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Automated external defibrillation skills by naive schoolchildren
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Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
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Simulation and education,
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Automated external defibrillation skills by naive schoolchildren夽
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Cristina Jorge-Soto a,b , Cristian Abelairas-Gómez b,c , Roberto Barcala-Furelos b,d , f ˜ a , Rubén Navarro-Patón e , María Muino-Pi ˜ ˜ Anxela Garrido-Vinas neiro , g a,b,h,i,∗ ˜ M. Pino Díaz-Pereira , Antonio Rodríguez-Núnez a
School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain CLINURSID Research Group, University of Santiago de Compostela, Spain University School of Health Sciences, European Atlantic University, Santander, Spain 9 d University School of Education and Sport Sciences, University of Vigo, Pontevedra, Spain 10 e University School of Teacher Training, University of Santiago de Compostela, Lugo, Spain 11 f University School of Sport Sciences and Physical Education, University of A Coru˜ na, A Coru˜ na, Spain 12 g University School of Educational Sciences, University of Vigo, Ourense, Spain 13 14 Q2 h Paediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, SERGAS, Santiago de Compostela, Spain i Institute of Research of Santiago (IDIS) and SAMID-II Network, Spain 15 7 8
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a r t i c l e
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Article history: Received 4 January 2016 Received in revised form 28 May 2016 Accepted 8 June 2016
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Keywords: Automated external defibrillator Cardiac arrest Resuscitation Basic life support Training Schoolchildren Simulation Quality
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Introduction
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Aim: Early defibrillation should achieve the highest survival rates when applied within the first minutes after the collapse. Public access defibrillation programs have increased the population awareness of the importance of defibrillation. Schoolchildren should be trained in basic life support (BLS) skills and some countries have included BLS in their school syllabus. However, little is known of the current knowledge and ability of schoolchildren to use an automated external defibrillator (AED). Methods: A multicentric descriptive study, 1295 children from 6 to 16 years of age without previous BLS or AED training. Subjects performed a simulation with an AED and a manikin with no training or feedback and were evaluated by means of a checklist. Results: A total of 258 participants (19.9%) were able to simulate an effective and safe defibrillation in less than 3 min and 25 (26.3% of this group) performed it successfully. A significant correlation between objective and age group was observed (G = 0.172) (p < 0.001). The average time to deliver a shock was 83.3 ± 26.4 s; that time decreased significantly with age [6 YO (108.3 ± 40.4) vs. 16 YO (64.7 ± 18.6) s] (p < 0.001). Conclusions: Around 20% of schoolchildren without prior training are able to use an AED correctly in less than 3 min following the device’s acoustic and visual instructions. However, only one quarter of those who showed success managed to complete the procedure satisfactorily. These facts should be considered in order to provide a more accurate definition and effective implementation of BLS/AED teaching and training at schools. © 2016 Elsevier Ireland Ltd. All rights reserved.
Shockable rhythms are present in 50–70% of cardiac arrests (CA).1 In such cases the restoration to a perfusing cardiac
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.06.007. ∗ Corresponding author at: Pediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain. ˜ E-mail address: [email protected] (A. Rodríguez-Núnez).
activity may be achieved by means of electrical defibrillation, resulting in four-fold higher survival rates when the shock is applied within the first 3–5 min.1,2 For this reason, early defibrillation is a key link of the chain of survival, which should be immediately initiated by the bystander. There are recommendations from the international scientific community, led by the European Resuscitation Council (ERC) and the American Heart Association (AHA), that endorse the training of non-medical staff in the use of automatic external defibrillators (AED)1,3 as well as the implementation of these devices in public spaces where crowds of people occur, such as airports, sports centres, schools, public transports, stations and shows.1
http://dx.doi.org/10.1016/j.resuscitation.2016.06.007 0300-9572/© 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Jorge-Soto C, et al. Automated external defibrillation skills by naive schoolchildren. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.06.007
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Children are considered to be an interesting target group to train in basic life support (BLS), they are also situated at a vital stage of easy learning4,5 ; their training should provide the guarantee to secure a large number of future rescuers for the community.5,6 In the last years, several training programs such as those directed by the AHA and ERC have been developed in several countries, using schoolchildren as the target population.4–10 Alongside Europe, teaching basic cardiopulmonary resuscitation (CPR) is included in the educational curriculum at schools from countries like Norway, Denmark, France, or the United Kingdom. Public-access defibrillation (PAD) programmes, placement of AEDs in public areas as well as mass media (movies, news, social networks, etc.) have increased the public (including children) knowledge of AED and the awareness of the importance of early defibrillation in case of CA.11,12 In order to design effective BLS/AED school-based training programmes aimed at ensuring a large number of present and future first responders in public places where AEDs are deployed, it is necessary to know the children’s baseline level of knowledge and skills. The objective of this study was to assess the current ability of schoolchildren to use an AED without any prior training or feedback during the performance.
