MandatoryCPR training for students may improvecardiac-arrest survival rate, MDs say

John Lyttle

\ niandatorvy cardiOpLlmtonaryr-e->;tsusctation (CPR) programn that

star1-tedl as a pilot project in Ottawva-

area h1i"h schools is expanding" to

other Canadian schools. Besides(AR1Z tcc hui1i(ltics, rade () stutnili ts

a1 1 C it)t I 11 ttIuLhrfit about hC;1e l th

;cstvles and bo t Ireco nlize Car-

dli8c arrest. phnergencIIs(cian

Justin \laloney thile prlgram splrinllc ipilal archiltect, b)elieves tliat n

decade t.his vnandatory trainilng will

tranI]slate into itncr-easecl bystander-

initiated CPR an.d imii.pro1ved chan1cesOt survival. for victilmls of Cardiac ar-

'CeSt.

anadian high school studentsare being trained to recognize

and respond to cardiac arrest, thanksto a new mandatory cardiopul-monary resuscitation (CPR) pro-

gram. What started as a pilot projectin Grade 9 physical-educationclasses in the Ottawa area is nowcatching on at schools across thecountry.The project began in 1994, soon

after Ottawa emergency physicianJustin Maloney and the AdvancedCoronary Treatment (ACT) Foun-dation of Canada began explaining

1n programme (l igatire de i-

n1ahtion1 carldiorespiratoire (RNC`R)Ilanc conine projet pilote dians (Its

ecoles secondaires (Ic ia retgion (1'()t-tawa sc propage (lans tout Ic pavs.Outrc les teclhn1iqueCs de RCR.cnse;figne miaix &lees e 2lannee unI

1miodc (ec viC Saill et onI leir app)renda reconnaitre XIarre-t CardiliauC.JUStinl one0C , ICIeI.C i11 llruen tistc

LI'i CSt IC I ncipal arlchitecte du pro-grammne, est davis quje dlans unie (Ic

cenlllle. cettc formation oblh)atilrtcse traduirai)ar une aumC entation desInterventions (dI RCR par des spec-

tateLIrs et ain6liorera les chalianices (IC

survic (des victimes (IXarret cardiaqu1.

to school boards and taxpayers thatCPR training should be compulsoryfor all students.

"This is part of our culture now,"said Maloney, medical director ofthe Base Hospital Program at theOttawa General Hospital. "CPRshouldn't be taught as an after-hoursor weekend [program] any longer. Itshould be nailed right into the heartof the curriculum."

Sandra Clarke, executive directorof the ACT Foundation, said the six

school boards in the Ottawa area

and community groups got behindthe project quickly because Ot-tawa-Carleton had already devel-oped a "chain of survival" whoseonly weak link was a lack of early-

stage CPR. The region had a 911emergency telephone system, andarea firefighters and ambulance at-

tendants were equipped and trainedto use automated external defibrilla-tors. As well, a paramedic program

approved in 1994 by the OntarioMinistry of Health was being intro-duced.

While these systems will help car-

diac-arrest patients, Maloney saidthey will not be enough to raise theoverall survival rate. Only 10% oflocal residents who experience pre-

hospital cardiac arrest have CPRperformed on them, said Maloney,"and that's not nearly good enough."Seattle, for instance, has about dou-ble that percentage.

In 1992 Maloney and seven coau-

thors published a study identifyingfactors that predict survival of out-of-hospital cardiac-arrest patients(Cardiac arrest in Ontario: circum-stances, community response, role ofprehospital defibrillation and predic-tors of survival. Can Med Assoc1992; 147:191-98). It determinedthat "the chances of survival in-creased by a factor of 10.8 whenCPR was started by a bystander and3.4 when CPR was started by a fire-fighter or police officer."The study concluded that defib-

rillators alone could not increasethe survival rate, which stood at2.5%. "To improve survival ratesafter cardiac arrest, ambulance re-

sponse times must be reduced and

1172 CAN MED ASSOC J * 15 OCT. 1996; 155 (8)

John Lyttle is a freelance writer living in Ottawa.

© 1996 John Lyttle

the frequency of bystander-initi-ated CPR increased. Once thesechanges are in place a beneficial ef-fect from advanced manoeuvres

such as prehospital defibrillationmay be seen."

It seems the latter change is nowoccurring. Maloney and Clarke say

they are delighted by how readilyschool boards accepted the idea ofmandatory CPR training. "It was re-

ally a surprise to see such as positiveresponse from the school boards,which I had always imagined to befairly bureaucratic," Maloney said.The Ottawa Roman Catholic

