CPR Education in Schools
Contemporary, Practicable and Rational
Dr. Ben K.A. WAN
Immediate Past President, HKSEMS
In Hong Kong, there are more than 6000 out-of-hospital cardiac arrest (OHCA) cases every year. According to a local territory-wide study on OHCA in 2012-2013, bystander CPR and use of automated external defibrillator (AED) were performed in only 28.8% and 1.4% of the OHCA scenarios respectively. The prognosis of OHCA in Hong Kong was poor with survival rate at 2.3%, while the global OHCA survival rate ranged from 2% to 11%.
The “chain of survival” is a widely adopted paradigm to optimise OHCA survival. Bystander CPR fills the gap between the onset of OHCA and arrival of emergency medical services. However, the fact that OHCA most commonly occurs at home makes timely bystander CPR less likely. Perhaps more OHCA victims can be saved if school-age children and adolescents can be educated early on CPR. Increasing the percentage of citizens trained in CPR is an integral component of the strategy to improve the community response to OHCA. Countries which incorporate mandatory CPR training in schools reported lay rescuers resuscitation up to 60-75% of OHCA cases, and survival could be tripled. Moreover, any previous CPR training has been shown to be a good predictor of whether a bystander would act and perform CPR to an OHCA victim.
CPR education in schools is not a novel concept. In 2003, the International Liaison Committee on Resuscitation (ILCOR) strongly recommended that CPR training be incorporated into the standard school curriculum. Some European countries such as Norway, Denmark and England have mandated some forms of first aid and CPR training in the primary or secondary school curriculum. The China General Office of State Council released the “Healthy China 2030” blueprint a few years ago which outlined the national strategies of healthcare promotion such as incorporating CPR training into school curriculums and academic assessments.
Children and adolescents demonstrate aptitude and motivation to learn first aid and CPR. The training should build up the knowledge and skills in an age-appropriate manner. For example, identifying a sick person and seeking help should be taught to younger children, while CPR skills should be taught to older children or adolescents because of their greater physical strengths for adequate compression depth. Skills may decay so repeated training enhances performance and skill retention, although how that could be optimally achieved is yet to be determined.
In Hong Kong, schools are currently not required to provide CPR training for their students. Abundant evidence supports CPR training in school, but the acceptance in Hong Kong is relatively low. A study done in 2017 found that only 1/3 of secondary schools in Hong Kong offered CPR training. Another survey involving 557 teachers from 22 schools in Hong Kong reviewed that only 25% of teachers supported CPR teaching in schools and 32% of them were willing to teach it. More than half of them were not confident with their CPR skills or teaching CPR. The legal liability was a concern among teachers. According to overseas experience, other obstacles include the funding, availability of certified instructors to teach CPR, and social acceptance and belief on CPR education in schools. Increasing public awareness is definitely an enabler but not the whole solution. To seek the assent from schools on CPR education, adequate supports on program administration, funding, training materials, trainers and equipment should be provided. Self-instruction training kits and web-based learning for students to bring home or share with family members may be helpful. Legislative approaches, such as changes on education framework, funding principles and Good Samaritan law, can also increase the stakeholders’ acceptance on CPR education in school and community awareness on the need to train more lay rescuers and save more lives.
OHCA causes substantial life and productivity loss, and critical impact to our healthcare system. Early CPR training could help alleviate the burden of premature death, and make Hong Kong a healthier city.
Wissenberg M, Lippert FK, Folke F et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013; 310: 1377-1384.
Plant N, Taylor K. How best to teach CPR to school children: a systematic review. Resuscitation 2013;
Fan M, Leung LP, Leung R, et al. Readiness of Hong Kong secondary school teachers for teaching cardiopulmonary resuscitation in schools: a questionnaire survey. Hong Kong J Emerg Med 2019; 26(3): 174–178.
Yim WC, Ip ML, Siu YC, et al. Cardiopulmonary resuscitation training in secondary education: A prospective cross-sectional survey of 110 Hong Kong secondary schools. Hong Kong J Emerg Med 2021; 28(1): 30–36.
Fan KL, Leung LP, Siu YC. Out-of-hospital cardiac arrest in Hong Kong: a territory-wide study. Hong
Kong Med J 2017; 23(1): 48–53.
Diana M. Cave, Tom P. Aufderheide, Jeff Beeson, et al. Importance and Implementation of Training in Cardiopulmonary Resuscitation and Automated External Defibrillation in Schools. Circulation 2011; 123: 691-706.