Methods Sample and study design We designed a multicentre, descriptive study. We recruited a convenience sample of 1318 schoolchildren without physical or mental disability from three school centres in Galicia (Spain), aged from 6 to 16 years. The aim and protocol of the study was communicated to the educational team of each school and it was orally presented in the classroom. An Informed consent signed by the pupils’ parents or guardians was required for the children to take part in the study. This project was carried out throughout the academic course 2014/2015. Schoolchildren from 6 to 16 years of age were eligible for the study, provided they had some knowledge of what an AED was and had not previously received BLS/AED training. Each subject was tested individually in a simulated scenario including an AED and a manikin. For the development of the test, pupils were asked to use the AED device in the way they believed to be correct by using their own intuition and following only the device’s indications. Their performance was evaluated by means of a checklist based on a simple algorithm (Fig. 1) which included three main issues: (1) time, (2) defibrillation objective, (3) quality objective. Time was registered from the moment the children touched the AED box until the discharge button was pressed. Arbitrarily, the test was considered failed if the pupil spent more than 3 min to deliver the simulated discharge. Safety concerns regarding the use of the AED were taken into account in the evaluation, whereby the participant should not to be in touch with the manikin at the moment of the discharge. For the quality assessment the following variables were taken into account: exchange of pad electrodes (error A), pads slightly displaced towards the longitudinal axis in the frontal plane (error B) and the order of execution (error C), which was the following: 1◦ turning on the device, 2◦ placing pad electrodes, 3◦ inserting the pad connector into the socket, 4◦ delivering the discharge. If any one of these conditions was not present, the quality objective was considered unmet. Teaching material used were a Laerdal AED training, a simulation of Heartstart FR2+ Phillips Defibrillator and Litlle Anne Laerdal’s maninkin.
Table 1 Age group distribution and analysis of the objective variables.
Q6
Age
N (%)
Objective N* (% of N)
Quality objective N** (% of N*)
6 7 8 9 10 11 12 13 14 15 16
103 (8) 140 (10.8) 135 (10.4) 111 (8.6) 182 (14.1) 176 (13.6) 54 (4.2) 131 (10.1) 99 (7.6) 107 (8.3) 57 (4.4)
9 (8.7) 15 (10.7) 23 (17) 27 (24.3) 41 (22.5) 41 (23.3) 10 (18.5) 25 (19.1) 27 (27.3) 21 (19.6) 19 (33.3)
1 (11.1) 2 (13.3) 3 (13.6) 6 (22.2) 10 (24.4) 10 (24.4) 0 (0) 1 (4) 4 (15.4) 5 (23.8) 10 (52.6)
G = 0.172 p < 0.001
G = 0.150 p = 0.152
G, Goodman and Kruskal’s Gamma coefficient.
Statistics We registered the participants’ age group, sex and education level of each participant. The achievement of both the defibrillation and quality objective was categorized as accomplishment/not accomplishment and mistakes were registered as present (committed)/absent (not committed). Categorical variables were presented in terms of absolute frequencies and percentages. Time was recorded in s. Descriptive statistics included mean, standard deviation and 95% confidence interval. Goodman and Kruskal’s Gamma coefficient was calculated to investigate the potential association between categorical variables. Values range from −1 (negative association) to +1 (positive association); value 0 indicates the absence of association. ANOVA test was used to investigate differences between means and Bonferroni test was used to check the statistical significance of results between different age groups. The homogeneity between groups was assessed by Kolgomorov–Smirnoff test and the equality of variances was determined using Levene test. A cutoff p-value <0.05 was used to determine statistical significance. Ethics Participation was voluntary and no personal incentive for participation was given. The study respected the Helsinki Declaration and was approved by the local institutional review board (Research Ethics Committee of the University School of Education and Sports Sciences, University of Vigo, Spain). Results Of the 1318 candidates, a total of 1295 children met the inclusion criteria. The age distribution of participants is shown in Table 1. A total of 258 participants (19.9%) managed to simulate an effective and safe discharge in less than 3 min. Gamma coefficient showed a mild but significant correlation between objective and age group (G = 0.172) (p < 0.001). A significant improvement was observed with increasing age, from 6 years old group [9 (8.7%)] to 16 years old group [19 (33.3%)]. From 9 years of age on, almost one out of four managed to achieve the defibrillation objective [9 years old: 27 (24.3%); 10 years old: 41 (23. 3%); 11 years old: 41 (23.3%)] (Table 1). Fifty two (26.3%) out of the 258 participants who reached the objective, achieved the quality objective too (Table 1). In this case, gamma coefficient showed a direct relation between age group and quality objective but no statistical significance was obtained (G = 0.150) (p = 0.152). While the number of participants who achieved the quality objective was small among younger age
Please cite this article in press as: Jorge-Soto C, et al. Automated external defibrillation skills by naive schoolchildren. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.06.007
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NAME (CODE): AGE:
TIME (seconds) _______ Time Assessment
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FAILED TEST
< 2 min
YES - Safe performance Objective Assessment
N
- Paddle electrodes correctly located
OBJECTIVE NOT ACHIEVED
YES OBJECTIVE ACHIEVED
- Paddle electrodes exchanged Quality Assessment (Incidences)
One
- Paddles lightly displaced. - Execution order changed.
QUALITY OBJECTIVE NOT
NO
QUALITY OBJECTIVE ACHIEVED Fig. 1. Check list.
153 154 155 156 157 158
groups [6 years old: 1 (11.1%); 7 years old: 2 (13.3%)] more than half of 16 years old participants who performed the discharge did it with quality [16 years old: 10 (52.6%)] (Table 1). The most common error committed by participants who achieved the defibrillation objective was change in order of execution [197 (76.4%)] followed by pads exchange [37 (14.3%)] (Table 2).
