Author + information
- Received July 21, 2017
- Revision received September 26, 2017
- Accepted September 27, 2017
- Published online November 20, 2017.
- aDivision of Cardiology, University of Louisville School of Medicine, Louisville, Kentucky
- bUniversity of Louisville School of Medicine, Louisville, Kentucky
- cDivision of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- ↵∗Address for correspondence:
Dr. Lorrel E. Brown, Division of Cardiovascular Medicine, University of Louisville School of Medicine, 201 Abraham Flexner Way, Suite 600, Louisville, Kentucky 40202.
Cardiopulmonary resuscitation (CPR) training in high schools is required by law in the majority of U.S. states. However, laws differ from state to state, and it is unknown how this legislation is being enacted. The authors sent a cross-sectional, closed survey to educational superintendents in 32 states with CPR laws in June 2016. The authors subsequently performed direct examination and categorization of CPR legislation in 39 states (several states passed legislation as of September 2017). Survey results indicated differing practices with regard to CPR instruction in areas such as course content (63% perform automated external defibrillator training), instructor (47% used CPR-certified teachers/coaches, 30% used other CPR-certified instructors, 11% used noncertified teachers/coaches), and method (7% followed American Red Cross methods, 55% followed American Heart Association methods). CPR laws differ, although almost all (97%) require hands-on training. Although hands-on practice during CPR instruction in high school is required by law in the majority of U.S. states, there is currently no standardized method of implementation.
Out-of-hospital cardiac arrest (OHCA) affects more than 350,000 people each year in the United States (1). Although bystander cardiopulmonary resuscitation (CPR) improves survival from OHCA (2), there are striking geographic variations in rates of bystander CPR (10% to 65%) and survival (3% to 22%) from OHCA (3,4). The disparate survival rates from OHCA based upon geography was deemed “unacceptable” in a recent report from the Institute of Medicine, which also called for strategic efforts to “educate the public in CPR” (5). Previous CPR training increases bystanders’ confidence and willingness to perform CPR (5). However, only a small proportion of the U.S. population (2.4%) is trained in CPR annually (6).
High school students may be an excellent target population for CPR training (7,8). The Institute of Medicine concluded that because “schools provide large-scale, centrally organized settings to which all children…have access, school-based interventions can be used to…boost responses to cardiac arrest, and ultimately improve survival and cardiac arrest outcomes” (5). Over 16 million students are enrolled in public and private secondary schools in the United States (Online Appendix 1a), representing a large audience for CPR training. Multiple organizations have endorsed CPR training in schools, including World Health Organization, the International Liaison Committee on Resuscitation, American Heart Association (AHA), American Academy of Pediatrics, the National Association of School Nurses, and the State Directors of Health, Physical Education, and Recreation (9–11). A growing number of state legislatures have passed laws requiring high school students to participate in CPR training prior to graduation (12,13). However, laws and requirements differ by state; it is unknown how CPR training is being implemented in schools across the nation.
In June of 2016, we identified 32 states with CPR laws through AHA “CPR in Schools” website (12). We performed an online search of state educational websites and identified superintendents in each of these states. We sent each superintendent an email communication that included a link to our online survey (SurveyMonkey, Palo Alto, California). We asked superintendents to either: 1) forward the email/link to district superintendents who would then forward to individual schools; or 2) provide a list of district superintendent emails for our direct communication. Reminder emails were sent approximately 1 and 3 months after initial contact. In the second round of communication, we attempted to identify district-level superintendents by using an online search (state educational websites) and communicated directly with them when possible. In the third round of communication, we attempted to identify and communicate with individual school principals. In instances when we were able to establish contact with either district-level or school-level officials, we had greater success with distributing surveys to individual schools. Several state and district superintendents did not respond to our repeated attempts at communication. All attempted communication was by email, and the authors acted independently without assistance from AHA or the American Red Cross (ARC). Of note, the website misidentified Maine as having no CPR law, although subsequent review identified a law passed in 2015 (13). Maine was unintentionally omitted from our survey due to its misidentification on the “CPR in Schools” website.
