- Email: [email protected]
ERC initiatives to reduce the burden of cardiac arrest: The European Cardiac Arrest Awareness Day
Best Practice & Research Clinical Anaesthesiology 27 (2013) 307–315
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ERC initiatives to reduce the burden of cardiac arrest: The European Cardiac Arrest Awareness Day Marios Georgiou, CCRN, Resuscitation Officer a, *, Andrew S. Lockey, Consultant in emergency medicine b a b
Nicosia General Hospital, 2029 Strovolos, Nicosia, Cyprus Emergency Department, Calderdale Royal Hospital, Salterhebble, Halifax HX3 0PW, UK
Keywords: cardiac arrest bystander CPR children
The rate of survival from out-of-hospital cardiac arrest in Europe remains unacceptably low and could be increased by better bystander cardiopulmonary resuscitation (CPR) rates. The European Resuscitation Council has announced that there will be a European Cardiac Arrest Awareness Day every year on the 16th of October. This is to coincide with the goals of the Written Declaration passed by the European Parliament in June 2012 that emphasised the importance of equal access to CPR and automated external defibrillator (AED) training. The topic of this year’s Awareness Day is ‘Children Saving Lives’ and it is hoped that all national resuscitation councils will promote awareness of the benefits of training all children in CPR and AED use and lobby for legislative change to ensure that all children receive this training. Children are not just the adults of tomorrow – they are the lifesavers of today and tomorrow. Ó 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ357 3799784580; Fax: þ357 22604337. E-mail addresses: [email protected] (M. Georgiou), [email protected] (A.S. Lockey). 1521-6896/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpa.2013.07.004
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Practice points All children should benefit from education to train them to perform cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED) in an emergency situation. Fulfilling this objective could result in a doubling of survival rates from out-of-hospital cardiac arrest. The European Parliament supported this goal in June 2012. The European Resuscitation Council is actively promoting this through a European Cardiac Arrest Awareness Day on 16 October 2013.
Research agenda Audit and research to demonstrate the benefits of more widespread training
About European Resuscitation Council The European Resuscitation Council (ERC) is a not-for-profit, scientific, European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was founded in 1989 and is currently based in Antwerp, Belgium. It consists of a network of national resuscitation councils (NRCs). The countries that currently join forces with the ERC are in alphabetical order: Austria, Belgium, Bosnia-Herzegovina, Croatia, Cyprus, Denmark, Egypt, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Switzerland, Tunisia, Turkey, United Arab Emirates and the United Kingdom. The ERC Mission Statement is “To preserve human life by making high-quality resuscitation available to all”. The main goal of the ERC is to promote measures that will help increase the rate of survival for inhospital and out-of-hospital cardiac arrest (OHCA) in Europe. It endeavours to do this by raising the awareness of the problem amongst target audiences through a series of dedicated activities such as: liaison between relevant stakeholders for the exchange of experience, information and data on cardiac arrest (survivors, physicians, nurses, emergency professionals, patients and family members), drive the development of political guidelines on cardiac arrest prevention and management, promote a uniform European approach to reporting of cardiac arrests, particularly the European Registry of Cardiac Arrest (EURECA), engage in discussion with the European Parliament (EP) and its member states to address the problem of cardiac arrest and its risk factors and to advocate new policy initiatives, provide input and guidance on the inclusion of cardiac arrest in the revised Public Health Action Programme, the EU Health Strategy, other health policy initiatives and the EP Resolution on cardiovascular health and promote policies such as the education of the public (including schoolchildren) about sudden cardiac arrest and advocate for better emergency response and better access to preventive medical care. The ERC’s core activities are: 1. to produce resuscitation guidelines for Europe, 2. to facilitate resuscitation courses for lay and professional rescuers, 3. to organise scientific congresses and
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4. to promulgate research into resuscitation matters and to publish the findings; the journal Resuscitation is the official journal of the ERC. The ERC, in order to produce resuscitation guidelines, participates in the International Liaison Committee on Resuscitation (ILCOR) in co-operation with the following scientific bodies: – – – – – –
American Heart Association, Australian and New Zealand Committee on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia and Resuscitation Council of Southern Africa
The burden of cardiac arrest The Council of Europe defines Europe as 47 countries with a population of 830 million. The exact magnitude of the burden of cardiac arrest is not accurately known as reliable data are incomplete. This can be concluded from published reports such as Atwood (2005), where 37 European centres were included [1] and Berdowski (2010), where 30 European centres were included [2]. Other published reports include Müller (2008) [3], the EuroHeart survey and European cardiovascular disease statistics (2008) [4]. Many of those used different methods and were based on national, regional or local reports and thus did not cover the whole of Europe. Many of those reports were self-reporting; others were based on Emergency Medical Services (EMS) or hospital data. Furthermore, important information is missing regarding the resuscitation process, the type of patients, the interventions and the survival. Based on the above, the following statistics can be assumed:
All cardiac arrest 0:4 0:9=1000=Year From shockable rhythm ðVF=VTÞ 0:2=1000=Year
Survival 11% Survival 21%
