Basic Life Support for Highschoolers: A Wellness Promotion ...



Staying Alive: A Community Wellness Promotion ProjectJessica OwenSUNY Polytechnic InstituteStaying Alive: A Community Wellness Promotion ProjectOut-of-hospital cardiac arrests (OHCA) globally affect 55 people per 100,000 a year, with an average survival rate of 7% (Berdowski, Berg, Tijssen, & Koster, 2010). The main factors associated with increased survival rates of those affected by OHCA are timely bystander cardiopulmonary resuscitation (CPR) and pre-hospital defibrillation (Vaillancourt, Stiell, & Wells, 2008). Every minute without CPR and an AED means up to a 10% decrease in the chance of surviving sudden cardiac arrest. Early bystander CPR slows the progression of ventricular fibrillation to asystole and is administered on average 4 minutes earlier than CPR performed by emergency medical services (Sasson, Rogers, Dahl, & Kellermann, 2010). However, bystanders attempt CPR in only 32% of cases (Sasson et al., 2010). Research suggest that this is mostly because lack of training and fear of causing damage (Sacastano & Vanni, 2011). In 2010 the American Heart Association suggested CPR to be a requirement for high school graduation (Cave et al., 2011). Introduction of CPR and basic life support (BLS) training in schools could lead to acquisition of the skills needed to possibly increase the likelihood of survival from OHCA. Our Community: The Town of Brookfield, NYBrookfield lies in the southeast corner of Madison County and is bounded by State Route 20 and the townships of Hamilton and Madison on the west; on the north by State Route 12 and the townships of Sangerfield and Bridgewater in Oneida County; on the east and south by State Route 8 and The Unadilla River. According to the United States Census Bureau, the town has a total area of 78.0 square miles, of which, 77.9 square miles of it is land and 0.1 square miles of it is water ("Analysis of Brookfield Town, New York," 2014). Brookfield encompasses the hamlets of North Brookfield, South Brookfield and munity PopulationBrookfield is 78 square miles in size with a 2010 population of 2926 people, of whom differ in many areas such as socioeconomic status, housing statistics, and health values ("City Data," 2013). The racial makeup of the town is 98.29% Caucasian, 0.54% African American, 0.25% Native American, 0.37% Asian, 0.04% from other races, and 0.50% from two or more races ("Analysis of Brookfield Town, New York," 2014). Hispanic or Latino of any race were 0.33% of the population ("Analysis of Brookfield Town, New York," 2014). The average age of the population is 39.9 years of age ("City Data," 2013). There are 1.6 percent more females than males ("City Data," 2013). Of the population fifteen years or older, 58.8% are married, 21.4% have never been married, 10.2% are divorced, 7.4% are widowed, and 2.2% are separated ("City Data," 2013). The difference in the socioeconomic status lies in the wide range of educational levels, incomes, and occupations. 77.5 % percent of the population over the age of 25 has graduated from high school ("Analysis of Brookfield Town, New York," 2014). Those with bachelor’s degrees make up 9.2% of the population, and 4.2% have graduate or professional degrees ("Analysis of Brookfield Town, New York," 2014). Seven point two percent of the population is unemployed, surprisingly below the state average of seven point eight percent ("City Data," 2013). Brookfield remains true to its history as a rural town whose primary occupations are agriculture and construction ("City Data," 2013). Dairy farms are common to the area and the most common occupation ("Analysis of Brookfield Town, New York," 2014). The second most common occupation is building and grounds cleaning and maintenance occupations ("Analysis of Brookfield Town, New York," 2014). Other occupations include transportation, metal work, education services, and healthcare. The estimated median income is $35,000 per year ("City Data," 2013). About 10.4% of families and 13.9% of the population are below the poverty line, including 19.4% of those under age 18 and 5.5% of those age 65 or over ("Analysis of Brookfield Town, New York," 2014).Environmental FactorsThe majority of the homes and buildings in Brookfield were built prior to 1950 ("Analysis of Brookfield Town, New York," 2014). The majority of the homes in Brookfield are older, constructed from brick, wood, and vinyl siding. There is a large percentage of mobile homes. These homes vary in size and condition. The estimated median house value is $73,310, significantly below state average ("City Data," 2013). The average home in this community consists of families made up by two or more people with the average size of the family being three people ("Analysis of Brookfield Town, New York," 2014). Over 70 percent of homes in this community have families with children under the age of 18 living in them ("City Data," 2013). Madison County as a whole is challenged by limited transportation (Madison County Department of Health, 2013). The infrastructure that provides the stability and access to essential functions needed not only to obtain healthcare, but