Learning cardiopulmonary resuscitation at school

Learning cardiopulmonary resuscitation at school

EDITORIAL
Learning cardiopulmonary resuscitation at school
ÒSCAR MIRÓ1,2,3, NÚRIA DÍAZ2,3,4, MIQUEL SÁNCHEZ1,2,3
Coordinadores del Programa de Reanimación Cardiopulmonar Orientado a Centros de Educación
Secundaria (PROCES), Barcelona, Spain. 2Área de Urgencias, Hospital Clínic, Barcelona, Spain. 3Grupo de
Investigación: “Urgencias: procesos y patologías”, IDIBAPS, Barcelona, Spain. 4Coordinadora pedagógica,
Escuela Molina, Barcelona, Spain.
1
In an ideal world, this editorial would be unnecessary. A school activity such as the teaching
of cardiopulmonary resuscitation (CPR) should be
fully integrated in the educational routine of children at different levels. CPR can help save a life, is
easy to learn and widely accepted by the educational community, has clearly positive pedagogical
connotations, is held in high esteem by students
and requires few resources and little time. However, it appears this is not the case, either in Spain
or in most developed countries. What then is the
problem? Are all the above statements not true?
Or are there no initiatives in Spain to implement
the recommendations made by major scientific
organizations in this field? Let us examine the
components of the problem.
That CPR saves lives is beyond question. However, the figures, although numerous, are often
not comprehensive or accurate. Without going
any further, in Spain there is no general uniform
registry of out-of-hospital cardiac arrest (OHCA)
which would allow us to accurately determine its
frequency, incidence, circumstances, development
of CPR and short and long term outcomes. Instead, local results are limited to a particular
healthcare unit, geographic area or, at most, an
autonomous community. However, the incidence
of OHCA is estimated at 0.1 - 0.5 per 1,000 inhabitants per year, with return to spontaneous circulation in situ occurring in 20-25% of cases and
survival to hospital discharge below 10%1-4. A recent review of OHCA data including 142,740 cases during a period of 30 years noted that if bystanders initiate CPR, the odds of survival could
increase five-fold5, but these maneuvers were only
initiated in less than half the cases. There is therefore, a patent lack of training. The ease of learn-
ing basic CPR has been repeatedly shown in lay
groups using different means, sometimes with
similar results to those obtained in healthcare settings6. The positive connotations of a CPR teaching program in schools and colleges include, at
least, the translation of academic concepts to
practical activity, addressing the concept of death
in the educational environment, awareness about
healthy life habits, the sense of responsibility to
act in emergency situations in general and improvement in student self-esteem7. When questioned, both teachers and parents have expressed
their approval and their willingness to see CPR
form part of school activities7,8. And when actually
applied, students have shown high levels of satisfaction and performance, largely independent of
academic performance 9-11. With respect to resources, the time required for such a training
course is about 8 hours per year at most11,12, and
the costs are low when the program is based on a
teaching pyramid structure (of accredited instructors to school teachers to pupils)11-13 or when other imaginative formulas are explored14.
It cannot be said there are no initiatives in
Spain to translate knowledge of basic CPR to
school children. There are many groups that have
organized CPR courses or activities at local levels,
and emergency medical systems (EMS) have
played an important role in many of these. Some
have been limited in time and then discontinued,
but others have a long tradition. This is the case
of the SAMUR “Alertante” program in the city of
Madrid, which has been running since 1996. The
program freely provides training for students aged
10 to 18 years at schools requesting it15. In the
same line, a noteworthy activity of teaching CPR
to secondary school students has been in opera-
CORRESPONDENCE: D. Òscar Miró. Área de Urgencias. Hospital Clínic. Villarroel, 170. 08036 Barcelona. Spain. E-mail: [email protected]
RECEIVED: 1-10-2012. ACCEPTED: 2-10-2012.
CONFLICT OF INTEREST: The PROCES program has received support from Nestle España, Laboratorios Menarini, Ajuntament de
Barcelona and the Faculty of Medicine, University of Barcelona.
Emergencias 2012; 24: 423-425
423
O. Miró et al.
tion since 2007 in Tarragona, organized by the
National Congresses of the Spanish Society of
Emergency Medicine (SEMES), with over 2,000
student participants to date 16. Moreover, some
CPR programs in Spanish schools have adopted a
more scientific approach, and results have been
published in medical journals. Thus, the very successful RCP na Aula (Classroom CPR) program in
the city of Lugo12 is currently analyzing the results
of training based on secondary school teachers
and cyclic student retraining from the first year of
compulsory secondary education (ESO) to the first
year of high school. Meanwhile, in the southern
regions of Tarragona an interesting program is being carried out: it aims to establish what the promoters call spiral training in basic CPR concepts at
all levels of compulsory education from kindergarten (3 year-olds) to high school (18 yearolds)13,17. The results in terms of acceptance, cost
and performance obtained with this program are
important to assess possible development and extension. We in Barcelona have gained experience
in this field through a program called Proces (Programa de Reanimación Cardiopulmonar Orientado a Centros de Enseñanza Secundaria) didactically developed for specific application in secondary
schools for students in their last two years (15-16
year.olds) that has been in operation in the city of
Barcelona since 20009-11. According to our data,
more than 60% of students achieve satisfactory
levels and more than two-thirds of them retain
the knowledge one year later11. These figures are
even better when teachers themselves (previously
trained in CPR) are fully responsible for developing the program11, and performance is only slightly lower than that obtained in a police cadet standardized training program 8; in some particular
aspects, girls and students who consistently pass
all subject exams show better performance than
boys and students with worse academic results.