The online closed survey consisted of 12 questions that included demographics and current status of CPR training (Online Appendix 2). This survey was developed by modifying previously published surveys from Iowa and Washington states (14,15). All questionnaire items were mandatory except for type of manikin used, as we believed educators (particularly principals) were unlikely to know the answer to this question. Free text fields were provided for comments. Respondents were able to review answers prior to submission. Because the link was sent by forwarded email, we did not limit to 1 response per link; however, no entries were duplicated. Participants were informed that completion of the survey indicated consent to participate. This study was deemed exempt by the Institutional Review Board of University of Louisville and granted a waiver of informed consent (16.0548). All answers were confidential, identifiable only by school name, and analyzed in aggregate. Survey answers were kept electronically on a password-protected device.
The number and enrollment of public and private secondary schools by state were accessed from published statistics by using the National Center for Education Statistics (Online Appendix 1a to 1e). We used online data to classify schools as public or private. To generate urban/rural designations, schools were organized by zip code and matched with a corresponding Federal Information Processing Standard (FIPS) code. Responses were then sorted by using an Urban-Rural classification scheme generated by the 2013 National Center for Health Statistics report (Online Appendix 1f).
In September 2017, we identified 39 states with laws requiring CPR training in high school by using AHA’s CPR in Schools (12) and “School CPR” websites (13). Several additional states had passed legislation since the time of survey in June 2016. We directly examined, categorized, and compared legislative language (Online Appendix 1g) according to the following requirements: class specified for CPR training, instructor certification required, automated external defibrillator (AED) instruction, CPR training program recommended/required, hands-on practice required, and state funding availability.
All data were analyzed using SurveyMonkey or Excel software (Microsoft, Redmond, Washington). Descriptive statistics were used to describe sample characteristics and survey variables. Frequencies and percentages were used to describe categorical variables.
CPR implementation survey
Of 25,694 eligible high schools in 32 states (Online Appendix 1b and 1e), 424 (1.7%) completed the survey. Not all participants answered all questions. These 424 schools represent more than 348,000 students (missing data: 2.6%; n = 11 of 424 schools). Of participating schools, 96% (n = 406 of 424 schools) were public and 3% (n = 12 of 424 schools) were private (missing data: 1%; n = 6 of 424 schools); 53% (n = 226 of 424 schools) were urban and 44% (n = 185 of 424 schools) were rural (missing data: 3%; n =13 of 424 schools) (Table 1). Responses came from 12 of the 32 states contacted (Figure 1). The response rate among eligible schools varied from 15.8% in Iowa to 1% in Delaware. Highest response rates tended to be in states where individual principals were contacted directly. We received no response from schools in 20 states despite multiple attempts. Responses were similar between schools that responded early (after first contact, August to September 2016) versus those who responded late (after multiple contacts, October to December 2016). The primary differences were in grade taught and during which school activity (81.3% of schools in the early responder group teach CPR during health class, compared to 55.1% in the late-responder group).
Although all surveyed schools were located in states with laws requiring CPR training in high school, only 77% (n = 328 of 424 schools) of respondents indicated that CPR training was provided at their schools. Several of the participating states (e.g., Kentucky and Missouri) had passed CPR laws only within the previous year (12). Many schools in these states commented that they are in the process of creating programs in response to the new laws. Schools indicating they do not have a CPR program were located in all responding states, except for Delaware.
