BLS for High School

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INTERNATIONAL NURSING

EVALUATION OF GREEK HIGH SCHOOL TEACHERS’ KNOWLEDGE IN BASIC LIFE SUPPORT, AUTOMATED EXTERNAL DEFIBRILLATION, AND FOREIGN BODY AIRWAY OBSTRUCTION: IMPLICATIONS FOR NURSING INTERVENTIONS
Authors: Anastasia Patsaki, RN, MSc, Ioannis Pantazopoulos, MSc, Ismene Dontas, PhD, Christina Passali, RN, MSc, Lila Papadimitriou, PhD, and Theodoros Xanthos, PhD, Athens, Greece Section Editors: Pat Clutter, RN, MEd, CEN, FAEN, and Carole Rush, RN, MEd, CEN, FAEN

Introduction: The aim of this study was to evaluate the theoretic knowledge of high school teachers regarding cardiopulmonary resuscitation, automated external defibrillation, and foreign body airway obstruction. Methods: Three hundred ten respondents were tested prospectively by use of a scoring system. Data were obtained by use of a questionnaire that included 24 questions. Data were collected between April 9 and June 16, 2009. Results: Only 21.03% of the teachers had ever participated in life support courses, and most of them did not possess adequate theoretic knowledge in the management of adult cardiac arrest or foreign body airway obstruction. As the age of the teachers increases, the ratio of correct answers decreases. Life support course attendance has a positive effect on their theoretic knowledge. The majority of the teachers would welcome an emergency nurse to educate them and

their students on basic life support and foreign body airway obstruction.
Discussion: This study shows that most of the respondents had a mediocre level of knowledge in basic life support, automated external defibrillation, and foreign body airway obstruction. Given that emergency nurses regularly practice resuscitation in the emergency department in which they are working, they have the motivation to be kept updated with the current guidelines on resuscitation, because guidelines on resuscitation are revised every 5 years. Teachers, on the other hand, are less motivated to be kept updated; thus emergency nurses may be the key component in educating teachers and school students. Therefore we believe that emergency nurses should take on the responsibility and act as school educators regarding cardiopulmonary resuscitation. Key words: Teachers; Cardiopulmonary resuscitation; Airway obstruction; Basic life support; Automatic external defibrillator

lthough approximately 1 million cardiac arrests occur every year in the United States and Europe, cardiac arrest remains a clinical condition that is still characterized by poor prognosis.1 One possible explanation may be the fact that although 70% of cardiac arrests take

A

place in out-of-hospital settings, the majority of the patients do not receive basic life support (BLS) before the arrival of EMS.2 Survival of out-of-hospital cardiac arrest patients strongly depends on prompt cardiopulmonary resuscitation (CPR) by lay rescuers.3 Survival rates will only improve if
Theodoros Xanthos is Medical Doctor, Department of Anatomy, University of Athens Medical School, Athens, Greece. For correspondence, write: Theodoros Xanthos, PhD, Department of Experimental Surgery and Surgical Research, University of Athens Medical School, 15B Agiou Thoma St, 11527, Athens, Greece; E-mail: [email protected]. J Emerg Nurs 2012;38:176-81. Available online 20 October 2010. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.09.002

Anastasia Patsaki is Registered Nurse, Coronary Care Unit, “Red Cross” Hospital, Athens, Greece. Ioannis Pantazopoulos is Medical Doctor, 12th Department of Respiratory Medicine, Sotiria General Hospital, Athens, Greece. Ismene Dontas is Veterinarian, Department of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens, Greece. Christina Passali is Registered Nurse, Catheterization Laboratory, “Thriassion” Hospital, Athens, Greece. Lila Papadimitriou is Medical Doctor, Department of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens, Greece.

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the delay time until the initiation of CPR is kept to an absolute minimum.4 Thus, to maximize the number of persons with cardiac arrest receiving prompt CPR by bystanders, a large proportion of the population needs to be trained.5 The American Heart Association suggests that morbidity and mortality rates in out-of-hospital cardiac arrest patients could be significantly decreased if 20% of the population were able to perform CPR.6 Therefore the European Resuscitation Council recommended that BLS should be included in the school curriculum and school teachers should be trained to teach BLS, because they have the time to impart CPR knowledge and skills to school children.7 Training all school children in CPR could ultimately ensure reaching the whole population.8 Moreover, life-threatening emergencies can happen at any school anytime. These can be the result of pre-existing health problems, violence, unintentional injuries, natural disasters, or toxins. Teachers are often the first aid providers and should be prepared to deal with such emergencies.9 This prospective study was performed to evaluate the theoretic knowledge of Greek high school teachers regarding BLS, automatic external defibrillator (AED), and foreign body airway obstruction (FBAO).
Methods

