical care test was developed and pretested. A discrimination index was used for validation of the instrument and a reliability coefficient of .82 was computed using the Kuder-Richardson Formula 20. A randomly recruited group of public school nurses from Arkansas, Kansas, and Missouri administered the instrument to 334 teachers who had no prior knowledge of the test. A random telephone survey of local school patrons also was completed to determine parental assumptions and expectations for emergency care and cardiopulmonary resuscitation (CPR) training in teachers.

RESULTS

One-third (112 teachers) had no specific training in first-aid and 40% never had been trained in CPR. However, most (87%) of the respondents strongly agreed that emergency care training should be required in teacher preparation programs. Eighteen percent of the teachers responded to more than 20 injured or ill students annually, and 17% reported that they had encountered at least one life-threatening emergency in a student during their career. The average score for all respondents on the emergency care test was 58% (chi 2 = 8.12 +/- 2.42). Those with prior first-aid training averaged 60.5% (chi 2 = 8.47 +/- 2.32). Significant deficiencies were noted for recognition and appropriate treatment of student emergencies involving basic life support (BLS) and airway interventions, diabetic emergencies, and treatment of profuse bleeding. Forty of the 50 (80%) parents surveyed assumed that all teachers were adequately trained in first-aid and CPR.

CONCLUSION

Public school teachers represent a potentially effective first-response component during disasters and isolated emergencies in the school environment. Overall, most of public school teachers in this study were deficient in both training and knowledge of emergency care and BLS modalities. Lack of effective, formal emergency care training in teacher preparation programs coupled with no continuing education requirement is a possible explanation of these results. Emergency medical services providers should seek opportunities to help with first-responder training and continuing education in their schools.

Use of supplemental oxygen during bystander-initiated CPR

STUDY OBJECTIVE

To evaluate the efficacy of three methods by which rescuers can breathe supplemental oxygen to increase their delivered oxygen concentration (FDO2) during single-rescuer, bystander-initiated CPR.

DESIGN

Controlled, randomized, crossover study.

SETTING

Simulation in laboratory setting using a CPR manikin.

SUBJECTS

Thirteen-volunteer convenience sample group.

INTERVENTIONS

Volunteers trained only in basic life support performed ventilation only and full CPR on a CPR manikin using room air and each of three supplemental oxygen delivery methods: nasal cannula, oxygen supply tube, and demand valve. The volunteers received minimal instruction on how to use the supplemental oxygen delivery methods.

MAIN OUTCOME MEASURES

Peak FDO2 and peak carbon dioxide concentration; American Heart Association-defined ventilation and CPR compression performance indices. The data were analyzed using Duncan's method of analysis of variance.

RESULTS

The mean peak FDO2 during ventilation-only/full CPR for the baseline (room air ventilation) and each supplemental oxygen delivery method (at specified flow rate) was: baseline (room air), -17.96% +/- 0.56%/16.77% +/- 0.56%; nasal cannula (at 10 L/min), -31.77% +/- 3.06%/27.01% +/- 3.68%; oxygen supply tubing (at 15 L/min), -36.82% +/- 9.93%/30.41% +/- 4.88%; and demand valve, -78.17% +/- 9.10%/68.22% +/- 7.10%. CPR performance was not hampered by the use of the supplemental oxygen methods.

CONCLUSION

The use of supplemental oxygen increases the rescuer's FDO2 during ventilation-only and full CPR without interfering with CPR performance.

Education in adult basic life support training programs

The Panel on Educational Issues in Adult Basic Life Support Training Programs reviewed the characteristics of adult learners, aspects of educational theory, issues concerning barriers to learning and performing CPR, and issues concerning testing and evaluation. The panel made the following recommendations: a comprehensive evaluation of the basic life support program with the goal of improving the program design and educational tools must be initiated; adult programs must be designed to motivate laypersons to become trained in CPR, as well as to target relatives and friends of high-risk individuals; and emotional and attitudinal issues, including the student's reluctance to act in an emergency, must be addressed. Programs must incorporate information on the willingness of an individual to perform CPR; CPR programs must be simplified and focus on critical success factors; flexible educational approaches in programs are encouraged; flexible programming that addresses the needs of the allied health professional is encouraged; formal testing should be eliminated for layperson programs; and formal testing for health care providers and instructors should be continued.