to improve the overall quality of life is brutally lacking. Some of the specific issues cited through community outreach efforts included access to care issues (missed appointments or delay in care) are a result of the person’s inability to get to a physician’s office. Scores on multiple national tests reflect multiple gaps within the sphere of healthcare amongst residents of Brookfield. The expense of medical care and lack of transportation remains a barrier for many residents. According to the 2009 Behavioral Risk Factor Surveillance System (BRFSS), nearly twelve percent (11.6%) of Madison County adults reported that “cost prevented a visit to the doctor” (Madison County Department of Health, 2013). Furthermore, existing medical services are not equitably located throughout the county. Providers tend to locate in the more populated northern half of the county, making it more difficult for residents of 13314 to access care. In addition, the lack of transportation affects community members’ ability to access other basic necessities such as food, clothing, socialization and employment. The design of Brookfield’s community directly impacts the town’s public’s health. Many factors in the built environments contribute to or exacerbate diseases such as heart disease, diabetes, and obesity. When home, work, shopping, and schools are isolated from each other, such as they are in 13314, people are dependent on the automobile to get to each place they need to go and are less likely to walk or bike. This has the unintentional consequence of creating places that promote sedentary rather than active lifestyles. Of particular concern is the prevalence of risk factors for sudden cardiac arrest coupled with lack of medical resources in and near the munity Diagnosis. Inadequate systematic programs for populations at risk for premature death, related to inadequate planning among community systems. A Review of the LiteratureCardiac arrest is defined as the abrupt loss of cardiac function. It arises instantaneously, often without preceding symptoms. Each year nearly 568,500 sudden cardiac arrest occur in the United States (Go, Mozaffarian, & Rogers, 2014). Of the nearly 360,000 cardiac arrest that happen outside hospitals, 88% occur in the home. 92% of the 360,000 Americans who suffer and OHCA each year will die (Vaillancourt et al., 2008). If effective CPR is initiated immediately after cardiac arrest, the victim’s probability of survival is doubled or tripled (Sasson et al., 2010). However, despite decades of national programs provided by organizations such as the AHA and American Red Cross, and countless public service announcements, only 32% to 40% of OHCAs are responded to with bystander CPR (Berdowski et al., 2010). Many lay people are not willing to provide care due to fear of infection, electrical shock, legal consequences and risk of harming the victim (Sacastano & Vanni, 2011). Interventions that improve survival in private homes, including increased familiarity with CPR, are needed. A CPR program designed and taught as part of a school curriculum would have a significant impact on public health. The AHA suggests that morbidity and mortality of out of hospital cardiac arrest could be significantly decreased if 20% of the population were able to perform CPR (Connolly, Toner, Connolly, & McCluskey, 2007). The AHA and the American Academy of Pediatrics both recommend that resuscitation be taught to school children (Naqvil, Siddiqi, Hussain, Bateel, & Arshad, 2011). Training all school children in CPR would ultimately ensure reaching the entire population. Efforts to train the adult population in BLS skills has been limited. Children, unlike adults, are an easily accessible population. Training school children would allow a large cohort of the population to be trained, which would over time, increase the population of trained adults in the population. In addition, training in the school setting would allow for the distribution of BLS education across cultural and social groups. Furthermore, children and adolescence trained in CPR are likely to discuss the training with siblings, friends and other family members, raising awareness about BLS and the demand for traditional training courses, which will result in the increase in the number of adults trained in CPR in the community (Fernandes et al., 2014). Children are physically able to perform BLS, according to the AHA by 9th grade (Naqvil et al., 2011). One study found that 13 and 14 year old adolescents can perform chest compressions as well as adults (Meissner, Kloppe, & Hanefeld, 2012). Other studies have shown that even nine-year-old school children have the cognitive skills to perform CPR, and even elementary school students have sufficient cognitive skills to correctly apply the AED (Naqvil et al., 2011). There exist many arguments for CPR training in schoolchildren, one of which is that resuscitation skills should be learnt in school, since children are easily motivated, learn quickly, and retain skills. Furthermore, early CPR training contributes to better retention rates for subsequent courses (Fernandes et al., 2014). CPR is specifically important in adolescence