According to data obtained from the Ministry of Education, 3087 high school teachers work in Athens, Greece. Thus 10% of this population would be statistically representative. A stratified sampling method was used to randomly obtain 400 subjects. Finally, 310 completed the questionnaire (response rate, 77.5%). The purpose of the study was explained to the head teachers to acquire their permission to carry out the study. Any feeling of obligation to join our study was minimized by assuring the teachers that participation was voluntary and that they were free to withdraw any time they wanted. The 15 theoretic knowledge questions included in the questionnaire were derived from the 2005 guidelines on adult BLS/AED and FBAO that were produced by the International Liaison Committee on Resuscitation in collaboration with the American Heart Association and the European Resuscitation Council. Each question was followed by 3 possible answers, 1 of which was correct. Experts on resuscitation were consulted for advice. All questions were prepared by the authors. The survey was piloted in a group of 10 BLS-AED course directors from various training centers in Athens. The few questions that were not clear to the pilot participants were rephrased to achieve clarity. Pilot interviews were performed among 50 teachers to test the wording and clarity of the questions. Pilot questionnaires were also sent to 3 local CPR experts, all professors at

the University of Athens, to assess questionnaire validity using Likert scaling. After the pilot stage, the questionnaire and the interview instructions were modified and standardized. By use of a test-retest procedure, the questionnaire reliability was assessed. Ten percent of the previously surveyed respondents were randomly selected for re-interview 1 week later. The mean level of answer agreement was 92% between the 2 sets of results (range, 80%-100%; SD, 7%). All questionnaires were distributed along with an explanatory cover letter providing instructions on completing the questionnaire. Data were collected by the principal investigator between April 9 and June 16, 2009. To evaluate the level of knowledge, a scoring system was created. One point was allocated to each correct answer in the 15 theoretic knowledge questions, with no negative marking. When up to 5 correct answers were given, the level of knowledge was rated insufficient, whereas with 6 to 10 correct answers, the level of knowledge was considered to be mediocre. When 11 to 15 correct answers were given, the level of knowledge was rated as exceptional. The questionnaire consisted of 4 distinct parts: (1) 5 demographic questions (age, sex, working experience in years, work in public or privately owned schools, and previous resuscitation training); (2) 2 resuscitation experience questions, which surveyed the respondents’ experience in managing a cardiac arrest or an FBAO patient; (3) 1 question investigating the reasons for school teachers’ unwillingness to attend CPR courses and 1 question on who should teach BLS/AED and FBAO management to teachers and school children; and (4) 15 theoretic knowledge questions, which surveyed familiarity with the current BLS-AED and FBAO guidelines (Appendix). These questions included issues regarding cardiac arrest recognition, safety, compression-ventilation ratio, compression frequency, EMS activation, electrode pad placement, safe delivery of a shock, and recognition of signs and symptoms of FBAO, as well as management of the FBAO patient until professional help arrives. Data were analyzed by use of SPSS software, version 17 for Windows (SPSS, Chicago, IL). We considered the difference to be statistically significant when the P value was < .05 for all analyses. χ2 Test and contingency coefficient test were used to determine relationships between responses in knowledge questions and the respondents’ demographic information.
Results

Demographic characteristics of the population are shown in Table 1. The mean number of correctly answered knowledge questions did not correlate significantly with age, sex, and place of work. A negative correlation between

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TABLE 1

Demographic characteristics of the population studied
Data

Sex Female Male Age 18-24 y 25-34 y 35-44 y 45-54 y ≥55 y Type of school Public Private BLS/AED course attendance Yes No Working experience (mean) (y)

67.18% 32.82% 5.13% 29.23% 38.46% 23.8% 4.10%
FIGURE

67.18% 32.31% 21.03% 78.97% 11.68

Level of theoretic knowledge in our study group.