The rate of survival appears in a wide range: 11% (6–31%) for cardiac arrests of all causes and 21% (8– 43%) for cardiac arrests due to shockable rhythms (ventricular fibrillation or ventricular tachycardia treated with electroshock defibrillation). The differences are, to some extent, due to the absence of uniformity of definitions and reporting systems and also due to true differences in epidemiology, organisation, training and care [2]. The magnitude of the problem has been effectively summarised by a previous Chairman of the ERC, Prof Dr. Bernd Böttiger: “the number of people who die from a cardiac arrest is the same as two fully booked Jumbo Jets crashing down each day in Europe – without any survivors. This means 350,000 lives are lost per year in Europe, which corresponds to around one thousand deaths per day. This is a problem of an extreme magnitude with heavy individual, social, economic and public health consequences”. The number of unsuccessful resuscitation attempts every year is eight times higher than deaths from car accidents [5]. It is proposed that if more people were trained (e.g., in key public places such as airports, gyms, hotels, etc.) and if more automated external defibrillators (AEDs) were placed in strategic points, >50% of the deaths by cardiac arrest could effectively be prevented [6]. The ERC has already commenced an effort to promote uniformity in cardiac arrest reporting via the EuReCa project. The first results have already been published. The two major obstacles in completing a high-quality and representative registry are the lack of the necessary funding and the absence of a European policy or directive to simplify the establishment of such a registry, as this is currently hindered by restrictive and varying national legislations [7]. Moreover, as Ornato reported in 2010, it seems that the funding for research on cardiac arrest is minimum compared to other diseases [8]. Fighting the burden of cardiac arrest and increasing the rate of survival for OHCA The success and the rate of survival of OHCA depend on several factors: where the arrest takes place, whether bystanders witness the arrest, the bystanders’ ability to recognise the arrest, how soon the
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EMS are called and, most importantly, the ability of the bystanders to perform CPR [9–11]. When bystander CPR is initiated, the survival rate is doubled [12–14]. It is also known that delay in treatment is associated with mortality [15]. The outcome of OHCA and the rate of bystander CPR are also associated with the location. In fact, it seems there is an association between measures of socioeconomic status and the provision of bystander CPR [11]. It is worthy of note that there is a great variation in the incidence of survival from as low as 3.0%–16.3% [16]. Another variable affecting the outcome is the time of day the prehospital cardiac arrest happens. Rates of 30-day survival were significantly higher for OHCA occurring during the day compared with that at night [17]. This variation in survival rate is attributed to the different rates of bystander CPR. Sasson et al., in a systematic review and a metaanalysis, found that the number of CPR attempts needed to treat to save one life ranged from 16 to 23 for EMS-witnessed arrests, from 17 to 71 for bystander-witnessed arrests and from 24 to 36 for those receiving bystander CPR [18]. It is therefore accepted that a promising approach in order to increase the rate of survival for OHCA is to increase the rate of bystander CPR. Nevertheless, this does not seem to be a straightforward action as demonstrated by the rates in the United States, which vary from 10% to 65% [19]. Differences in relation to the prevalence and the rate of survival are also observed between metropolitan, urban and rural areas. In a nationwide study, it was observed that the incidence rate and survival to discharge rate of EMS-assessed OHCAs increased annually in metropolitan and urban communities but did not increase in rural communities [20]. In order to address this important topic, it is important to understand the reasons for this variability in the rate of bystander CPR. Among several reports, it seems that the reasons for bystander hesitancy include fear of doing further harm, panic, delays in recognition, fear of contamination from mouth-to-mouth ventilation, fear of performing CPR incorrectly and legal concerns [21,45]. Public awareness of cardiopulmonary resuscitation (CPR) and cardiac arrest is also influenced by systemic factors including related policies and legislations in the community. As Lee et al. report, national policies about resuscitation have the power to increase the willingness of citizens to perform bystander CPR. In their study, they demonstrated that the factors most related with initiation of bystander CPR were male gender, younger age, CPR awareness, recent CPR training and qualified CPR learning [22]. The ERC response to this is that public awareness campaigns of how simple and safe it is to initiate bystander CPR are paramount to success. Public awareness should, in particular, target strategies to eliminate the aforementioned fears of commencing bystander CPR. A good example is the campaign for chest-compression-only CPR initiated by the American Heart Association, which has resulted in a significant increase in bystander CPR [23]. The Internet, social media and new technologies all have a part to play in increasing public awareness. ‘Viral’ videos, social media pages, games, mobile phone applications and web pages are being used in the battle to fight the burden of cardiac arrest. A simple search of the Internet will easily find more than 4000 results. One recent example is the free Lifesaver [24] programme released by the Resuscitation Council (UK). This immersive real-time production is available on web and smartphone platforms and enables the user to participate in three real-time resuscitation scenarios. Bad decisions result in bad outcomes, whilst good decisions save the life of the simulated victim. The ERC has joined the social media revolution by launching a Facebook page. It has also successfully used the power of the social media to spread the word before, during and after its last international congress held in Vienna 2012. The methods of reaching the public via multimedia campaigns are proven to be effective, especially for public access defibrillation programmes [25]. The effect that televised public service announcements (PSAs) have in increasing bystander CPR is not something new. Becker and colleagues in 1999 compared two communities where two 30-s PSAs were shown 597 times. 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%) [26]. Moreover, an educational intervention of an 8-min multimedia educational video, written and produced by physicians to provide educational information about cardiac resuscitation to the lay public, showed improvements in the resuscitation knowledge base, resulting in significant effects on resuscitation preferences among the lay public [27]. Further, multimedia has been proven to not only affect willingness to perform bystander CPR but also significantly affect its quality [28]. Similarly, cellular phones with video demonstration on how to perform CPR, compared to audio coaching, affect the time to initiate the CPR, the quality of CPR regarding the compression depth,