And we aware of many other similar initiatives
than those mentioned here, which means that
school CPR programs are increasing in Spain.
In this context, we would highlight the work of
Marchiori et al.18 carried out in Aragon, a community whose EPs have always been highly involved
in disseminating CPR to the public, especially the
educational community19. The authors developed a
video game that simulates basic CPR, complemented by videos, which makes it a pioneering
initiative in Spain. The game is available as a free
software program20 which again is remarkable in a
field where courses and related activities are sometimes costly and restrictive. Moreover, the authors
have compared the results obtained using this
424
training tool with those of a more formal training
program, based an instructor certified in CPR. As
expected, the results obtained with the latter
method were better, but that may not be the
most relevant point. The most important aspect is
that the video game allows significant levels of
learning in users. Considering its zero cost, it is not
unreasonable to suggest it may be incorporated in
other programs in the future or even those being
used today. New versions of the video game may
be forthcoming, with greater variability and interactivity to make it more appealing to the target
user (in the end, a teenager), and with 4G mobile
phone applications. But until such upgrades appear, the video game can be considered as useful
supplementary material for incorporation in school
CPR programs.
There is some controversy about when and
how to introduce CPR training in schools. One
concern is at what age to start. Several studies
have shown that, from the age of 13 years and
with an average weight of 50 kilos, young people
already have the physical condition necessary to
properly perform CPR techniques. On the other
hand, there is no consensus on the age required
to cognitively appreciate the importance of PCR21.
However, even at young ages, knowledge of chain
of survival concepts can be beneficial, since the
mere fact of knowing that the EMS must be alerted may be sufficient to save a life22. There is no
doubt that schools constitute the ideal setting for
the teaching of CPR, considering that the ultimate
goal is that the entire population should posses
such skills and knowledge23,24. Although it may take
several decades to achieve that goal, we should remember that the training of young people in CPR
has additional short and medium term benefits;
they typically frequent public places where OHCA
is fairly likely to occur, and such young people are
more likely to actually apply CPR when necessary.
In summary, CPR training in schools is desirable
and feasible, a goal to achieve in Spain.
What then is stopping us from achieving our
objectives? We believe it is time that the conviction of doctors, teachers, students and parents be
transmitted to our political representatives and
the managers of our educational system. This is
not a zero cost activity, but well coordinated and
developed, it could be quite acceptable even in
these times of austerity25. A forum for discussion
on a generally acceptable model to apply is necessary, and from there we could progress to implementation. Perhaps we could thus avoid unnecessary loss of life because of omission to act
and errors due to bystander ignorance26.
Emergencias 2012; 24: 423-425
LEARNING CARDIOPULMONARY RESUSCITATION AT SCHOOL
References
1 Iglesias Vázquez JA, Rodríguez Núñez A, Barreiro Díaz MV, Sánchez
Santos L, Cegarra García M, Penas Penas M. Plan de desfibrilación
externa semiautomática en Galicia. Resultados finales de su implantación. Emergencias. 2009;21:99-104.
2 López-Mesa JB, Alonso-Fernández JI, Andrés-de Llano JM, Garmendia-Leiza JR, Ardura-Fernández J, De Castro-Rodríguez F, et al. Características generales de la parada cardiaca extrahospitalaria registrada
por un servicio de emergencias médicas. Emergencias. 2012;24:2834.
3 Moreno Martín JL, Esquilas Sánchez O, Corral Torres E, Suárez Bustamante RM, Vargas Román MI. Efectividad de la implementación de
la desfibrilación semiautomática en las unidades de soporte vital básico. Emergencias. 2009;21:12-6.
4 Navalpotro-Pascual JM, Fernández-Pérez C, Navalpotro Pascual S.
Supervivencia en las paradas cardiorrespiratorias en las que se realizó
reanimación cardiopulmonar durante la asistencia extrahospitalaria.
Emergencias. 2007;19:300-5.
5 Sasson C, Rogers MAM. Predictors of Survival From Out-of-Hospital
Cardiac Arrest. A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63-81.
6 Jiménez-Fábrega X, Escalada-Roig X, Sánchez M, Culla A, Díaz N,
Gómez X, et al. Results achieved by emergency physicians in teaching basic cardiopulmonary resuscitation to secondary school students. Eur J Emerg Med. 2009;16:139-44.