years in practice and the correct answers given was recorded (P = .016, χ2 test). The participants who had attended a life support course in the past provided significantly more correct answers to the theoretic knowledge questions. More specifically, a positive correlation was observed in questions regarding cardiac arrest recognition (P = .013, contingency coefficient) as well as the interventions regarding checking for unresponsiveness (P = .043, contingency coefficient). The level of theoretic knowledge in the use of AED, CPR, and FBAO is shown in Figure 1. Most of the respondents could recognize a cardiac arrest patient, check the patient’s response, and activate EMS, but they could not provide BLS. Regarding AED, most of the respondents were aware that its use is necessary in cardiac arrest patients, but they were unaware of the safe use of the device. In addition, although all teachers were able to identify seizures as an indication of serious airway obstruction, they were unaware of the management of the FBAO patient. The percentages of correct and incorrect answers to all theoretic knowledge questions are shown in Table 2. Previous resuscitation experience in dealing with a cardiac arrest or with an FBAO patient is shown in Table 3. Previous experience with cardiac arrest patients or FBAO management did not correlate significantly with the number of correct answers given. Seventy-nine percent of the teachers had never taken part in a life support course. When the subjects were asked

to identify the major reasons for their unwillingness to attend life support courses, 40% reported that lack of spare time was an inhibitory factor whereas 27.18% were not informed about the date when or the place where these courses were being held. Other reasons included long waiting lists (3.59%) and cost (2.05%), and finally, 4.10% of subjects did not consider these courses to be essential for their education and everyday practice. However, 93% of the respondents believe that nurses should teach resuscitation skills to teachers and school students.
Discussion

There are many reasons to support the concept that high school teachers should learn CPR. School teachers, athletic trainers, coaches, and staff are responsible for the physical well-being of a large proportion of the nation’s children for many hours each day.10,11 Unfortunately, in Greece 95% of schools are without professional medical health faculty members, such as school nurses, and as a result, much of the responsibility for the physical care of the students during the typical school day rests with non-trained teachers, athletic trainers, and coaches.12 Cardiac arrest that occurs in children and adolescents may be caused by inherited or congenital cardiac conditions or by acute medical problems.9 Many of these conditions may not be detected during routine screening for school physicals or sport activities, so cardiac arrest may be the first sign of these problems.10 In addition, approximately half of cardiac arrests in schools are associated with physical exertion, sports participation, or other injuries related to trauma or airway obstruction.13 No matter what the cause of cardiac arrest is, rescue actions that include cardiac arrest recognition, EMS activation, and early CPR are absolutely necessary.10 These procedures are time dependent,14 and all schools must

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TABLE 2

Percentages of correct and incorrect answers in theoretical knowledge questions
Theoretical knowledge questions Correct answer (%) Incorrect answer (%)

Safety Recognition of cardiac arrest Check for responsiveness Chest compression–rescue breath ratio Airway management and assessment of breathing Correct information when calling 911 Chest compression ratio Rescue breath sufficiency Use of AED in cardiac arrest patients Safety when using AED Signs of severe FBAO Management of patient with mild airway obstruction Management of patient with good level of consciousness and severe obstruction Management of unresponsive patient with severe obstruction

18.79 58.46 51.79 11.79 65.13 73.33 7.18 37.44 86.15 23.59 58.46 36.92 44.62 43.59

81.03 41.54 48.21 88.21 34.87 26.67 92.82 62.56 13.85 76.41 41.54 63.08 55.38 56.41

TABLE 3

Respondents' experience in managing cardiac arrest or FBAO patient
No. of experiences % of respondents

Cardiac arrest 0 1 2 4 6 FBAO 0 1 2 3 4 5 7

97.79% 4.10% 3.08% 0.51% 0.51% 76.41% 11.28% 7.18% 2.05% 0.51% 1.54% 1.03%

have a plan to ensure that trained teachers can identify the emergency and act quickly so as to provide appropriate treatment within a few minutes.9 To our knowledge, this is the first study in Greece that evaluates the theoretic knowledge of school teachers in BLS/ AED and FBAO. Our study shows that teachers recognize a cardiac arrest or FBAO patient and call for help, but after-

ward, they do not know how to act. One reason may be that the rescuer fears that he or she may cause harm to the patient. Participants who had attended BLS/AED courses in the past performed better in the theoretical knowledge evaluation. Our study also showed that the teachers’ age correlates with the ratio of incorrect answers. This can be attributed to the fact that most of the teachers fail to update their first aid knowledge. Because theoretic knowledge and skill retention rapidly decline after BLS/AED courses, keeping up to date is necessary.15 Children, unlike adults, are an easily accessible population; are capable of learning CPR; and may be more interested in learning resuscitation skills.16 Moreover, younger populations are most likely to state that they would provide CPR.17 Efforts to train older adults in CPR have been discouraging.18 In addition to the direct training of school students, children are likely to discuss their training with siblings, friends, and family members, which may increase awareness of BLS and demand for traditional training courses.7 Several societies and organizations have recommended that BLS should be taught in schools. CPR training in schools started in Norway in the 1960s. Since then, it has sporadically been offered to students in Scandinavia, Great Britain, Spain, and the United States.16,19
Limitations