Cardiopulmonary resuscitation skills retention in family members of cardiac patients

The purpose of this study was to determine if the use of a retention strategy would maintain cardiopulmonary resuscitation (CPR) skills in family members of cardiac patients. Thirty-one subjects trained in CPR received retention packets 3 and 6 months after CPR training. Sixteen subjects were tested for CPR retention at 7 months after initial training, and 15 at 12 months. Likelihood chi 2 was used to compare the 7- and 12-month groups. There were no differences between the 7- and 12-month groups, because CPR retention overall was poor. Only 19.4% of subjects reported using the retention packet; therefore, subjects were regrouped into practice and no practice groups for purposes of further statistical analysis. There were significant differences in retention in subjects who practiced compared with subjects who did not. These findings underscore the importance of promoting practice/review after initial CPR training for family members of cardiac patients.

Dispatcher-assisted cardiopulmonary resuscitation. Validation of efficacy

Dispatcher-delivered telephone instruction in cardiopulmonary resuscitation (CPR) has been proposed to increase rates of bystander CPR in cases of out-of-hospital cardiac arrest. We tested the efficacy of a previously developed CPR message using a recording mannikin in a high stress, simulated cardiac arrest scenario. Community volunteers were unaware they would perform CPR until immediately before each trial. Performance of volunteers without prior CPR training (group A, n = 65) who received telephone instruction was compared with that of previously trained volunteers (group B, n = 43) who received the same message. Performances of both groups were also compared with a third group (group C, n = 43) composed of previously trained volunteers who did not receive the message. Quality of CPR was graded by three CPR instructors using explicit criteria. Printout strips from the recording mannikins were also analyzed. Evaluators were unaware of the training status of volunteers. The three groups were of comparable sex, race, and educational level, but group C was significantly younger than groups A and B (31.7 vs. 37.7 years, p less than 0.001). Because of the time required for telephone instruction, groups A and B started chest compressions a mean of 4.0 minutes after collapse compared with 1.2 minutes for group C (p less than 0.0001). We found that the previously untrained volunteers of group A performed CPR of an overall quality comparable to that performed by previously trained members of group C. Group A performed chest compressions significantly better than group C (p less than 0.02) but had greater problems performing effective ventilations.(ABSTRACT TRUNCATED AT 250 WORDS)

The effectiveness of repeated cardiopulmonary resuscitation training in a school population

At the end of a study program, evaluating the feasibility and the effectiveness of a unique training session on a school population, the majority of the students were asking for additional training opportunities. We therefore set up the present study with the purpose of evaluating skills, knowledge and attitude concerning CPR, after respectively one and two training sessions. 265 students from 4 different school levels were trained. 6 months later 134 answered a questionnaire and were again trained in CPR, 129 students answered the same questionnaire and were tested for their skills in CPR. Ten months later 75 students who had two training sessions answered again the questionnaire and 65 among them were tested for their skills. The two training sessions were identical, given by lay teachers priorly instructed in CPR, and consisted of a video-program and practical demonstration, followed by individual practice on training manikins. Both training sessions lasted 100 min. Evaluation of skills was performed by emergency physicians not involved in the training. Seventeen different items, representing each step in CPR were scored. Repeated training induces significant improvement of total skill scoring, without significant difference between boys and girls, but with improvement of scoring with class level. When looking at the different steps, the improvement in scoring is most impressive in certain steps which scored poorly after one training session, such as backward tilt of the head, a keystone in CPR. The steps concerning mouth-to-mouth breathing and external thoracic compressions reach, 10 months after the second training, an average of 1.6 out of 2 (80% correct) as compared to 1.44 out of 2 (71.9% correct) after one training. Knowledge concerning CPR does not increase significantly after the second training session. The time lapse of 10 months since the second training session may have played a role, although the methodology excluding interactive instruction may also explain this discrepancy. The influence on attitude shows that fear to apply CPR increased significantly after one training session and does not significantly lower after the second training. This attitude seems to be rather person-linked, for no correlation was found with age, theoretical knowledge or practical skill scoring. We have no way of knowing whether the statement concerning fear to apply CPR will correspond with such an attitude when confronted with a concrete emergency situation.

Training lay persons to use automatic external defibrillators: success of initial training and one-year retention of skills

This study was conducted to determine the feasibility of recruitment of lay persons to use automatic external defibrillators (AEDs), the effectiveness of their initial training, and the need for and frequency of retraining over time. Volunteers (n = 146), recruited from a variety of settings, included security personnel and administrative staff from large corporate centers, supervisors from senior care and exercise facilities, and employees in high-rise office buildings. Seven sites for 14 AEDs were recruited. In a single, two-hour class, participants learned to identify and respond to cardiac arrest, to notify emergency personnel, to retrieve and attach the semiautomatic (shock advisory) AED, and to respond to instructions presented on the display screen of the device. A skills check list was used to grade each student on performance of cardiopulmonary resuscitation, operation of the device, and time required to deliver an electric countershock. Retesting was performed one or more times after initial training to assess skill retention. The study lasted 1 year. All age groups, both sexes, and each responder type easily learned to operate the AED, with a trend for lower performance scores in people aged greater than 60 years. Performance time and skills declined significantly after initial training, but returned to satisfactory levels after one retraining session and were even higher after two retraining sessions. With retesting, errors that would have prevented delivery of countershocks to patients in ventricular fibrillation were rare (six of 146 tests, 4%). During the year of this study only three cardiac arrests occurred in the study sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Targeted recruitment of senior citizens and cardiac patients to a mass CPR training course