Table 2 Errors made by participants who completed the defibrillation objective (without quality) [frequency (%)]. Age
N
Paddles exchanged
Paddles displaced
Incorrect execution order
6 7 8 9 10 11 12 13 14 15 16
9 15 22 27 41 41 10 25 26 21 19
5 (55.6) 1 (6.7) 9 (39.1) 5 (18.5) 2 (4.9) 5 (12.2) 0 3 (12) 0 4 (19) 3 (15.8)
1 (11.1) 1 (6.7) 2 (8.7) 7 (25.9) 5 (12.2) 2 (4.9) 1 (10) 3 (12) 3 (11.1) 2 (9.5) 1 (5.3)
9 (100) 9 (60) 18 (78.3) 21 (77.8) 31 (75.6) 28 (68.3) 10 (100) 23 (92) 23 (85.2) 13 (61.9) 12 (63.2)
Total
256
37 (14.3)
28(10.9)
197 (76.4)
Time was analyzed among the 258 students who accomplished the defibrillation goal. No significant differences were observed between those who attained the objective with or without with satisfaction. Global average time was 83.3 ± 26.4 s. Time to defibrillation decreased with increasing age [6 YO (108.3 ± 40. 4 s) vs. 16 YO (64.7 ± 18.6 s)] (p < 0.001). In a peer post hoc analysis we found that the average time was significantly shorter for older students [16 years old (64.7 ± 18.6 s); 15 years old (67.6 ± 13.6 s)] than for younger students [6 years old (108.3 ± 40.4 s); 7 years old (115.9 ± 33.2 s); 8 years old (101.3 ± 20.6 s)] (p < 0.001 in all contrast). No significant differences were found between the younger groups (from 6 to 10 years old) neither amongst the older groups (from 12 to 16 years old) (Fig. 2). Discussion Schoolchildren have been pointed out as an essential target for BLS training.3,5,13 Furthermore, PAD in school centres is related to shorter times from collapse to discharge, higher survival rates and better outcomes for victims of an out-of-hospital cardiac arrest (OHCA).14,15 Nowadays BLS/AED messages appear in the media, movies, internet videos, etc. and AEDs are present and visible in public places such as airports or shopping malls. Then, it is possible
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Mean + SD
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Age (years) Fig. 2. Time of performance (in s) for the whole sample.
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that a significant number of children have acquired some indirect learning (from parents or peers but also from exposure to the use of AEDs in television/movies or by the simple observation of the devices in public places) about the relevance of early defibrillation and the basis of AEDs use. However, it is not clear at what age schoolchildren are capable of learning different aspects of firstaid learning like AEDs use and how is their background knowledge on the subject. This question has encouraged us since the answer might be a good reference for school-based training programmes. Our study, which provides a large cohort, indicates that from the age of 9, one of every 4 schoolchildren are capable of applying the AED, and at the age of 16 half of the capable students are able to complete the procedure with quality. Previous studies, carried out in other countries with smaller groups of subjects, have revealed comparable results. In a study including 47 naïve school children between 6 and 7 years of age,16 8 pupils (17%) identified AED execution order correctly, and after a week of BLS training by health workers the number of pupils who identified AED execution order increased up to 24 (51%). Younas et al17 observed that students (13–16 years of age) who had some prior academic training in first-aid obtained better results than untrained students (control group) for all the evaluated skills: (1) checking for consciousness and breathing, (2) CPR, 3) AED use. AED use was the worst performed part of the algorithm (27% training students vs. 4% control group). In our study, the first to assess the intuitive AED use in a large sample (1295 untrained schoolchildren) with a wide age range (from 6 to 16 years of age), only 8.7% of the 6-year-old pupils applied the AED correctly; around 25% of the 9-year-old group achieved the goal and this percentage increased up to 33.3% for the 16-yearold group. Regarding the quality objective, in the subgroups who achieved the defibrillation goal, only 11.1% of the 6-year-old pupils performed the test without errors, whereas almost 25% of the subjects in the 10-year-old group and more than 50% in the 16-year-old group achieved the quality objective. The most frequent error was the incorrect order of execution. Other errors were related to the incorrect positioning of pads (displaced from the ideal site or interchange of pads’ position). These facts should be taken into account by the instructors in order to reinforce training and overcome these common errors. We were surprised by the limited competence of younger kids, who should be familiar with the handling of technological devices, to follow the instructions provided by an AED. There is a chance that the problem is not the pupils’ capacity but the design and/or instructions of AEDs, that have been developed considering an eventual adult rescuer and not a child. In this sense, perhaps alternative AED designs or instructions ought to be explored. Every minute that passes after a cardiac arrest without defibrillation, chances of survival decrease by approximately 10–12%,
whereas survival rates significantly increase when AED is applied within the first minutes after the collapse.1 In our sample, defibrillation time was shorter than 3 min in all cases and decreased as children’s age increased (6-year-olds: 108.3 s vs. 16-year-olds: 64.7 s). Importantly, all children older than 8 years finished the test in less than 2 min. Our results are similar to previous data published by Gundry et al.18 although in their study participants received some indications about AED management before performing the practical test. This suggests that schoolchildren might have an intuitive idea of the importance of the factor of time in the case of CA and early defibrillation.19 According to our results children from 9 to 14 years have similar level of knowledge and skills to use an AED, and this suggest that around 9 years old might be the age at which children should start to be trained in the use of AED, adapting the training and retraining activities to the characteristics of kids of different ages. Early training would permit not only BLS/AED training but also yearly (or even more frequent) retraining over the school career[25] in order to attenuate the effects of elapsed time on CPR knowledge Q5 and abilities.13,22 Our study has some limitations. The test was carried out under simulated conditions so results are probably not the same as those that would be obtained in a real situation. Our sample was recruited from three middle-class schools from a small city that should be representative of schoolchildren in our country, but we cannot completely discard some selection bias that would limit the generalization of results. Although this point was not considered in the initial design of the study, the authors feel now that a questionnaire explaining how kids had learned about AED (media, parents, advertisements, etc.) would add some relevant information to the study. Conclusions Currently around 20% of theoretically naïve schoolchildren are able to apply an AED in less than 3 min by means of their general knowledge and device’s acoustic and visual instructions. General performance quality increases with age. However, children’s background knowledge and AED instructions alone are not enough to perform the procedure satisfactorily. These facts should be considered to define and implement effective BLS/AED teaching and training at schools. Author contribution All authors have contributed substantially to the conception and design of the study protocol, acquisition, analysis and interpretation of data. In addition, all of them have been involved in the draft and revision of the manuscript. Conflicts of interest statement The authors declare that they have no conflicts of interest related to the present study. Acknowledgments We would like to thank all the people (students, parents and educational team) of the schools who have participated in our study. References 1. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99.