This study has several limitations. The participants constitute 10% of all high school teachers in Athens, so they may not reflect the entire population of all high school teachers of the capital city. Furthermore, self-reported data may

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produce bias, and some respondents may have given “expected” answers, although anonymity was kept. Furthermore, this study did not assess resuscitation skills in the study population.
Implications for Emergency Nurses

guidelines for resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 2005;67 (suppl 1):S7-S23. 3. 4. Roth R, Stewart RD, Rogers K, Cannon GM. Out-of-hospital cardiac arrest: Factors associated with survival. Ann Emerg Med. 1984;13:237-43. Uray T, Lunzer A, Ochsenhofer A, et al. Feasibility of life-supporting first-aid (LSFA) training as a mandatory subject in primary schools. Resuscitation. 2003;59:211-20. Xanthos T, Bassiakou E, Koudouna E, Papadimitriou L. Using the 30: 2 compression-ventilation ratio: five cycles is easier to follow than 2 min of cardiopulmonary resuscitation. Eur J Emerg Med. 2009;16: 339-41. Lester C, Donnelly P, Weston C, Morgan M. Teaching schoolchildren cardiopulmonary resuscitation. Resuscitation. 1996;31:33-8. Connolly M, Toner P, Connolly D, McCluskey DR. The ‘ABC for life’ programme—teaching basic life support in schools. Resuscitation. 2007; 72:270-9.

The presence of a school nurse in every developed society is considered to be indisputable and one of their most important roles is that of educators.20,21 Via teachers and students, the school nurse informs, educates, and enlightens not only the students themselves but also their families and, by extension, the whole community. For the success of this purpose, the sensitization of the teachers regarding first aid matters and the recognition of nursing service as an independent department on school grounds appear to be essential.9 To have healthy adults, education on health issues should start from an early age so that prevention and treatment can be effective.12 Moreover, in resuscitation training, the role of the emergency nurse is largely indisputable.22 Given that emergency nurses regularly practice resuscitation in the emergency department in which they are working, they have the motivation to be kept updated with the current guidelines on resuscitation, because guidelines on resuscitation are revised every 5 years. Teachers, on the other hand, are less motivated to be kept updated; thus emergency nurses may be the key component in educating teachers and school students. Therefore we believe that emergency nurses should take on the responsibility and act as school educators regarding CPR. By using the pyramidal system of CPR teaching and knowledge transfer, from emergency nurses to teachers and school children, over a period of 10 years, approximately 20% of the population would have acquired these life-saving skills.7
Conclusions

5.

6. 7.

8.

Lester CA, Weston CF, Donnelly PD, Assar D, Morgan MJ. The need for wider dissemination of CPR skills: are schools the answer? Resuscitation. 1994;28:233-7. 9. Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004;109:278-91. 10. Lotfi K, White L, Rea T, et al. Cardiac arrest in schools. Circulation. 2007;116:1374-9. 11. Andersen J, Courson RW, Kleiner DM, McLoda TA. National Athletic Trainers’ Association position statement: emergency planning in athletics. J Athl Train. 2002;37:99-104. 12. Gagliardi M, Neighbors M, Spears C, Byrd S, Snarr J. Emergencies in the school setting: are public school teachers adequately trained to respond? Prehosp Disaster Med. 1994;9:222-5. 13. Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333:337-42. 14. American Academy of Pediatrics. Guidelines for emergency medical care in school. Committee on School Health. Pediatrics. 2001;107:435-6. 15. Papadimitriou L, Xanthos T, Bassiakou E, Stroumpoulis K, Barouxis D, Iacovidou N. Distribution of pre-course BLS/AED manuals does not influence skill acquisition and retention in lay rescuers: a randomised study. Resuscitation. 2010;81:348-52. 16. Miró O, Jiménez-Fábrega X, Espigol G, et al. Teaching basic life support to 12-16 year olds in Barcelona schools: views of head teachers. Resuscitation. 2006;70:107-16. 17. Kelley J, Richman PB, Ewy GA, Clark L, Bulloch B, Bobrow BJ. Eighth grade students become proficient at CPR and use of an AED following a condensed training programme. Resuscitation. 2006;71:229-36. 18. Reder S, Quan L. Cardiopulmonary resuscitation training in Washington state public high schools. Resuscitation. 2003;56:283-8. 19. 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. 20. Başer M, Coban S, Taşci S, Sungur G, Bayat M. Evaluating first-aid knowledge and attitudes of a sample of Turkish primary school teachers. J Emerg Nurs. 2007;33:428-32.