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rate and total hands-off time [29]. Mobile phones seem to be promising as a potential lifesaving device. Ivor Kovic has illustrated its effectiveness by incorporating mobile phones into a new version of the classic chain of survival, named ‘The Mobile Chain of Survival’ [30]. Another application of mobile phone technology that relates to the early defibrillation link in the chain is a cell-phone web-system map displaying nearby AEDs to help to reduce the travel distance to access and retrieve an AED [31]. Another mobile phone feature that affects chains of early CPR and early defibrillation is a short messaging system (SMS) alert service which could potentially increase the number of laypersons who provide early aid [32]. All of these new ideas and scientific developments have been presented at ERC congresses and symposia. The notion of increasing bystander CPR and hence the rate of survival for OHCA is in line with the ERC mission statement ’Making High Quality Resuscitation Available to All’. With this in mind, the ERC has announced that it will promote a European Cardiac Arrest Awareness Day (ECAAD) every year on the 16th of October [33]. ECAAD: ‘Children Saving Lives’ Public awareness about resuscitation and cardiac arrest is linked to training. The ERC has committed to the promotion of training for lay people in basic life support since 1992 [34]. The 2010 ERC Guidelines [35] endorsed the recommendation that all citizens should be taught CPR. Following a lobbying campaign by the ERC, the European Parliament passed a Written Declaration in June 2012 with a majority vote of 396 signatures calling for comprehensive training programmes in CPR and AED use across all its member states. The Written Declaration calls for an adjustment of legislation in European Union (EU) member states to ensure national strategies for equal access to high-quality CPR and defibrillation [33]. The declaration also calls for the establishment of a European cardiac arrest awareness week. This achievement is a strong political tool that can be used by national councils around Europe in order to push for local actions in fighting the burden of cardiac arrest. Taking the opportunity that the Written Declaration offers, the ERC has announced that the 16th of October will be a reference day every year to trigger promotion and events by all European NRCs. It will now be referred to as the ‘European Cardiac Arrest Awareness Day (ECAAD)’. The ERC is committed to improving awareness of health-care personnel and communities at a national and a European level. The ERC anticipates that national councils will have an insight into and understanding of the local links in the chain of survival, promote uniformity in practice and reporting systems, create benchmarks and by learning from each other define weak links in the chain of survival in order to improve health-care practice. The low rate of bystander CPR signifies the lack of public awareness as part of the problem, thus justifying it as one of the first priorities for the ERC. Education of the public, for example, in the home and in the work environment, in the programme for obtaining a driving license and the possibility of educating schoolchildren, are all essential components to fight the burden of OHCA. The ERC has decided to have a different theme each year targeting different groups for its cardiac arrest awareness campaign. For 2013, the theme of ECAAD is ‘Children Saving Lives’, targeting the training of schoolchildren. Schoolchildren are not only seen as the adults of tomorrow but also as the rescuers of tomorrow. Targeting the awareness of schoolchildren gives a great opportunity to build and grow an altruistic culture in society, having the passion to help others. It is believed that if children get familiar and trained in resuscitation from a young age, then this will help us in overcoming the barriers to initiation of bystander CPR. As Colquhoun reported in May 2012 [36], CPR tuition should start at an early age and it should be a planned part of the school curriculum. He noted that the school is an ideal environment to capture all future citizens and that this type of learning is popular and effective at that age. Evidence from Germany [37] concluded that training in schools was practicable and could be provided by existing teaching staff. Indeed, teaching staffs are willing to provide this instruction as long as they receive appropriate training [38]. Kanstad et al. had pointed out the high motivation of young Norwegians and confirmed that secondary school students should be an important focus of efforts to increase the bystander CPR rate [39]. It has also been reported that the use of self-instruction manikin-digital video disc (manikin-DVD) sets can further educate a mean of 2.8 additional people [40]. Norway is one of the
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few countries in Europe where CPR is a mandatory component of the school curriculum reflecting better levels of bystander CPR and survival [41]. Plant and Taylor [42] have performed a comprehensive systematic review of how to teach CPR to schoolchildren. The authors have taken into account a broad range of evidence covering schoolchild factors (e.g., age and physical maturity) as well as training factors. The latter include effectiveness of CPR training, the role of practical training, delivery of rescue-breath training, selfinstruction kits, computer-based training, brief training effectiveness, retention strategies, trainer type and AED training. In their conclusion, they point out that short-term retention of skills and knowledge is possible from a wide range of training strategies. This can be further enhanced by repeating training at regular intervals and by starting training at an early age. They highlight that every training intervention should be relevant and appropriate to different age groups. In other words, one age group, for example, younger children, can be taught the principles of calling for help and older children, the skills of CPR, when they are physically mature enough to perform these skills. In an analysis of a database covering 40 American EMS systems, Swor et al. [43] investigated 30,603 cardiac arrests and in particular those that occurred in primary and secondary schools over a 5-year period. They found that only a small number (47, 0.15%) occurred in schools. Furthermore, the victims were mainly adults (66%). The majority received bystander CPR and the arrests occurred mainly during school hours. AEDs, when used, had a good outcome although they were not used in the majority of cases. Fifteen patients (31.9%) survived to hospital discharge. The authors concluded that it is essential that school emergency plans should be able to provide good emergency care when the buildings are occupied. Whilst the low numbers will come as a disappointment to those lobbying for the mandatory presence of AEDs in schools, this should still be balanced against the bigger picture. There still needs to be tuition for all children about AED use and this becomes easier if the children can visualise what an AED looks like. Their use need not be confined to the school and their location can still be advertised locally as part of a public access AED programme. Lockey and Georgiou conducted a survey on behalf of the ERC with responses from 23 of 30 NRCs [44]. It was found that there are official national learning outcomes for primary/secondary schools in 16 of the 23 