7 Miró O, Jiménez-Fábrega X, Espigol G, Culla A, Escalada-Roig X, Díaz N, et al. Teaching basic life support to 12-16 year olds in Barcelona schools: views of head teachers. Resuscitation. 2006;70:107-16.
8 López Unanua MC, Garrote Freire A, Freire Tellado M, Pérez Romero
E, Rodríguez Rodríguez A, Mosquera Castro M. Encuesta a profesores de Institutos de Secundaria sobre la enseñanza de la reanimación
cardiopulmonar básica en sus centros. Emergencias. 2008;20:251-5.
9 Miró O, Jiménez-Fábrega X, Díaz N, Coll-Vinent B, Bragulat E, Jiménez S, et al. Basic cardiopulmonary resuscitation program for high
school students (PROCES). Results from the pilot program. Med Clin
(Barc). 2005;124:4-9.
10 Miró O, Escalada X, Jiménez-Fábrega X, Díaz N, Sanclemente G, Gómez X, et al. Reanimación Cardiopulmonar Orientado a Centros de
Enseñanza Secundaria (PROCES): Conclusiones tras 5 años de experiencia. Emergencias. 2008;20:229-36.
11 Jiménez-Fábrega X, Escalada-Roig X, Miró O, Sanclemente G, Díaz
N, Gómez X, et al. Comparison between exclusively school teacherbased and mixed school teacher and healthcare provider-based programme on basic cardiopulmonary resuscitation for secondary schools. Emerg Med J. 2009;26:648-52.
12 López Unanua MC, Freire Tellado M, Rasines Sisniega R, Iglesias
González A. RCP na aula: programa de enseñanza de la reanimación
cardiopulmonar básica para estudiantes de secundaria. Emergencias.
2012;24:76.
13 Cerdà Vila M, Chanovas Borras M, Espuny Vidal C, Escalada Roig X,
Grupo de trabajo de SVB a Educació de Terres del Ebre. Plan piloto
Emergencias 2012; 24: 423-425
de formación en soporte vital básico en las escuelas. Formación en
espiral. Emergencias 2009; 21:76.
14 Toner P, Conolly M, Laverty L, McGrath P, Connolly D, McCluskey
DR. 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;75:169-75.
15 SAMUR–Protección civil. Programa alertante. (Consultado 8 Agosto
2012). Disponible en: https://www.munimadrid.es/portal/site/munimadrid/menuitem.f4bb5b953cd0b0aa7d245f019fc08a0c/?vgnextoid=c88fcdb1bfffa010VgnVCM100000d90ca8c0RCRD&vgnextchannel=84516c77e7d2f010VgnVCM1000000b205a0aRCRD&idCapitulo
=4328860
16 Menarini – Área de prensa. 300 alumnos de secundaria de Tarragona
inauguran el Congreso Nacional de Urgencias. (Consultado 9 Agosto
2012). Disponible en: http://www.menarini.es/sala-de-prensa/notasde-prensa/2479.html
17 Cerdà M, Chanovas Borras M, Escalada Roig X, Espuny Vidal C; Grupo de trabajo de SVB a Educació de Terres del Ebre. Pilot plan for
training in life support and CPR in schools. Med Intensiva.
2012;36:158-9.
18 Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar-Marco J, Suberviola JF, Giménez-Valverde A. Instrucción en maniobras de soporte vital
básico mediante videojuegos a escolares: comparación de los resultados frente a un grupo control. Emergencias. 2012;24:433-7.
19 SEMES Aragón. Salvacorazones RCP en las escuelas. (Consultado 9 Agosto 2012). Disponible en: http://www.semesaragon.org/index.php?option=com_k2&view=item&layout=item&id=206&Itemid=187
20 Adventure e-learning games. Primeros auxilios. (Consultado 3 Agosto
2012). Disponible en: http://e-adventure.e-ucm.es/course/view.php?id=25
21 Jones I, Whifield R, Colquhoun M, Chamberlain D, Vetter N,Newcombe R. At what age can schoolchildren provide effective chest
compressions? Na observational study from the heartstart UK schools training programme. BMJ. 2007;334:1201-3.
22 Cave DM, Aufderheide TP, Beeson J, Ellison A, Gregory A, Hazinski
MF, 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.
23 Chamberlain DA, Hazinski MF. Education in resuscitation: an ILCOR
symposium: Utstein Abbey: Stavanger, Norway: June 22-24. 2001.
Circulation. 2003;108:2575-94.
24 Hazinski MF, Markenson D, Neish S, Gerardi M, Hootman J, Nichol
G, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools-a statement for healthcare providers, policymakers, school administrators, and community leaders. Ann Emerg Med. 2004;43:83-99.
25 Miró O, Sánchez M, Jiménez-Fábrega X, Escalada-Roig X. Teaching
basic life support in schools: still waiting for public funding. Resuscitation. 2008;77:420-1.
26 Mateos-Rodríguez A, Vegas Gómez E, Rodríguez Rodil N. Motivo de
consulta telefónica en las paradas cardiorrespiratorias. Emergencias.
2009;21:235-6.
425