Our study shows that high school teachers do not have sufficient first aid knowledge. The presence of an emergency nurse who will educate teachers and school children seems to be necessary. However, to ensure validity, these findings need to be reproduced in a larger study.
Acknowledgments
The authors are extremely grateful to Mrs Elia Delaporta for the linguistic editing of the manuscript.

REFERENCES
1. Demestiha TD, Pantazopoulos IN, Xanthos TT. Use of the impedance threshold device in cardiopulmonary resuscitation. World J Cardiol. 2010;2:19-26. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L, European Resuscitation Council. European Resuscitation Council

2.

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21. Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics. 2005;116:e738-45. 22. Chamberlain DA, Hazinski MF, European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, Resuscitation Council of Southern Africa, Australia and New Zealand Resuscitation Council, Consejo Latino-Americano de Resusucitación. Education in resuscitation: an ILCOR symposium: Utstein Abbey: Stavanger, Norway: June 22-24, 2001. Circulation. 2003;108:2575-94.

8. Under what circumstances would you use the AED? A. When someone is choking B. When someone is not breathing C. When someone is having an epileptic seizure 9. How can you verify that your rescue breaths are ventilating a cardiac arrest patient? A. By placing a mirror in front of the patient’s mouth B. By looking down at the patient’s chest to see if the chest is rising C. By verifying that no resistance is met during each rescue breath 10. Why should everybody stand clear when you press the AED shock button? A. So that the AED does an accurate reading B. So that no one else is shocked by mistake C. For the patient’s protection 11. Which of the following should be your first priority after the AED’s activation? A. Put the pads on the patient’s chest B. Shave the patient’s chest C. Ensure that nobody touches the patient while the AED is analyzing the rhythm 12. Which of the following indicates severe airway obstruction? A. Speech B. Cough C. Seizure 13. What should you do first if someone who is choking maintains his/her consciousness? A. Call 911 B. Encourage cough C. Give 5 back blows 14. What should your first priority be in a mild FBAO? A. Encourage cough B. Give 5 abdominal thrusts C. Give 5 back blows 15. What should you do first when a choking person becomes unresponsive? A. Call 911 B. Check the person’s mouth and remove anything you might see C. Give 30 chest compressions
Submissions to this column are encouraged and may be sent to Pat Clutter, RN, MEd, CEN, FAEN [email protected] or Carole Rush, RN, MEd, CEN, FAEN [email protected]

Appendix

Theoretic knowledge questions 1. Which of the following indicates that a person is in cardiac arrest: A. Difficulty in breathing B. Severe chest pain C. Absence of breathing 2. What should you do in order to check responsiveness? A. Call 911 and then await further instructions from the paramedics B. Shake the patient’s shoulders and ask if he/she is OK C. Switch the AED on and await further instructions from it 3. According to the 2005 guidelines on resuscitation, which is the ratio of chest compressions to rescue breaths? A. 5 chest compressions/2 rescue breaths B. 15 chest compressions/3 rescue breaths C. 30 chest compressions/2 rescue breaths 4. What is the first thing you should do if you find a person collapsed in the middle of the street? A. Open the patient’s airway, by using head tilt and chin lift B. Check for the person’s responsiveness C. Ensure your safety 5. What should you do when assessing a person’s breathing? A. Give 5 rescue breaths B. Check responsiveness C. Head tilt and chin lift in order to open the patient’s airway 6. When activating EMS, what information should you give? A. Caller’s name and surname, location of the incident, and that the patient is not breathing B. That the patient is in cardiac arrest C. Spoken instructions of the AED 7. Which is the recommended rate of chest compressions? A. 80 chest compressions per minute B. 70 chest compressions per minute C. 100 chest compressions per minute

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