countries. In four of these 16 countries (25%), the learning outcomes include training in first aid incorporating CPR. In 11 of these 16 countries (68.75%), first aid is included in the curriculum of primary/secondary schools. The use of an AED is included in the teaching of only one country. Obstacles reported to AED training included the cost of AEDs and the minimal public availability, the absence of legislation on the use of an AED by lay people, communication and co-operation problems between ministries of health and NRCs and the fact that education is a federal rather than a national responsibility in some countries. The structure of CPR training varies in the four countries that have CPR training in their primary/ secondary school curriculum. In three out of four countries, it is a once-only training. The duration of the training varies from 3 to 4 h to 6–8 h. The age of schoolchildren who receive the training varies from 7 to 15 years. A standardised curriculum and a standardised package of education material are used in only one country. No country provides standardised certificates. The instructor/participant ratio varies both within and across countries from 1 per 10 to 1 per 25 participants. The instructors are schoolteachers in two countries, who may or may not have followed a proper postgraduate course for schoolteachers. In the other two countries, the instructors range from qualified rescue instructors to unqualified self-educated individuals [44]. It is obvious that there is no standardisation in how CPR is taught to schoolchildren – there is significant variability in practice across Europe. Plant et al. [42] show that a range of strategies could be effective, although standardisation would help with larger-scale evaluation of effectiveness. The challenge is to ensure that widespread training of some description now occurs and this is the basis behind the ‘Children Saving Lives’ project that the ERC is coordinating. In December 2011, the ERC (Project Coordinator) launched the idea for a Comenius proposal and application: ‘Children Saving Lives’. The idea is to draw on exchange of best practice and to promote transfer of innovation among its members to develop course material for 12–14-year-olds on how to perform CPR and how to use an AED. Close co-operation with professionals (teachers) working in
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schools across Europe is considered essential. From the beginning, it was clear that the major outcome of the project would be twofold: a train-the-trainers programme (online) and the course material for the specific target group of schoolchildren. As mentioned previously, only four out of 23 countries surveyed [44] include training in CPR skills in their primary/secondary school curriculum. The survey results further illustrate that when training CPR and the use of an AED are optional, the motivation to effectively organise the course drops dramatically because of several obstacles: teachers claim that curricula are too packed already, existing programmes often lack structure, the cost of AED is prohibitive and there is low public availability of AEDs in certain member states. All of these elements/challenges were taken into account by the ERC when developing the Children Saving Lives project. The ERC, as a network for NRCs, is in an excellent position to coordinate the project and to safeguard its sustainability in the long run. The project outcome will indeed be disseminated among a wide network of contacts in the sector. Major dissemination channels are the ERC Official Journal, the ERC website and the many events that are organised by the association. There is a standardised logo that will be used every year and a different one for each year according to that year’s theme. The ERC has prepared a promotional marketing package including a poster, press release and a flyer about how to perform CPR with special illustrations for children. All of these materials will be translated by NRCs into national languages. To spread the word of this year’s ECAAD, other relevant organisations have joined forces with ERC. These are the European Society of Cardiology (ESC), European Society of Intensive Care Medicine (ESICM), European Society of Emergency Medicine (EUSEN), European Society of Anaesthesiology (ESA) and Red Cross. To promote the day and increase public awareness, messages have been sent to NRCs. In addition, the power of the Internet and social media will be fully utilised. The ERC is also planning an important central event in the EU Parliament in Brussels, which will include lectures and demonstrations about how to deal with OHCA. Conclusion The ERC’s primary policy goal is to inform the public that many lives can be saved with resuscitation. It is essential to be aware that we can “prevent death from cardiac arrest due to CVD or any other aetiology by making high-quality resuscitation available to all”. This is indeed in line with ERC’s mission statement. Unfortunately, the EU cannot issue any regulations on how member states should deliver health services. Nonetheless, the matter of making high-quality resuscitation available to all can be addressed through the EU health and safety policy and patients’ rights. This pathway can be followed to promote and develop directives in line with the EU baseline that all citizens should have equal opportunities, to have access to high-quality resuscitation. Assistance in reaching this goal might come through forging alliances with organisations already heavily involved in the EU health policy-making process and which are respected as representative stakeholders by EU officials. As such, the ERC realises it has to make European policy makers more sensitive to the issue of cardiac arrest and other related issues. It is important to join forces with other relevant European scientific bodies such as ESC, ESA, EuSEM and ESICM, in order to jointly fight the burden of cardiac arrest and participate in collaborations such as the European Health Forum, European Heart Network, MEP Heart Group, the European Public Health Alliance, etc. The ERC, by setting up an ECAAD, is stimulating awareness and anticipates increasing the rate of bystander CPR and hence the rate of survival from OHCA. We would like to promote a formal question from the EU towards all the member states asking them to provide figures on cardiac arrests (annual report). In addition, we feel that further research is essential and needs to be focussed on early recognition, early CPR and addressing the reasons for low bystander CPR rates. In summary, we believe that the most effective weapons to fight the burden of cardiac arrest are to consider cardiac arrest as a priority for Europe, the uniformity of education and reporting and management of implementation through European legislations and regulations. Last but not the least is training of schoolchildren, which seems to be a promising approach in changing behaviour and educating the rescuers of tomorrow. We should believe that “small hands can do big things”.