Results were pooled for all responding schools. The majority of schools provide CPR training during regular school hours (97%; n = 301 of 310 schools). CPR training is provided at a variety of grade levels, most commonly ninth (37%; n = 115 of 310 schools) and 10th (27%, n = 85 of 310 schools) grades (Figure 2A). For schools providing training during school hours, most use health class (70%; n = 209 of 298 schools) (Figure 2B). Some respondents (n = 6) from Iowa indicated that 12th grade students were trained in CPR during the time when the underclassmen were taking state-wide mandatory tests. Most commonly, a CPR-certified teacher/coach (47%; n = 138 of 296 schools) or other CPR-certified instructor (30%; n = 88 of 296 schools) led the training. However, 11% (n = 33 of 296) of schools reported using a noncertified teacher/coach (Figure 2C). Most responding schools used a method that incorporated hands-on CPR practice (96%; n = 283 of 296 schools), including an ARC course (7%; n = 20 of 296 schools) or any of a number of AHA courses (55%; n = 163 of 296 schools) (Figure 2D). A small proportion of schools did not incorporate hands-on practice (3%; n = 8 of 296 schools). Noninflatable manikins were used by 64% (n = 188 of 294) of responding schools. AED training was conducted in 63% (n = 240 of 379 schools) of responding schools. Within states for which more than 1 school responded, there was variation in all reported items (Online Table S1).
The Central Illustration demonstrates differences in CPR requirements by U.S. state. Of the 39 states with legislation requiring CPR training in high schools as of September 2017, only 1 state did not require hands-on training (Figure 3A). The majority of laws (89%; n = 35 of 39 states) required a nationally recognized training method (AHA, ARC, or other), 8% (n = 3 of 39 states) did not specify training method, and 1 state required full CPR certification (Figure 3B). AED training was required in 77% (n = 30 of 39) of states (Figure 3C). Only 8% (n = 3 of 39) of states required the instructor to be certified to teach CPR (Figure 3D). Approximately three-quarters (75%; n = 29 of 39) of state laws specified that training should be performed during a specific class (most often health class) (Figure 3E). Table 2 presents a summary of state laws.
Although legislation requiring CPR training in high school is becoming increasingly common, there is variability between laws and their implementation. The AHA recommendation for CPR training in schools is descriptive rather than prescriptive. It emphasizes: 1) recognition of need to initiate CPR; 2) hands-on training/practice of CPR skills; and 3) awareness of the purpose of the AED (9). When we examined the 39 laws at the time of this analysis, the AHA recommendation for requiring hands-on training was present in almost all state laws. Hands-on training is vital to the acquisition of CPR skills; therefore, it is appropriate that state laws reflect this requirement. Most states require a CPR training method from a nationally recognized program, most commonly the AHA or the ARC. However, there are several different training programs from these organizations, all of which differ in length. State laws do not specify requirements for course duration. Moreover, 10% of states do not specify the type of training program, and only 8% of states require the instructor be certified to teach CPR. This degree of flexibility may be beneficial in allowing individual schools to fulfill the requirement within their local financial, administrative, and educational context. There has been concern raised about the financial burden of imposing an unfunded mandate on schools (5,14–16). The lack of specificity in laws may allow financial flexibility. However, this lack of specification regarding training program content and duration also leads to substantial variability in implementation, as demonstrated by the results of our survey.
Surveyed schools reported variation in all items, even within a single state. There was striking variability in who performs the training and use of what method. There is much debate about efficacy, efficiency, and durability of CPR training. As no gold standard currently exists, it is not surprising that no standard method is being used in high schools. It is noteworthy that only 8% of state laws require the instructor to be certified to teach CPR, raising questions as to the quality of CPR teaching.
A large degree of heterogeneity exists in current implementation of CPR legislation. This heterogeneity may be explained by a number of factors. Resources (including financial, CPR-trained personnel, and available time in the high school curriculum) differ by region and by school. No gold standard method for teaching CPR currently exists, and therefore, a variety of methods are used in high schools in response to CPR laws.
Although it is clear that high-quality CPR improves survival following cardiac arrest (2), it remains unclear how best to train the public, including high school students, for longitudinal skill retention. Not all CPR training is equivalent; however, any form of training is likely superior to no training. We calculated that 81.8% of U.S. 12th grade students live in states that require CPR training (Online Appendix 1e and 1f). Therefore, every year nearly 700,000 high school students will graduate without CPR training due to lack of legislation. This represents a missed opportunity to equip our population with this crucial skill.