CPR courses attract a predominance of young, healthy adults. Targeted recruitment of senior citizens and family members of cardiac patients has been suggested but inadequately studied. We used a targeted recruitment strategy for our annual mass CPR training course to determine if such an approach would be effective in attracting the target group. Targeting significantly increased the percentage of senior citizen participants and participants who took the course because they or a close friend or relative had cardiac disease (P less than .00001). These data have important implications regarding potential future CPR training course recruitment methods compared with nontargeted recruitment approaches.

Influence of emergency medical services systems and prehospital defibrillation on survival of sudden cardiac death victims

This article reviews the influence of emergency medical systems and prehospital defibrillation on survival of sudden cardiac death. The historical perspective and epidemiologic considerations of prehospital sudden cardiac death are highlighted. Factors predictive of successful resuscitation and impact of community activity on sudden death are discussed. Influences of emergency medical services on outcome of prehospital cardiac arrest are reviewed, with emphasis on the role of dispatchers, emergency medical technicians, and paramedics. The recent emergence of prehospital automatic defibrillation by emergency medical technicians, first responders, and lay persons is discussed in depth, as it has great potential to positively influence outcome of prehospital sudden cardiac death.

Improved survival from cardiac arrest in the community

We now know that the elements required to achieve the highest survival rates from out-of-hospital cardiac arrest include: witnessed arrest, rapid telephone notification of the emergency medical service, early initiation of cardiopulmonary resuscitation, rapid arrival within minutes of emergency personnel equipped with a defibrillator, and early advanced airway management and intravenous pharmacology. In the United States, and in several other countries innovative approaches have been tried to bring all these elements together in one system. These approaches include community-wide CPR training programs, telephone-assisted CPR instruction delivered at the time of a cardiac arrest, early defibrillation performed by family members of high risk patients, early defibrillation performed by minimally trained community responders, and early defibrillation performed by minimally trained ambulance personnel. Controlled, prospective studies have demonstrated the effectiveness and practicality of all of these approaches. New studies are in progress with the prehospital use of early transcutaneous cardiac pacing and these show promise. This article reviews the evidence that supports these multi-layered and innovative approaches to the treatment of out-of-hospital cardiac arrest.

A survey of participants in a mass CPR training course

To determine demographic data and reasons for CPR course taking among 891 participants of a mass CPR training event, a questionnaire was distributed at the time of the course. Of the 728 persons completing this initial survey, 379 (52.6%) were less than 20 years of age. Only 41 (5.6%) took the course because of a family member or close relative with cardiac disease. Of this subgroup, seven (17.1%) had taken a previous CPR course, compared with 25.7% for the entire population. Thirty-eight percent of the 60-and-over age group mentioned cardiac disease as their reason for taking the course, compared to only 2.1% for the under-20 age group. To assess recall and actual performance of CPR, a follow-up survey was mailed to all participants six months after the course. Seventy-two percent were still confident in their ability to perform CPR, although no one had performed the technique on a real victim; 61.9% thought there should have been more manikin practice time; 92.2% still had their CPR refresher card. Only 32.3% would perform CPR on a known AIDS patient. This survey provides demographic and personal data that should be considered when planning future large-scale CPR training programs.

Factors influencing survival after out-of-hospital cardiac arrest

Survival to hospital discharge was related to the clinical history and emergency care system factors in 285 patients with witnessed cardiac arrest due to ventricular fibrillation. Only the emergency care factors were associated with differences in outcome. Both the period from collapse until initiation of basic life support and the duration of basic life support before delivery of the first defibrillatory shock were shorter in patients who survived compared with those who died (3.6 +/- 2.5 versus 6.1 +/- 3.3 minutes and 4.3 +/- 3.3 versus 7.3 +/- 4.2 minutes; p less than 0.05). A linear regression model based on emergency response times for 942 patients discovered in ventricular fibrillation was used to estimate expected survival rates if the first-responding rescuers, in addition to paramedics, had been equipped and trained to defibrillate. Expected survival rates were higher with early defibrillation (38 +/- 3%; 95% confidence limits) than the observed rate (28 +/- 3%). Because outcome from cardiac arrest is primarily influenced by delays in providing cardiopulmonary resuscitation and defibrillation, factors affecting response time should be carefully examined by all emergency care systems.