Separate School Board arranged forthe tendering to supply mannequins,and course evaluations. The Car-leton Roman Catholic SeparateSchool Board prepared a unit out-

line for all boards and has been try-ing to arrange mass cleaning ofmannequins. Meanwhile, the Car-leton Board of Education has of-fered to print certificates for stu-

dents.Support from the private sector

was also crucial. The ACT Founda-tion receives no government funds,but has sponsorship from five Cana-dian pharmaceutical companies: As-tra Pharma, Marion Merrell Dow,Merck Frosst, Parke-Davis andSchering. Two local newspapers, theOttawa Citizen and Le Droit, printedthe student manual Maloney hadwritten, and the Kiwanis Club ofOttawa donated 800 mannequins to

ensure that every student could pro-vide hands-on training.When the pilot project was get-

ting on its feet in 1994, CatherineGelowsky wrote to the ACT Foun-dation and express expressed thefeelings of many parents: "It wouldbe the best thing in the world to

have this as a subject in our highschools. We have three high schoolsin Kanata [an Ottawa suburb] andno hospital. As I have two teenagers

and also have a medical problem, itwould be great for them as well as

myself to have them learn such a

life-saving technique."Grade 9 was chosen because it is

the last year for mandatory healthand physical-education classes inOntario. Experience the previousyear with a small mandatory CPRprogram in Prince Edward Islandhad convinced the ACT Foundationthat students in their mid-teens weremature enough to learn lifesavingskills.Not only does the school-based

approach give the community a

sense of ownership and a vested in-terest in the training, said Maloney,but having CPR taught by class-room teachers also gives the pro-

gram an air of permanence. "Thesepeople are teaching this just likethey're teaching history and geog-

raphy."Schools tailor the program to

meet their needs, Clarke added.Some teachers add infant-rescueskills, and others ask CPR-trainedparents to get involved.

Other communities are now

adopting the pilot project. Montrealand Ontario's Peel region will be thenext communities to institutemandatory training, and Vancouvermay not be far behind.

Dr. Pierre Frechette, medicalconsultant to the Quebec Ministryof Health, thinks CPR training inschools is an essential initiative.

Courses began in three of Mon-treal's eight school boards this fall,and the ACT Foundation hopes theremaining five boards will be in-volved by the beginning of the1997-98 school year. "I expect it willhave a beneficial effect on the rest ofthe province when it is known in the

CAN MED ASSOC J* OCT. 15,1996; 155 (8) 1173

Students practise on mannequins at an Ottawa-area high school

media that Montreal is starting sucha program," Frechette added.

Since teachers already face a

heavy workload, some may be leerythat the new program will make ex-

cessive demands on their time, butFrechette believes the ACT Founda-tion is doing a good job allayingthose fears.

In the evaluation of the 1994-95pilot project, 23 of 24 teachers saidCPR training should be mandatoryfor students. Scheduling adequatetime seemed to raise the most prob-lems: teachers felt a half-day was not

sufficient to teach the course, buthaving two half-day sessions al-though good for students was

hard on staff. With a year's experi-ence behind them, the teachers havefound that 4 hours' training is suffi-cient, Clarke said, and familiaritywith the material has made thetraining routine smoother.

Feedback from students has beenpositive. In the 1994-95 evaluation,about 80% of the 560 student re-

spondents said the class was easy to

understand. "I think it should betaught in every school," said one

Grade 9 student.Another commented: "I've always

wanted to learn CPR but I never gotaround to it, so teaching it in theregular program was a great idea."

In Brampton, just west ofToronto, Dr. Peter Cole is enthusi-astic about the program that was

starting there this fall. Cole, medicalofficer of health for the RegionalMunicipality of Peel, felt some anxi-ety when he first heard of the train-

ing project because there is no guar-

antee that students will retain theskill or take refresher courses. "Sub-sequently, I was convinced thatsomething is better than nothing."Even if their resuscitation tech-niques deteriorate, the training maystill help students recognize thesigns of cardiac arrest and cause

them to seek immediate medicalhelp instead of panicking.

Maloney said there is more to thecourse than "puffing and pumping."The program also identifies heart

disease as the country's number-onekiller and encourages discussion ofrelated lifestyle issues."We know that the retention of

skills is always called into question,"Maloney said. "Does that mean thatit's a bad thing? That you don't do it?I think the challenge was to intro-duce CPR as a life skill for students."

In the past CPR students per-

formed tests on elaborate man-

nequins and had to perform a per-

fect ratio of breaths to pumps. Todaythe training is less demanding butstill meets standards determined bycurrent research. "You still have tobe competent," said Maloney, butthe payoff with the more relaxedcourse is that "more people willwant to take it."

Dr. Jim Christenson hopes Van-couver students will be given thetraining too. As director of researchin the Department of EmergencyMedicine at St. Paul's Hospital, hehas been working with other BCdoctors to launch the program on

the West Coast."The concept that it will make a

difference that it's not futile - isimportant," Christenson said. "Whatit's saying to kids is we all have a re-

sponsibility to other people in soci-ety. One of our responsibilities is to

help other people in a crisis."Vancouver doesn't have a target

date for mandatory CPR training,but Christenson and Clarke believethe successes in other cities willtranslate into nationwide acceptance.The future looks much brighter

than the past, said Maloney. In 1991he spoke to a group of CPR instruc-tors about the challenges facingCPR training in Ontario. "At thetalk, I gave handouts that illustratedthe problem. I had given a very simi-lar talk 10 years earlier, and thesewere the same handouts, unchanged.In 10 years, we had made no

progress."Now that CPR training has

started in schools, he thinks the fu-ture looks bright. "After the first 10years, I think we'll be able to lookback and see a huge change." -

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