because they tend to engage in high risk behaviors. In addition, teenagers tend to spend a good amount of their free time in public locations, such as shopping malls and public sport venues, areas with a high incidence of cardiac arrests. Furthermore, BLS training increases self-esteem and introduces ideas of responsibility with the notion that helping in an emergency situation is a ‘normal’ response (Plant & Taylor, 2013). Despite the overwhelming evidence that training students will minimize the reluctance to conduct bystander CPR and increase the number of positive outcomes after sudden cardiopulmonary collapse, there are barriers for the introduction of a training program in schools, particularly those involving cost and time availability in the curriculum. The AHA has identified the need for simplification of the technique for performing CPR, and has developed a video-based high school CPR program. This simplified CPR technique requires shorter CPR training sessions. Additional barriers relate to the limited funding for instructional expenses of CPR training. The cost of providing CPR student training is about $2,500 for 150 students (Reder & Quan, 2003). Funding options for CPR programs, including grant funding, should be provided to schools. Another method of funding that merits investigation is the development of private funding partnerships such as from local businesses and service organizations. Efforts to increase training need to address strategies for offering student training in environment where time and dollars are scarce. Project ‘Staying Alive’The “Staying Alive’ program is a joint effort with Bassett Medical Center and in cooperation with the Brookfield Central School Board. The program is designed to introduce BLS training into Brookfield Central high school. The aim is to train students in tenth through twelfth grade to perform adequate CPR with provisions made to facilitate ingoing training to improve skill retention. Material and MethodsThe ‘Staying Alive’ program was adapted from the AHA CPR in Schools training program. It uses AHA certified instructors to instruct small groups of student (ratio 1:6) in 45 minute training sessions. In order for this approach to be effective three conditions must be met: (1) The training sessions must be taught at a level suitable for 15-18 year old adolescence so that they are able to understand the process, practice the skills, and perform effective CPR; (2) There must be successful transfer of skills along the teaching chain form AHA instructor to student; (3) There must be a structure for ongoing training to prevent decline in the psychomotor skills necessary for effective CPR. A PowerPoint specifically for adolescence was developed based on the 2010 Heartsaver Guidelines. Particular emphasis was placed on simple language, and the avoidance of medical terminology. The teaching was divided into three distinct parts with visual aids used to facilitate recall; calling for help and obtaining and AED, adult/child/infant CPR, and use of the AED.Teaching PathwayEach teaching session lasts 45 minutes. CPR is taught according to the 2010 Heartsaver guidelines and follows the three stage technique of skill acquisition. Stage 1 comprises a short video of a simulated cardiac arrest. Stage 2 follows with small group teaching around a CPR manikin with each step explained and highlighted using a PowerPoint. Stage 3 involves supervised practice by students with instructor feedback. At the end of the session, students are expected to simulate an arrest situation from start to finish using the manikin. An AHA skills checklist is used for each student to ensure that all stages are performed to AHA standards. The session is concluded with a short discussion to motivate and encourage students to react in the event of a cardiac arrest, and to address any questions or concerns they may have. Additional accommodations are made to facilitate skills practice on an as needed basis. EvaluationA ten question multiple choice questionnaire (Appendix A) was developed and distributed prior to the course to assess students’ baseline knowledge of CPR. An AHA instructor then trained students in small group sessions (1:6) as outlined above. Students were then asked to again complete the questionnaire immediately after training. In total 40 students from the grades tenth through twelfth were trained in CPR. No students answered all the questions correctly prior to training, however two students whom acknowledged prior training scored over 80%. The majority of the students scored 50% or less prior to training. Following training, a significant improvement in knowledge was observed and the average score improved to > 80%. My experience with the ‘Staying Alive’ program is that it is well received by students and teachers. Most find the training enjoyable, and feel confident that they have learned lifesaving skills. The results of this project show that students’ knowledge of BLS is significantly increased by the training program and subjectively that students were able to perform CPR adequately.Training a large number of the general population to perform CPR would be a major