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*[30] Kovic Ivor, Lulic Ileana. Mobile phone in the chain of survival. Resuscitation 2011;82:776–9. *[31] Sakai T, Iwami T, Kitamura T, et al. Effectiveness of the new ‘Mobile AED Map’ to find and retrieve an AED: a randomised controlled trial. Resuscitation 2011 Jan;82(1):69–73. *[32] Scholten AC, van Manen JG, van der Worp WE, et al. Early cardiopulmonary resuscitation and use of automated external defibrillators by laypersons in out-of-hospital cardiac arrest using an SMS alert service. Resuscitation 2011 Oct;82(10): 1273–8. *[33] http://www.europarl.europa.eu/sides/getDoc.do?pubRef¼-//EP//TEXTþTAþP7-TA-2012-0266þ0þDOCþXMLþV0// EN&language¼EN. [34] Basic life support working party of the European Resuscitation Council. Guidelines for basic life support. Resuscitation 1992;24:103–10. [35] Soar J, Mancini ME, Bhanji F, et al. Part 12: education, implementation, and teams: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e288–332. *[36] Colquhoun M. Learning CPR at school – everyone should do it. Resuscitation 2012;83(5):543–4. [37] Bohn A, Van Aken HK, Möllhoff T, et al. Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four year prospective cohort study. Resuscitation 2012;83:619–25. [38] McCluskey D, Moore P, Campbell S, et al. Teaching CPR in secondary education: the opinions of head teachers in one region of the UK. Resuscitation 2010;81:1601. [39] Kanstad BK, Nilsen SA, Fredriksen K. CPR knowledge and attitude to performing bystander CPR among secondary school students in Norway. Resuscitation 2011;82:1053–9. [40] Lorem T, Steen PA, Wik L. High school students as ambassadors of CPR – a model for reaching the most appropriate target population? Resuscitation 2010;81:78–81. [41] Lindner TW, Soreide E, Nilsen OB, et al. Good outcome in every fourth resuscitation attempt is achievable – an utstein template report from the stavanger region. Resuscitation 2011;82:1508–13. [42] Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review. Resuscitation 2013 Apr;84(4):415–21. [43] Swor R, Grace H, McGovern H, et al. Cardiac arrests in schools: assessing use of automated external defibrillators (AED) on school campuses. Resuscitation 2013 Apr;84(4):426–9. *[44] Lockey AS, Georgiou M. Children can save lives. Resuscitation 2013 Apr;84(4):399–400. [45] Bradley SM, Rea TD. Improving bystander cardiopulmonary resuscitation. Curr Opin Crit Care 2011;17:219–24.
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ERC initiatives to reduce the burden of cardiac arrest: The European Cardiac Arrest Awareness Day Marios Georgiou, CCRN, Resuscitation Officer a, *, Andrew S. Lockey, Consultant in emergency medicine b a b
Nicosia General Hospital, 2029 Strovolos, Nicosia, Cyprus Emergency Department, Calderdale Royal Hospital, Salterhebble, Halifax HX3 0PW, UK
Keywords: cardiac arrest bystander CPR children
The rate of survival from out-of-hospital cardiac arrest in Europe remains unacceptably low and could be increased by better bystander cardiopulmonary resuscitation (CPR) rates. The European Resuscitation Council has announced that there will be a European Cardiac Arrest Awareness Day every year on the 16th of October. This is to coincide with the goals of the Written Declaration passed by the European Parliament in June 2012 that emphasised the importance of equal access to CPR and automated external defibrillator (AED) training. The topic of this year’s Awareness Day is ‘Children Saving Lives’ and it is hoped that all national resuscitation councils will promote awareness of the benefits of training all children in CPR and AED use and lobby for legislative change to ensure that all children receive this training. Children are not just the adults of tomorrow – they are the lifesavers of today and tomorrow. Ó 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ357 3799784580; Fax: þ357 22604337. E-mail addresses: [email protected] (M. Georgiou), [email protected] (A.S. Lockey). 1521-6896/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpa.2013.07.004
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Practice points All children should benefit from education to train them to perform cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED) in an emergency situation. Fulfilling this objective could result in a doubling of survival rates from out-of-hospital cardiac arrest. The European Parliament supported this goal in June 2012. The European Resuscitation Council is actively promoting this through a European Cardiac Arrest Awareness Day on 16 October 2013.
Research agenda Audit and research to demonstrate the benefits of more widespread training
About European Resuscitation Council The European Resuscitation Council (ERC) is a not-for-profit, scientific, European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was founded in 1989 and is currently based in Antwerp, Belgium. It consists of a network of national resuscitation councils (NRCs). The countries that currently join forces with the ERC are in alphabetical order: Austria, Belgium, Bosnia-Herzegovina, Croatia, Cyprus, Denmark, Egypt, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Switzerland, Tunisia, Turkey, United Arab Emirates and the United Kingdom. The ERC Mission Statement is “To preserve human life by making high-quality resuscitation available to all”. The main goal of the ERC is to promote measures that will help increase the rate of survival for inhospital and out-of-hospital cardiac arrest (OHCA) in Europe. It endeavours to do this by raising the awareness of the problem amongst target audiences through a series of dedicated activities such as: liaison between relevant stakeholders for the exchange of experience, information and data on cardiac arrest (survivors, physicians, nurses, emergency professionals, patients and family members), drive the development of political guidelines on cardiac arrest prevention and management, promote a uniform European approach to reporting of cardiac arrests, particularly the European Registry of Cardiac Arrest (EURECA), engage in discussion with the European Parliament (EP) and its member states to address the problem of cardiac arrest and its risk factors and to advocate new policy initiatives, provide input and guidance on the inclusion of cardiac arrest in the revised Public Health Action Programme, the EU Health Strategy, other health policy initiatives and the EP Resolution on cardiovascular health and promote policies such as the education of the public (including schoolchildren) about sudden cardiac arrest and advocate for better emergency response and better access to preventive medical care. The ERC’s core activities are: 1. to produce resuscitation guidelines for Europe, 2. to facilitate resuscitation courses for lay and professional rescuers, 3. to organise scientific congresses and
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4. to promulgate research into resuscitation matters and to publish the findings; the journal Resuscitation is the official journal of the ERC. The ERC, in order to produce resuscitation guidelines, participates in the International Liaison Committee on Resuscitation (ILCOR) in co-operation with the following scientific bodies: – – – – – –
American Heart Association, Australian and New Zealand Committee on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia and Resuscitation Council of Southern Africa