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˜ de Resucitación Cardiopulmonar. Recomendaciones del Con2. Consejo Espanol ˜ de Resucitación Cardiopulmonar sobre la instalación, autorización sejo Espanol y formación para el uso del desfirbilador externo automático fuera del ˜ de Resucitación Cardiopulmonar; ámbito sanitario. Madrid: Consejo Espanol 2012. http://www.semicyuc.org/sites/default/files/recomendaciones cercp en uso dea v.0.9.pdf [accessed 01.12.15]. 3. Cave DM, Aufderheide TP, Beeson J, 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. 4. Jones I, Whitfield R, Colquhoun M, Chamberlain D, Vetter N, Newcombe R. At what age can schoolchildren provide effective chest compressions? An observational study from the Heartstart UK schools training programme. BMJ 2007;334:1201. 5. Böttiger BW, Van Aken H. Kids save lives – training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO). Resuscitation 2015:A5–7. 6. Dieltjens T, De Buck E, Verstraeten H, et al. Evidence-based recommendations on automated external defibrillator training for children and young people in Flanders-Belgium. Resuscitation 2013;84:1304–9. 7. Lind B. Teaching mouth-to-mouth resuscitation in primary schools. Acta Anaesthesiol Scand Suppl. 1961; Suppl 9:63-81. Acta Anaesthesiol Scand 2007;51:1044–50. 8. Maconochie I, Simpson S, Bingham B. Teaching children basic life support skills. BMJ 2007;334:1174. 9. Isbye DL, Rasmussen LS, Ringsted C, Lippert FK. Disseminating cardiopulmonary resuscitation training by distributing 35,000 personal manikins among school children. Circulation 2007;116:1380–5. 10. Andreu OM, Roig XE, Fabrega XJ, et al. Programa de Reanimación Cardiopul˜ Secundaria (PROCES): conclusiones monar Orientado a Centros de Ensenanza ˜ tras 5 anos de experiencia. Emerg Rev Soc Esp Med Urgenc Emerg 2008;20:229–36. 11. Mgbako OU, Ha YP, Ranard BL, et al. Defibrillation in the movies: a missed opportunity for public health education. Resuscitation 2014;85:1795–8.
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12. Schober P, van Dehn FB, Bierens JJLM, Loer SA, Schwarte LA. Public access defibrillation: time to access the public. Ann Emerg Med 2011;58:240–7. 13. Greif R, Lockey AS, Conaghan P, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation. Resuscitation 2015;95:288–301. 14. Mitani Y, Ohta K, Yodoya N, et al. Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. Europace 2013;15:1259–66. 15. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120:518–25. 16. Uray T, Lunzer A, Ochsenhofer A, et al. Feasibility of life-supporting firstaid (LSFA) training as a mandatory subject in primary schools. Resuscitation 2003;59:211–20. 17. Younas S, Raynes A, Morton S, Mackway-Jones K. An evaluation of the effectiveness of the Opportunities for Resuscitation and Citizen Safety (ORCS) defibrillator training programme designed for older school children. Resuscitation 2006;71:222–8. 18. Gundry JW, Comess KA, DeRook FA, Jorgenson D, Bardy GH. Comparison of naive sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999;100:1703–7. 19. De Buck E, Van Remoortel H, Dieltjens T, et al. Evidence-based educational pathway for the integration of first aid training in school curricula. Resuscitation 2015;94:8–22. 20. Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review. Resuscitation 2013;84:415–21. 21. Iserbyt P, Schouppe G, Charlier N. A multiple linear regression analysis of factors affecting the simulated Basic Life Support (BLS) performance with Automated External Defibrillator (AED) in Flemish lifeguards. Resuscitation 2015;89:70–4. 22. Bobrow BJ, Vadeboncoeur TF, Spaite DW, et al. The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes 2011;4:220–6.