public health benefit. The ‘Staying Alive’ program has the potential to introduce widespread basic life support skills in the population. Furthermore, it has the potential of changing attitudes towards performing CPR in real life situations, and has the potential to have long-term health benefits for the population. There is little doubt, based upon the overwhelming evidence, that teaching school children BLS skills is beneficial to society. By using the ‘Staying Alive’ model, a large number of children can be trained in a short period of time and at relatively low cost.AcknowledgementsI thank Ms. Jones, Ms. Hewlett, and Mr. Plows from Brookfield Central School for their logistic cooperation with this project and Kathy Waro the AHA coordinator from Bassett Medical Center for her support with training materials. I am very grateful to the town of Brookfield, Brookfield Central School, their teachers and students for their voluntary participation in the project. ReferencesBerdowski, J., Berg, R., Tijssen, J., & Koster, R. (2010). Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation, 81, 1479-1487. , D., Aufderheide, T., Beeson, J., Ellison, A., Gregory, A., & Hazinski, M. (2011). Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: A science advisory from the American Heart Association. Circulation, 123, 691-706.Connolly, M., Toner, P., Connolly, D., & McCluskey, D. (2007). The ’ABC for life’ programme: Teaching basic life support in schools. Resuscitation, 72, 270-279.Fernandes, J., Leite, A., Auto, B., Lima, J., Rivera, I., & Mendonca, M. (2014). Teaching basic life support to students of public and private high schools. Arq Bras Cardiol, 102(6), 593-601.Go, A., Mozaffarian, D., & Rogers, V. (2014). Executive summary: Heart disease and stroke statictcs 2014 update . Circulation, 129, 399-410.Meissner, T., Kloppe, C., & Hanefeld, C. (2012). Basic life support skills of high school students before and after cardiopulmonary resuscitation training: A longitudinal investigation. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 20(31).Naqvil, S., Siddiqi, R., Hussain, S., Bateel, H., & Arshad, H. (2011). School children training for basic life support. Journal of the College of Physicians and Surgeons Pakistan, 21(10), 611-615.Plant, N., & Taylor, K. (2013). How best to teach CPR to schoolchildren: A systematic review. Resuscitation, 84, 415-421.Reder, S., & Quan, L. (2003). Cardiopulmonary resuscitation training in Washington state public high schools. Rescscitation, 56, 283-288.Sacastano, S., & Vanni, V. (2011). Cardiopulmonary resuscitation in real life: The most frequent fears of lay rescuers. Resuscitation, 82, 568-571.Sasson, C., Rogers, M., Dahl, J., & Kellermann, A. (2010). Predictors of survival from out-of-hospital cardiac arrest: A systematic review and meta-analysis. Circulation: Cardiovascular and Quality Outcomes, 3, 63-81.Vaillancourt, C., Stiell, A., & Wells, G. (2008). Understanding and improving low bystander SPR rates: A systematic review of the literature. Canadian Journal of Emergency Medicine, 10, 51-65.Appendix A‘Staying Alive’ AssessmentPlease check the box that you think is correct. Please check only one box per question. What is the first thing you should do if you find a collapsed person?Shake and shout at the personCheck for safe surroundingsSend for helpWhat is the second thing you would do?Shake and shout at the personCheck for safe surroundingsSend for helpWhat is the third thing you would do?Shake and shout at the personCheck for safe surroundingsSend for helpIf you are on your own and no one comes after shouting for help, would you:Start CPRPut the person in the recovery positionLeave the person to call for help and get an AEDIf the person is breathing what would you do?Put in recovery positionStart chest compressionsShake and shout at the personIf the person in not breathing what would you do?Put in recovery positionStart chest compressionsShake and shout at the personWhere in the chest would you press if you were giving chest compressions?Middle of chestLower half of breastboneTop of chestAt what rate would you give chest compressions?50 per minute75 per minuteAt least 100 per minuteHow many chest compressions would you give per cycle of CPR?151030How many breaths would you give per cycle of CPR?123Thank you for answering the above questions. Finally, could you please provide the following information:Pre Assessment Post AssessmentGrade: ___________Have you received any previous CPR training? Yes NoTHANK YOU FOR COMPLETING THIS QUESTIONNAIREAppendix BJessica OwenPO Box 43Brookfield, NY 13314[Date][Recipient Name][Title][Company Name][Street Address][City, ST ZIP Code]Dear [Recipient Name]:Thank you for your contribution to project ‘Staying Alive’. Thanks in part to your contribution, over 40 students at Brookfield Central School were successfully trained in CPR!Because nearly 90% of cardiac arrests occur within the home, most of us will encounter victims who are family members, close friends, or neighbors. “The life you save with CPR is most likely to be someone you love.” Best Regards,Jessica Owen ................
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