The burden of cardiac arrest The Council of Europe defines Europe as 47 countries with a population of 830 million. The exact magnitude of the burden of cardiac arrest is not accurately known as reliable data are incomplete. This can be concluded from published reports such as Atwood (2005), where 37 European centres were included [1] and Berdowski (2010), where 30 European centres were included [2]. Other published reports include Müller (2008) [3], the EuroHeart survey and European cardiovascular disease statistics (2008) [4]. Many of those used different methods and were based on national, regional or local reports and thus did not cover the whole of Europe. Many of those reports were self-reporting; others were based on Emergency Medical Services (EMS) or hospital data. Furthermore, important information is missing regarding the resuscitation process, the type of patients, the interventions and the survival. Based on the above, the following statistics can be assumed:
All cardiac arrest 0:4 0:9=1000=Year From shockable rhythm ðVF=VTÞ 0:2=1000=Year
Survival 11% Survival 21%
The rate of survival appears in a wide range: 11% (6–31%) for cardiac arrests of all causes and 21% (8– 43%) for cardiac arrests due to shockable rhythms (ventricular fibrillation or ventricular tachycardia treated with electroshock defibrillation). The differences are, to some extent, due to the absence of uniformity of definitions and reporting systems and also due to true differences in epidemiology, organisation, training and care [2]. The magnitude of the problem has been effectively summarised by a previous Chairman of the ERC, Prof Dr. Bernd Böttiger: “the number of people who die from a cardiac arrest is the same as two fully booked Jumbo Jets crashing down each day in Europe – without any survivors. This means 350,000 lives are lost per year in Europe, which corresponds to around one thousand deaths per day. This is a problem of an extreme magnitude with heavy individual, social, economic and public health consequences”. The number of unsuccessful resuscitation attempts every year is eight times higher than deaths from car accidents [5]. It is proposed that if more people were trained (e.g., in key public places such as airports, gyms, hotels, etc.) and if more automated external defibrillators (AEDs) were placed in strategic points, >50% of the deaths by cardiac arrest could effectively be prevented [6]. The ERC has already commenced an effort to promote uniformity in cardiac arrest reporting via the EuReCa project. The first results have already been published. The two major obstacles in completing a high-quality and representative registry are the lack of the necessary funding and the absence of a European policy or directive to simplify the establishment of such a registry, as this is currently hindered by restrictive and varying national legislations [7]. Moreover, as Ornato reported in 2010, it seems that the funding for research on cardiac arrest is minimum compared to other diseases [8]. Fighting the burden of cardiac arrest and increasing the rate of survival for OHCA The success and the rate of survival of OHCA depend on several factors: where the arrest takes place, whether bystanders witness the arrest, the bystanders’ ability to recognise the arrest, how soon the
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EMS are called and, most importantly, the ability of the bystanders to perform CPR [9–11]. When bystander CPR is initiated, the survival rate is doubled [12–14]. It is also known that delay in treatment is associated with mortality [15]. The outcome of OHCA and the rate of bystander CPR are also associated with the location. In fact, it seems there is an association between measures of socioeconomic status and the provision of bystander CPR [11]. It is worthy of note that there is a great variation in the incidence of survival from as low as 3.0%–16.3% [16]. Another variable affecting the outcome is the time of day the prehospital cardiac arrest happens. Rates of 30-day survival were significantly higher for OHCA occurring during the day compared with that at night [17]. This variation in survival rate is attributed to the different rates of bystander CPR. Sasson et al., in a systematic review and a metaanalysis, found that the number of CPR attempts needed to treat to save one life ranged from 16 to 23 for EMS-witnessed arrests, from 17 to 71 for bystander-witnessed arrests and from 24 to 36 for those receiving bystander CPR [18]. It is therefore accepted that a promising approach in order to increase the rate of survival for OHCA is to increase the rate of bystander CPR. Nevertheless, this does not seem to be a straightforward action as demonstrated by the rates in the United States, which vary from 10% to 65% [19]. Differences in relation to the prevalence and the rate of survival are also observed between metropolitan, urban and rural areas. In a nationwide study, it was observed that the incidence rate and survival to discharge rate of EMS-assessed OHCAs increased annually in metropolitan and urban communities but did not increase in rural communities [20]. In order to address this important topic, it is important to understand the reasons for this variability in the rate of bystander CPR. Among several reports, it seems that the reasons for bystander hesitancy include fear of doing further harm, panic, delays in recognition, fear of contamination from mouth-to-mouth ventilation, fear of performing CPR incorrectly and legal concerns [21,45]. Public awareness of cardiopulmonary resuscitation (CPR) and cardiac arrest is also influenced by systemic factors including related policies and legislations in the community. As Lee et al. report, national policies about resuscitation have the power to increase the willingness of citizens to perform bystander CPR. In their study, they demonstrated that the factors most related with initiation of bystander CPR were male gender, younger age, CPR awareness, recent CPR training and qualified CPR learning [22]. The ERC response to this is that public awareness campaigns of how simple and safe it is to initiate bystander CPR are paramount to success. Public awareness should, in particular, target strategies to eliminate the aforementioned fears of commencing bystander CPR. A good example is the campaign for chest-compression-only CPR initiated by the American Heart Association, which has resulted in a significant increase in bystander CPR [23]. The Internet, social media and new technologies all have a part to play in increasing public awareness. ‘Viral’ videos, social media pages, games, mobile phone applications and web pages are being used in the battle to fight the burden of cardiac arrest. A simple search of the Internet will easily find more than 4000 results. One recent example is the free Lifesaver [24] programme released by the Resuscitation Council (UK). This immersive real-time production is available on web and smartphone platforms and enables the user to participate in three real-time resuscitation scenarios. Bad decisions result in bad outcomes, whilst good decisions save the life of the simulated victim. The ERC has joined the social media revolution by launching a Facebook page. It has also successfully used the power of the social media to spread the word before, during and after its last international congress held in Vienna 2012. The methods of reaching the public via multimedia campaigns are proven to be effective, especially for public access defibrillation programmes [25]. The effect that televised public service announcements (PSAs) have in increasing bystander CPR is not something new. Becker and colleagues in 1999 compared two communities where two 30-s PSAs were shown 597 times. 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%) [26]. Moreover, an educational intervention of an 8-min multimedia educational video, written and produced by physicians to provide educational information about cardiac resuscitation to the lay public, showed improvements in the resuscitation knowledge base, resulting in significant effects on resuscitation preferences among the lay public [27]. Further, multimedia has been proven to not only affect willingness to perform bystander CPR but also significantly affect its quality [28]. Similarly, cellular phones with video demonstration on how to perform CPR, compared to audio coaching, affect the time to initiate the CPR, the quality of CPR regarding the compression depth,