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Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
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Simulation and education,
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Automated external defibrillation skills by naive schoolchildren夽
4
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Cristina Jorge-Soto a,b , Cristian Abelairas-Gómez b,c , Roberto Barcala-Furelos b,d , f ˜ a , Rubén Navarro-Patón e , María Muino-Pi ˜ ˜ Anxela Garrido-Vinas neiro , g a,b,h,i,∗ ˜ M. Pino Díaz-Pereira , Antonio Rodríguez-Núnez a
School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain CLINURSID Research Group, University of Santiago de Compostela, Spain University School of Health Sciences, European Atlantic University, Santander, Spain 9 d University School of Education and Sport Sciences, University of Vigo, Pontevedra, Spain 10 e University School of Teacher Training, University of Santiago de Compostela, Lugo, Spain 11 f University School of Sport Sciences and Physical Education, University of A Coru˜ na, A Coru˜ na, Spain 12 g University School of Educational Sciences, University of Vigo, Ourense, Spain 13 14 Q2 h Paediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, SERGAS, Santiago de Compostela, Spain i Institute of Research of Santiago (IDIS) and SAMID-II Network, Spain 15 7 8
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Article history: Received 4 January 2016 Received in revised form 28 May 2016 Accepted 8 June 2016
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Keywords: Automated external defibrillator Cardiac arrest Resuscitation Basic life support Training Schoolchildren Simulation Quality
34
Introduction
24 25 Q3 26 27 28 29 30 31
35Q4 36
Aim: Early defibrillation should achieve the highest survival rates when applied within the first minutes after the collapse. Public access defibrillation programs have increased the population awareness of the importance of defibrillation. Schoolchildren should be trained in basic life support (BLS) skills and some countries have included BLS in their school syllabus. However, little is known of the current knowledge and ability of schoolchildren to use an automated external defibrillator (AED). Methods: A multicentric descriptive study, 1295 children from 6 to 16 years of age without previous BLS or AED training. Subjects performed a simulation with an AED and a manikin with no training or feedback and were evaluated by means of a checklist. Results: A total of 258 participants (19.9%) were able to simulate an effective and safe defibrillation in less than 3 min and 25 (26.3% of this group) performed it successfully. A significant correlation between objective and age group was observed (G = 0.172) (p < 0.001). The average time to deliver a shock was 83.3 ± 26.4 s; that time decreased significantly with age [6 YO (108.3 ± 40.4) vs. 16 YO (64.7 ± 18.6) s] (p < 0.001). Conclusions: Around 20% of schoolchildren without prior training are able to use an AED correctly in less than 3 min following the device’s acoustic and visual instructions. However, only one quarter of those who showed success managed to complete the procedure satisfactorily. These facts should be considered in order to provide a more accurate definition and effective implementation of BLS/AED teaching and training at schools. © 2016 Elsevier Ireland Ltd. All rights reserved.
Shockable rhythms are present in 50–70% of cardiac arrests (CA).1 In such cases the restoration to a perfusing cardiac
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.06.007. ∗ Corresponding author at: Pediatric Emergency and Critical Care Division, Hospital Clínico Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain. ˜ E-mail address: [email protected] (A. Rodríguez-Núnez).
activity may be achieved by means of electrical defibrillation, resulting in four-fold higher survival rates when the shock is applied within the first 3–5 min.1,2 For this reason, early defibrillation is a key link of the chain of survival, which should be immediately initiated by the bystander. There are recommendations from the international scientific community, led by the European Resuscitation Council (ERC) and the American Heart Association (AHA), that endorse the training of non-medical staff in the use of automatic external defibrillators (AED)1,3 as well as the implementation of these devices in public spaces where crowds of people occur, such as airports, sports centres, schools, public transports, stations and shows.1
http://dx.doi.org/10.1016/j.resuscitation.2016.06.007 0300-9572/© 2016 Elsevier Ireland Ltd. All rights reserved.
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Children are considered to be an interesting target group to train in basic life support (BLS), they are also situated at a vital stage of easy learning4,5 ; their training should provide the guarantee to secure a large number of future rescuers for the community.5,6 In the last years, several training programs such as those directed by the AHA and ERC have been developed in several countries, using schoolchildren as the target population.4–10 Alongside Europe, teaching basic cardiopulmonary resuscitation (CPR) is included in the educational curriculum at schools from countries like Norway, Denmark, France, or the United Kingdom. Public-access defibrillation (PAD) programmes, placement of AEDs in public areas as well as mass media (movies, news, social networks, etc.) have increased the public (including children) knowledge of AED and the awareness of the importance of early defibrillation in case of CA.11,12 In order to design effective BLS/AED school-based training programmes aimed at ensuring a large number of present and future first responders in public places where AEDs are deployed, it is necessary to know the children’s baseline level of knowledge and skills. The objective of this study was to assess the current ability of schoolchildren to use an AED without any prior training or feedback during the performance.
