Cardiopulmonary Resuscitation Training in China: Current Situation and Future Development.

In China, there are more than 230 million people with cardiovascular disease, and 550 000 individuals experience cardiacarresteveryyear.Thesurvivalrateofout-of-hospital cardiac arrest is less than 1% in China (compared with 12% in the United States). Early initiation and good quality of cardiopulmonary resuscitation (CPR) by bystanders and automated external defibrillator use are crucial for saving patients in cardiac arrest. However, the implementation rate for bystander CPR in China is low (4.5% in 8 large and medium-sized cities around China, 11.4% in Beijing, and 4.2% in Shanghai, vs 46.1% in the United States, 29% in Canada, 46%-73% in Sweden, 32.2% in Japan, and 21.2% in Australia), and the quality is also poor, which is reflected by the low survival rates following bystander CPR in China.1 In addition to laws, culture, and publicity, the lack of dissemination of CPR training among the lay public is a critical cause for the low rate of bystander CPR. In the United States, 13.1 million persons received CPR training in 2012.2 However, the prevalent training rate in China is less than 1% (33% in the United States, 40% in France), and skill retention training is also rare.2,3 On October 12, 2016, the first CPR training center for the general public in China, which is supported by the American Heart Association (AHA) and the China Social Assistance Foundation, was established in Beijing,4 based on an agreement between the Chinese government and the AHA announcing a new cooperation in training millions of Chinese in CPR.5 Several months ago, another national CPR training project was also initiated by the Science Popularization Section of the Chinese Medical Association, a nonprofit academic organization, with assistance from the Red Cross Society of China (RCSC). 3 These events represent a remarkable milestone in spreading CPR training in China. Obviously, it is a huge project to train the lay public in such a large populous and diverse country, and there is much progress to be made. Herein, we review the current situation in China and related research in CPR training and highlight important issues to be addressed in future work. First, in China, there is a lack of coordination of those institutions responsible for ensuring the education of lay people in CPR skills and for the quality of that training. Traditionally, the RCSC focuses on the training of the lay public.3 Emergency medical centers and emergency, cardiovascular, or internal medicine departments in medical institutions take the responsibility to train their staff, and occasionally train some communities. Over the past decade, an estimated 177 training centers applying AHA standardized courses have been established (Figure), most of which are located in tertiary or secondary hospitals and emergency medical centers in medium to large cities. This number remains low compared with that of the United States, in which there are dozens to hundreds of training centers sponsored by the AHA or American Red Cross in every state.2 Moreover, the financial support of China’s centers usually comes from these institutions themselves, rather than from public funding sources. These training centers are often established to meet a temporary need by these medical institutions, and the model is difficult to expand throughout the country due to lack of coordination of those institutions and the decentralized nature of this funding. Thus, it is impossible for these centers to be responsible for national training of the general public, regardless of financial support or training faculty. The second issue is the availability of full-time, dedicated trainers. In the aforementioned training centers, many physicians in emergency or cardiology departments were recruited as part-time trainers, and they usually had to dedicate substantial time to this work in addition to their clinical responsibilities. Although this kind of use of specialists rich in CPR knowledge and skills boosted the rapid development of CPR training centers in China in the initial stage, this model poses a heavy additional burden on professionals with substantial outside clinical responsibilities. Skilled Chinese physicians are in short supply and already overworked, and their number is insufficient for the need of widespread public training. Thus, it should be a national priority to recruit and educate a body of full-time workers, assistants, and parttime volunteers specialized in CPR training. Third are the training strategies and prioritized trainees. Currently, most training centers are located in large cities, some in medium-sized cities, but few in rural counties. Although urbanization in China has developed rapidly, 47% of the population still lives in rural areas, where there is a higher percentage of elderly people who are at highest risk of cardiovascular disease. Even in urban areas, it is difficult for citizens to spend time to attend classroom training due to busy lifestyles and highintensity occupations. In addition, CPR skills need to be regularly evaluated and updated. The modes of training should be varied to meet the needs of a large, varied population. Online courses, mobile applications, and videos should be produced to support training availability over long distances and at any time.2,6 Even if various strategies are initiated, products must be costeffective to increase training prevalence in the setting of limited resources. Moreover, community workers and physicians should be fully used as training assistants. Some special populations including students, policemen, firefighters, and soldiers should be given first priority based on the experience of developed countries.2,7 As a special group with ready access to a CPR-skilled person, the family members of physicians and nurses could also receive family CPR education, based on the VIEWPOINT