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rate and total hands-off time [29]. Mobile phones seem to be promising as a potential lifesaving device. Ivor Kovic has illustrated its effectiveness by incorporating mobile phones into a new version of the classic chain of survival, named ‘The Mobile Chain of Survival’ [30]. Another application of mobile phone technology that relates to the early defibrillation link in the chain is a cell-phone web-system map displaying nearby AEDs to help to reduce the travel distance to access and retrieve an AED [31]. Another mobile phone feature that affects chains of early CPR and early defibrillation is a short messaging system (SMS) alert service which could potentially increase the number of laypersons who provide early aid [32]. All of these new ideas and scientific developments have been presented at ERC congresses and symposia. The notion of increasing bystander CPR and hence the rate of survival for OHCA is in line with the ERC mission statement ’Making High Quality Resuscitation Available to All’. With this in mind, the ERC has announced that it will promote a European Cardiac Arrest Awareness Day (ECAAD) every year on the 16th of October [33]. ECAAD: ‘Children Saving Lives’ Public awareness about resuscitation and cardiac arrest is linked to training. The ERC has committed to the promotion of training for lay people in basic life support since 1992 [34]. The 2010 ERC Guidelines [35] endorsed the recommendation that all citizens should be taught CPR. Following a lobbying campaign by the ERC, the European Parliament passed a Written Declaration in June 2012 with a majority vote of 396 signatures calling for comprehensive training programmes in CPR and AED use across all its member states. The Written Declaration calls for an adjustment of legislation in European Union (EU) member states to ensure national strategies for equal access to high-quality CPR and defibrillation [33]. The declaration also calls for the establishment of a European cardiac arrest awareness week. This achievement is a strong political tool that can be used by national councils around Europe in order to push for local actions in fighting the burden of cardiac arrest. Taking the opportunity that the Written Declaration offers, the ERC has announced that the 16th of October will be a reference day every year to trigger promotion and events by all European NRCs. It will now be referred to as the ‘European Cardiac Arrest Awareness Day (ECAAD)’. The ERC is committed to improving awareness of health-care personnel and communities at a national and a European level. The ERC anticipates that national councils will have an insight into and understanding of the local links in the chain of survival, promote uniformity in practice and reporting systems, create benchmarks and by learning from each other define weak links in the chain of survival in order to improve health-care practice. The low rate of bystander CPR signifies the lack of public awareness as part of the problem, thus justifying it as one of the first priorities for the ERC. Education of the public, for example, in the home and in the work environment, in the programme for obtaining a driving license and the possibility of educating schoolchildren, are all essential components to fight the burden of OHCA. The ERC has decided to have a different theme each year targeting different groups for its cardiac arrest awareness campaign. For 2013, the theme of ECAAD is ‘Children Saving Lives’, targeting the training of schoolchildren. Schoolchildren are not only seen as the adults of tomorrow but also as the rescuers of tomorrow. Targeting the awareness of schoolchildren gives a great opportunity to build and grow an altruistic culture in society, having the passion to help others. It is believed that if children get familiar and trained in resuscitation from a young age, then this will help us in overcoming the barriers to initiation of bystander CPR. As Colquhoun reported in May 2012 [36], CPR tuition should start at an early age and it should be a planned part of the school curriculum. He noted that the school is an ideal environment to capture all future citizens and that this type of learning is popular and effective at that age. Evidence from Germany [37] concluded that training in schools was practicable and could be provided by existing teaching staff. Indeed, teaching staffs are willing to provide this instruction as long as they receive appropriate training [38]. Kanstad et al. had pointed out the high motivation of young Norwegians and confirmed that secondary school students should be an important focus of efforts to increase the bystander CPR rate [39]. It has also been reported that the use of self-instruction manikin-digital video disc (manikin-DVD) sets can further educate a mean of 2.8 additional people [40]. Norway is one of the
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few countries in Europe where CPR is a mandatory component of the school curriculum reflecting better levels of bystander CPR and survival [41]. Plant and Taylor [42] have performed a comprehensive systematic review of how to teach CPR to schoolchildren. The authors have taken into account a broad range of evidence covering schoolchild factors (e.g., age and physical maturity) as well as training factors. The latter include effectiveness of CPR training, the role of practical training, delivery of rescue-breath training, selfinstruction kits, computer-based training, brief training effectiveness, retention strategies, trainer type and AED training. In their conclusion, they point out that short-term retention of skills and knowledge is possible from a wide range of training strategies. This can be further enhanced by repeating training at regular intervals and by starting training at an early age. They highlight that every training intervention should be relevant and appropriate to different age groups. In other words, one age group, for example, younger children, can be taught the principles of calling for help and older children, the skills of CPR, when they are physically mature enough to perform these skills. In an analysis of a database covering 40 American EMS systems, Swor et al. [43] investigated 30,603 cardiac arrests and in particular those that occurred in primary and secondary schools over a 5-year period. They found that only a small number (47, 0.15%) occurred in schools. Furthermore, the victims were mainly adults (66%). The majority received bystander CPR and the arrests occurred mainly during school hours. AEDs, when used, had a good outcome although they were not used in the majority of cases. Fifteen patients (31.9%) survived to hospital discharge. The authors concluded that it is essential that school emergency plans should be able to provide good emergency care when the buildings are occupied. Whilst the low numbers will come as a disappointment to those lobbying for the mandatory presence of AEDs in schools, this should still be balanced