Methods Sample and study design We designed a multicentre, descriptive study. We recruited a convenience sample of 1318 schoolchildren without physical or mental disability from three school centres in Galicia (Spain), aged from 6 to 16 years. The aim and protocol of the study was communicated to the educational team of each school and it was orally presented in the classroom. An Informed consent signed by the pupils’ parents or guardians was required for the children to take part in the study. This project was carried out throughout the academic course 2014/2015. Schoolchildren from 6 to 16 years of age were eligible for the study, provided they had some knowledge of what an AED was and had not previously received BLS/AED training. Each subject was tested individually in a simulated scenario including an AED and a manikin. For the development of the test, pupils were asked to use the AED device in the way they believed to be correct by using their own intuition and following only the device’s indications. Their performance was evaluated by means of a checklist based on a simple algorithm (Fig. 1) which included three main issues: (1) time, (2) defibrillation objective, (3) quality objective. Time was registered from the moment the children touched the AED box until the discharge button was pressed. Arbitrarily, the test was considered failed if the pupil spent more than 3 min to deliver the simulated discharge. Safety concerns regarding the use of the AED were taken into account in the evaluation, whereby the participant should not to be in touch with the manikin at the moment of the discharge. For the quality assessment the following variables were taken into account: exchange of pad electrodes (error A), pads slightly displaced towards the longitudinal axis in the frontal plane (error B) and the order of execution (error C), which was the following: 1◦ turning on the device, 2◦ placing pad electrodes, 3◦ inserting the pad connector into the socket, 4◦ delivering the discharge. If any one of these conditions was not present, the quality objective was considered unmet. Teaching material used were a Laerdal AED training, a simulation of Heartstart FR2+ Phillips Defibrillator and Litlle Anne Laerdal’s maninkin.
Table 1 Age group distribution and analysis of the objective variables.
Q6
Age
N (%)
Objective N* (% of N)
Quality objective N** (% of N*)
6 7 8 9 10 11 12 13 14 15 16
103 (8) 140 (10.8) 135 (10.4) 111 (8.6) 182 (14.1) 176 (13.6) 54 (4.2) 131 (10.1) 99 (7.6) 107 (8.3) 57 (4.4)
9 (8.7) 15 (10.7) 23 (17) 27 (24.3) 41 (22.5) 41 (23.3) 10 (18.5) 25 (19.1) 27 (27.3) 21 (19.6) 19 (33.3)
1 (11.1) 2 (13.3) 3 (13.6) 6 (22.2) 10 (24.4) 10 (24.4) 0 (0) 1 (4) 4 (15.4) 5 (23.8) 10 (52.6)
G = 0.172 p < 0.001
G = 0.150 p = 0.152
G, Goodman and Kruskal’s Gamma coefficient.
Statistics We registered the participants’ age group, sex and education level of each participant. The achievement of both the defibrillation and quality objective was categorized as accomplishment/not accomplishment and mistakes were registered as present (committed)/absent (not committed). Categorical variables were presented in terms of absolute frequencies and percentages. Time was recorded in s. Descriptive statistics included mean, standard deviation and 95% confidence interval. Goodman and Kruskal’s Gamma coefficient was calculated to investigate the potential association between categorical variables. Values range from −1 (negative association) to +1 (positive association); value 0 indicates the absence of association. ANOVA test was used to investigate differences between means and Bonferroni test was used to check the statistical significance of results between different age groups. The homogeneity between groups was assessed by Kolgomorov–Smirnoff test and the equality of variances was determined using Levene test. A cutoff p-value <0.05 was used to determine statistical significance. Ethics Participation was voluntary and no personal incentive for participation was given. The study respected the Helsinki Declaration and was approved by the local institutional review board (Research Ethics Committee of the University School of Education and Sports Sciences, University of Vigo, Spain). Results Of the 1318 candidates, a total of 1295 children met the inclusion criteria. The age distribution of participants is shown in Table 1. A total of 258 participants (19.9%) managed to simulate an effective and safe discharge in less than 3 min. Gamma coefficient showed a mild but significant correlation between objective and age group (G = 0.172) (p < 0.001). A significant improvement was observed with increasing age, from 6 years old group [9 (8.7%)] to 16 years old group [19 (33.3%)]. From 9 years of age on, almost one out of four managed to achieve the defibrillation objective [9 years old: 27 (24.3%); 10 years old: 41 (23. 3%); 11 years old: 41 (23.3%)] (Table 1). Fifty two (26.3%) out of the 258 participants who reached the objective, achieved the quality objective too (Table 1). In this case, gamma coefficient showed a direct relation between age group and quality objective but no statistical significance was obtained (G = 0.150) (p = 0.152). While the number of participants who achieved the quality objective was small among younger age
Please cite this article in press as: Jorge-Soto C, et al. Automated external defibrillation skills by naive schoolchildren. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.06.007
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NAME (CODE): AGE:
TIME (seconds) _______ Time Assessment
N
FAILED TEST
< 2 min
YES - Safe performance Objective Assessment
N
- Paddle electrodes correctly located
OBJECTIVE NOT ACHIEVED
YES OBJECTIVE ACHIEVED
- Paddle electrodes exchanged Quality Assessment (Incidences)
One
- Paddles lightly displaced. - Execution order changed.
QUALITY OBJECTIVE NOT
NO
QUALITY OBJECTIVE ACHIEVED Fig. 1. Check list.
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groups [6 years old: 1 (11.1%); 7 years old: 2 (13.3%)] more than half of 16 years old participants who performed the discharge did it with quality [16 years old: 10 (52.6%)] (Table 1). The most common error committed by participants who achieved the defibrillation objective was change in order of execution [197 (76.4%)] followed by pads exchange [37 (14.3%)] (Table 2).