Previous CPR training is the single most powerful factor contributing to performance of bystander CPR (17). Furthermore, early CPR training contributes to better skill retention in subsequent training (18). School CPR training has contributed to increased community rates of bystander CPR in Norway (19), Denmark (20), and Minnesota (21). From these locations we learned that implementing CPR training in schools is most effective when it is undertaken as a societal responsibility, rather than the responsibility of the medical profession. Future studies are required to evaluate whether CPR in schools legislation leads to an increase in the rate of bystander CPR in the United States.
Thanks to CPR legislation, high school students represent the largest group of people receiving CPR training in the United States today. However, CPR legislation varies from state to state, and there is no standard method of implementation. Further studies are necessary to elucidate the most effective teaching method that leads to long-term CPR skill retention, which would allow for standardization of CPR training in U.S. high schools.
First, overall survey response rate was low. We did not liaise with organizations such as AHA or ARC; collaboration with such organizations might have increased our survey response rate. However, responding schools represent geographically diverse locations throughout the United States (Figure 1). Responding schools were located in states with a range of time since passage of CPR laws: >5 years in Iowa; 3 to 5 years in Rhode Island and Vermont; 1 to 3 years in Delaware, Indiana, Minnesota, New Jersey, Washington, and West Virginia; and <1 year in Kentucky, Missouri, and Wisconsin (12). Therefore, this sample represents a diverse range of schools both geographically and with regard to timing of CPR legislation. Second, responding schools might have been self-selected for those that have interest in CPR training compared to nonresponding schools. However, responses were similar from early compared to late-responding schools, arguing against this self-selection bias. The marked variability in reported teaching methods suggests that at least this degree of heterogeneity exists across the nation.
Although CPR instruction in high school is required by law in a growing number of U.S. states, there is currently no standardized method of implementation, particularly with regard to content, instructor, and duration of CPR instruction. In alignment with the AHA recommendation, hands-on practice is required by most state laws and implemented in most schools responding to this survey. Thanks to advocacy efforts leading to state legislation, a growing number of students in the United States are receiving CPR training. However, we have yet to establish a standard for CPR instruction that is effective, efficient, financially feasible and leads to increased nationwide rates of bystander CPR and survival following OHCA.
Dr. Halperin is a consultant for and has received research funding from Zoll. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- automated external defibrillator
- cardiopulmonary resuscitation
- out-of-hospital cardiac arrest
- Received July 21, 2017.
- Revision received September 26, 2017.
- Accepted September 27, 2017.
- 2017 American College of Cardiology Foundation
- Mozaffarian D.,
- Benjamin E.J.,
- et al.
- Sasson C.,
- Rogers M.A.,
- Dahl J.,
- Kellermann A.L.
- Girotra S.,
- van Diepen S.,
- Nallamothu B.K.,
- et al.
- Sasson C.,
- Meischke H.,
- Abella B.S.,
- et al.
- ↵Institute of Medicine. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Washington, DC: The National Academies Press. 2015.
- Cave D.M.,
- Aufderheide T.P.,
- Beeson J.,
- et al.
- Bottiger B.W.,
- Van Aken H.
- ↵American Heart Association. CPR in schools. Available at: http://cpr.heart.org/AHAECC/CPRAndECC/Programs/CPRInSchools/UCM_475820_CPR-in-Schools-Legislation-Map.jsp. Accessed June 10, 2016.
- ↵Pro Trainings, LLC. United States high school cpr map. Available at https://schoolcpr.com/about/states-where-cpr-training-is-mandatory-for-high-school-graduation. Accessed September 10, 2017.
- Hoyme D.B.,
- Atkins D.L.
- Salvatierra G.G.,
- Palazzo S.J.,
- Emery A.