against the bigger picture. There still needs to be tuition for all children about AED use and this becomes easier if the children can visualise what an AED looks like. Their use need not be confined to the school and their location can still be advertised locally as part of a public access AED programme. Lockey and Georgiou conducted a survey on behalf of the ERC with responses from 23 of 30 NRCs [44]. It was found that there are official national learning outcomes for primary/secondary schools in 16 of the 23 countries. In four of these 16 countries (25%), the learning outcomes include training in first aid incorporating CPR. In 11 of these 16 countries (68.75%), first aid is included in the curriculum of primary/secondary schools. The use of an AED is included in the teaching of only one country. Obstacles reported to AED training included the cost of AEDs and the minimal public availability, the absence of legislation on the use of an AED by lay people, communication and co-operation problems between ministries of health and NRCs and the fact that education is a federal rather than a national responsibility in some countries. The structure of CPR training varies in the four countries that have CPR training in their primary/ secondary school curriculum. In three out of four countries, it is a once-only training. The duration of the training varies from 3 to 4 h to 6–8 h. The age of schoolchildren who receive the training varies from 7 to 15 years. A standardised curriculum and a standardised package of education material are used in only one country. No country provides standardised certificates. The instructor/participant ratio varies both within and across countries from 1 per 10 to 1 per 25 participants. The instructors are schoolteachers in two countries, who may or may not have followed a proper postgraduate course for schoolteachers. In the other two countries, the instructors range from qualified rescue instructors to unqualified self-educated individuals [44]. It is obvious that there is no standardisation in how CPR is taught to schoolchildren – there is significant variability in practice across Europe. Plant et al. [42] show that a range of strategies could be effective, although standardisation would help with larger-scale evaluation of effectiveness. The challenge is to ensure that widespread training of some description now occurs and this is the basis behind the ‘Children Saving Lives’ project that the ERC is coordinating. In December 2011, the ERC (Project Coordinator) launched the idea for a Comenius proposal and application: ‘Children Saving Lives’. The idea is to draw on exchange of best practice and to promote transfer of innovation among its members to develop course material for 12–14-year-olds on how to perform CPR and how to use an AED. Close co-operation with professionals (teachers) working in
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schools across Europe is considered essential. From the beginning, it was clear that the major outcome of the project would be twofold: a train-the-trainers programme (online) and the course material for the specific target group of schoolchildren. As mentioned previously, only four out of 23 countries surveyed [44] include training in CPR skills in their primary/secondary school curriculum. The survey results further illustrate that when training CPR and the use of an AED are optional, the motivation to effectively organise the course drops dramatically because of several obstacles: teachers claim that curricula are too packed already, existing programmes often lack structure, the cost of AED is prohibitive and there is low public availability of AEDs in certain member states. All of these elements/challenges were taken into account by the ERC when developing the Children Saving Lives project. The ERC, as a network for NRCs, is in an excellent position to coordinate the project and to safeguard its sustainability in the long run. The project outcome will indeed be disseminated among a wide network of contacts in the sector. Major dissemination channels are the ERC Official Journal, the ERC website and the many events that are organised by the association. There is a standardised logo that will be used every year and a different one for each year according to that year’s theme. The ERC has prepared a promotional marketing package including a poster, press release and a flyer about how to perform CPR with special illustrations for children. All of these materials will be translated by NRCs into national languages. To spread the word of this year’s ECAAD, other relevant organisations have joined forces with ERC. These are the European Society of Cardiology (ESC), European Society of Intensive Care Medicine (ESICM), European Society of Emergency Medicine (EUSEN), European Society of Anaesthesiology (ESA) and Red Cross. To promote the day and increase public awareness, messages have been sent to NRCs. In addition, the power of the Internet and social media will be fully utilised. The ERC is also planning an important central event in the EU Parliament in Brussels, which will include lectures and demonstrations about how to deal with OHCA. Conclusion The ERC’s primary policy goal is to inform the public that many lives can be saved with resuscitation. It is essential to be aware that we can “prevent death from cardiac arrest due to CVD or any other aetiology by making high-quality resuscitation available to all”. This is indeed in line with ERC’s mission statement. Unfortunately, the EU cannot issue any regulations on how member states should deliver health services. Nonetheless, the matter of making high-quality resuscitation available to all can be addressed through the EU health and safety policy and patients’ rights. This pathway can be followed to promote and develop directives in line with the EU baseline that all citizens should have equal opportunities, to have access to high-quality resuscitation. Assistance in reaching this goal might come through forging alliances with organisations already heavily involved in the EU health policy-making process and which are respected as representative stakeholders by EU officials. As such, the ERC realises it has to make European policy makers more sensitive to the issue of cardiac arrest and other related issues. It is important to join forces with other relevant European scientific bodies such as ESC, ESA, EuSEM and ESICM, in order to jointly fight the burden of cardiac arrest and participate in collaborations such as the European Health Forum, European Heart Network, MEP Heart Group, the European Public Health Alliance, etc. The ERC, by setting up an ECAAD, is stimulating awareness and anticipates increasing the rate of bystander CPR and hence the rate of survival from OHCA. We would like to promote a formal question from the EU towards all the member states asking them to provide figures on cardiac arrests (annual report). In addition, we feel that further research is essential and needs to be focussed on early recognition, early CPR and addressing the reasons for low bystander CPR rates. In summary, we believe that the most effective weapons to fight the burden of cardiac arrest are to consider cardiac arrest as a priority for Europe, the uniformity of education and reporting and management of implementation through European legislations and regulations. Last but not the least is training of schoolchildren, which seems to be a promising approach in changing behaviour and educating the rescuers of tomorrow. We should believe that “small hands can do big things”.
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