Table 2 Errors made by participants who completed the defibrillation objective (without quality) [frequency (%)]. Age
N
Paddles exchanged
Paddles displaced
Incorrect execution order
6 7 8 9 10 11 12 13 14 15 16
9 15 22 27 41 41 10 25 26 21 19
5 (55.6) 1 (6.7) 9 (39.1) 5 (18.5) 2 (4.9) 5 (12.2) 0 3 (12) 0 4 (19) 3 (15.8)
1 (11.1) 1 (6.7) 2 (8.7) 7 (25.9) 5 (12.2) 2 (4.9) 1 (10) 3 (12) 3 (11.1) 2 (9.5) 1 (5.3)
9 (100) 9 (60) 18 (78.3) 21 (77.8) 31 (75.6) 28 (68.3) 10 (100) 23 (92) 23 (85.2) 13 (61.9) 12 (63.2)
Total
256
37 (14.3)
28(10.9)
197 (76.4)
Time was analyzed among the 258 students who accomplished the defibrillation goal. No significant differences were observed between those who attained the objective with or without with satisfaction. Global average time was 83.3 ± 26.4 s. Time to defibrillation decreased with increasing age [6 YO (108.3 ± 40. 4 s) vs. 16 YO (64.7 ± 18.6 s)] (p < 0.001). In a peer post hoc analysis we found that the average time was significantly shorter for older students [16 years old (64.7 ± 18.6 s); 15 years old (67.6 ± 13.6 s)] than for younger students [6 years old (108.3 ± 40.4 s); 7 years old (115.9 ± 33.2 s); 8 years old (101.3 ± 20.6 s)] (p < 0.001 in all contrast). No significant differences were found between the younger groups (from 6 to 10 years old) neither amongst the older groups (from 12 to 16 years old) (Fig. 2). Discussion Schoolchildren have been pointed out as an essential target for BLS training.3,5,13 Furthermore, PAD in school centres is related to shorter times from collapse to discharge, higher survival rates and better outcomes for victims of an out-of-hospital cardiac arrest (OHCA).14,15 Nowadays BLS/AED messages appear in the media, movies, internet videos, etc. and AEDs are present and visible in public places such as airports or shopping malls. Then, it is possible
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Seconds
140 120 100 80 60 40
Mean + SD
20 0 6
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8
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13
14
15
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Age (years) Fig. 2. Time of performance (in s) for the whole sample.
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that a significant number of children have acquired some indirect learning (from parents or peers but also from exposure to the use of AEDs in television/movies or by the simple observation of the devices in public places) about the relevance of early defibrillation and the basis of AEDs use. However, it is not clear at what age schoolchildren are capable of learning different aspects of firstaid learning like AEDs use and how is their background knowledge on the subject. This question has encouraged us since the answer might be a good reference for school-based training programmes. Our study, which provides a large cohort, indicates that from the age of 9, one of every 4 schoolchildren are capable of applying the AED, and at the age of 16 half of the capable students are able to complete the procedure with quality. Previous studies, carried out in other countries with smaller groups of subjects, have revealed comparable results. In a study including 47 naïve school children between 6 and 7 years of age,16 8 pupils (17%) identified AED execution order correctly, and after a week of BLS training by health workers the number of pupils who identified AED execution order increased up to 24 (51%). Younas et al17 observed that students (13–16 years of age) who had some prior academic training in first-aid obtained better results than untrained students (control group) for all the evaluated skills: (1) checking for consciousness and breathing, (2) CPR, 3) AED use. AED use was the worst performed part of the algorithm (27% training students vs. 4% control group). In our study, the first to assess the intuitive AED use in a large sample (1295 untrained schoolchildren) with a wide age range (from 6 to 16 years of age), only 8.7% of the 6-year-old pupils applied the AED correctly; around 25% of the 9-year-old group achieved the goal and this percentage increased up to 33.3% for the 16-yearold group. Regarding the quality objective, in the subgroups who achieved the defibrillation goal, only 11.1% of the 6-year-old pupils performed the test without errors, whereas almost 25% of the subjects in the 10-year-old group and more than 50% in the 16-year-old group achieved the quality objective. The most frequent error was the incorrect order of execution. Other errors were related to the incorrect positioning of pads (displaced from the ideal site or interchange of pads’ position). These facts should be taken into account by the instructors in order to reinforce training and overcome these common errors. We were surprised by the limited competence of younger kids, who should be familiar with the handling of technological devices, to follow the instructions provided by an AED. There is a chance that the problem is not the pupils’ capacity but the design and/or instructions of AEDs, that have been developed considering an eventual adult rescuer and not a child. In this sense, perhaps alternative AED designs or instructions ought to be explored. Every minute that passes after a cardiac arrest without defibrillation, chances of survival decrease by approximately 10–12%,
whereas survival rates significantly increase when AED is applied within the first minutes after the collapse.1 In our sample, defibrillation time was shorter than 3 min in all cases and decreased as children’s age increased (6-year-olds: 108.3 s vs. 16-year-olds: 64.7 s). Importantly, all children older than 8 years finished the test in less than 2 min. Our results are similar to previous data published by Gundry et al.18 although in their study participants received some indications about AED management before performing the practical test. This suggests that schoolchildren might have an intuitive idea of the importance of the factor of time in the case of CA and early defibrillation.19 According to our results children from 9 to 14 years have similar level of knowledge and skills to use an AED, and this suggest that around 9 years old might be the age at which children should start to be trained in the use of AED, adapting the training and retraining activities to the characteristics of kids of different ages. Early training would permit not only BLS/AED training but also yearly (or even more frequent) retraining over the school career[25] in order to attenuate the effects of elapsed time on CPR knowledge Q5 and abilities.13,22 Our study has some limitations. The test was carried out under simulated conditions so results are probably not the same as those that would be obtained in a real situation. Our sample was recruited from three middle-class schools from a small city that should be representative of schoolchildren in our country, but we cannot completely discard some selection bias that would limit the generalization of results. Although this point was not considered in the initial design of the study, the authors feel now that a questionnaire explaining how kids had learned about AED (media, parents, advertisements, etc.) would add some relevant information to the study. Conclusions Currently around 20% of theoretically naïve schoolchildren are able to apply an AED in less than 3 min by means of their general knowledge and device’s acoustic and visual instructions. General performance quality increases with age. However, children’s background knowledge and AED instructions alone are not enough to perform the procedure satisfactorily. These facts should be considered to define and implement effective BLS/AED teaching and training at schools. Author contribution All authors have contributed substantially to the conception and design of the study protocol, acquisition, analysis and interpretation of data. In addition, all of them have been involved in the draft and revision of the manuscript. Conflicts of interest statement The authors declare that they have no conflicts of interest related to the present study. Acknowledgments We would like to thank all the people (students, parents and educational team) of the schools who have participated in our study. References 1. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99.
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˜ de Resucitación Cardiopulmonar. Recomendaciones del Con2. Consejo Espanol ˜ de Resucitación Cardiopulmonar sobre la instalación, autorización sejo Espanol y formación para el uso del desfirbilador externo automático fuera del ˜ de Resucitación Cardiopulmonar; ámbito sanitario. Madrid: Consejo Espanol 2012. http://www.semicyuc.org/sites/default/files/recomendaciones cercp en uso dea v.0.9.pdf [accessed 01.12.15]. 3. Cave DM, Aufderheide TP, Beeson J, 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. 4. Jones I, Whitfield R, Colquhoun M, Chamberlain D, Vetter N, Newcombe R. At what age can schoolchildren provide effective chest compressions? An observational study from the Heartstart UK schools training programme. BMJ 2007;334:1201. 5. Böttiger BW, Van Aken H. Kids save lives – training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO). Resuscitation 2015:A5–7. 6. Dieltjens T, De Buck E, Verstraeten H, et al. Evidence-based recommendations on automated external defibrillator training for children and young people in Flanders-Belgium. Resuscitation 2013;84:1304–9. 7. Lind B. Teaching mouth-to-mouth resuscitation in primary schools. Acta Anaesthesiol Scand Suppl. 1961; Suppl 9:63-81. Acta Anaesthesiol Scand 2007;51:1044–50. 8. Maconochie I, Simpson S, Bingham B. Teaching children basic life support skills. BMJ 2007;334:1174. 9. Isbye DL, Rasmussen LS, Ringsted C, Lippert FK. Disseminating cardiopulmonary resuscitation training by distributing 35,000 personal manikins among school children. Circulation 2007;116:1380–5. 10. Andreu OM, Roig XE, Fabrega XJ, et al. Programa de Reanimación Cardiopul˜ Secundaria (PROCES): conclusiones monar Orientado a Centros de Ensenanza ˜ tras 5 anos de experiencia. Emerg Rev Soc Esp Med Urgenc Emerg 2008;20:229–36. 11. Mgbako OU, Ha YP, Ranard BL, et al. Defibrillation in the movies: a missed opportunity for public health education. Resuscitation 2014;85:1795–8.
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12. Schober P, van Dehn FB, Bierens JJLM, Loer SA, Schwarte LA. Public access defibrillation: time to access the public. Ann Emerg Med 2011;58:240–7. 13. Greif R, Lockey AS, Conaghan P, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation. Resuscitation 2015;95:288–301. 14. Mitani Y, Ohta K, Yodoya N, et al. Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. Europace 2013;15:1259–66. 15. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120:518–25. 16. Uray T, Lunzer A, Ochsenhofer A, et al. Feasibility of life-supporting firstaid (LSFA) training as a mandatory subject in primary schools. Resuscitation 2003;59:211–20. 17. Younas S, Raynes A, Morton S, Mackway-Jones K. An evaluation of the effectiveness of the Opportunities for Resuscitation and Citizen Safety (ORCS) defibrillator training programme designed for older school children. Resuscitation 2006;71:222–8. 18. Gundry JW, Comess KA, DeRook FA, Jorgenson D, Bardy GH. Comparison of naive sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999;100:1703–7. 19. De Buck E, Van Remoortel H, Dieltjens T, et al. Evidence-based educational pathway for the integration of first aid training in school curricula. Resuscitation 2015;94:8–22. 20. Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review. Resuscitation 2013;84:415–21. 21. Iserbyt P, Schouppe G, Charlier N. A multiple linear regression analysis of factors affecting the simulated Basic Life Support (BLS) performance with Automated External Defibrillator (AED) in Flemish lifeguards. Resuscitation 2015;89:70–4. 22. Bobrow BJ, Vadeboncoeur TF, Spaite DW, et al. The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes 2011;4:220–6.
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