The School Lifesavers Study
Condition: Cardiac Arrest
MeSH terms: Heart Arrest
Study type: Interventional

Summary: 
      60,000 people suffer an out of hospital cardiac arrest in the United Kingdom (UK) every year.
      Bystander cardiopulmonary resuscitation (CPR) rates are dismal (30%) compared with places
      where CPR education is mandatory for all school children (>50%). Strategies are needed to
      increase these rates through innovative approaches. Lifesaver (www.life-saver.org.uk) is an
      immersive interactive programme/application that presents such an opportunity. This study
      aims to assess the effectiveness of Lifesaver on CPR attitudes, knowledge, skills acquisition
      and retention in school children. Additionally, it aims to examine whether Lifesaver provides
      additional benefits in terms of CPR attitudes, knowledge, skills acquisitions and retention
      in school children when combined with face-to-face BLS training.
    

Detailed description: 
      The UK has one of the highest rates of cardiovascular disease in the world and approximately
      60,000 out-of-hospital cardiac arrests occur every year, half of which are attended to by the
      emergency services. The public health implications of this are significant as the number of
      out of hospital cardiac arrests will increase with the rising incidence of obesity and other
      co-morbidities in the UK's ageing population. Basic Life Support (BLS) can improve the
      outcomes of these people if it is swiftly performed at the scene of the cardiac arrest.

      BLS is defined as a set of skills that can be used to 'help keep someone alive in an
      emergency...before professional help arrives'. One of the main elements of BLS is cardio-
      pulmonary resuscitation (CPR). Bystander CPR is important because it slows down the rapid
      decline in a patient's chances of survival while waiting for professional help. If a patient
      is found to be in a 'shockable rhythm' such as ventricular fibrillation (VF) or ventricular
      tachycardia (VT) then receiving bystander CPR could treble the chances of survival.

      Currently the average bystander CPR rate in the UK is 30%. This figure is very poor when
      compared to Seattle where the bystander CPR rates are 61% after routinely training school
      children for the past 32 years. Similar results have also been achieved in Norway.

      While educating the lay public in BLS is key to increasing survival from cardiac arrests, it
      is difficult to reach the entire population. One potential strategy is to educate school
      children as young as 12 years old. The American Heart Association advocated compulsory
      resuscitation training in American schools in 2011, and countries in which resuscitation has
      been integrated into educational programs in schools report significantly higher
      resuscitation rates. In Denmark, successful training of school children has led to the rate
      of bystander CPR doubling after 5 years with a threefold improvement in survival following
      out-of-hospital cardiac arrest over 10 years. A threefold improvement in survival cannot be
      achieved solely by improvements in professional medical care in this area.

      CPR training in school children has many potential benefits. School children at a young age
      have a less inhibited approach to resuscitation training and both medical professionals and
      teachers achieve success after appropriate training themselves. The response to instruction
      is easier and better at a younger age. Research has shown that the strongest factor
      preventing laypeople to help in real-life cardiac arrest is a fear of making mistakes. This
      fear can hopefully be prevented when taught during a young age at school. A more favourable
      attitude to learning is also reflected by the fact that practical training can be
      communicated in a more positive way. Embedding resuscitation in related school subjects such
      as biology, sports or health education is possible and it can make it meaningful.

      If school children receive such training, they are also likely to teach this to their family
      at home. Not only will there be an increase in the number of cardiac arrest survivors
      worldwide, but also the social benefits of enthusiastic and positive young people. They learn
      to help others and a sense of responsibility can be instilled in children from a young age.
      School children and teachers are important "multipliers" in both private and public settings
      and thus, in the longer term, the proportion of trained individuals in society will markedly
      increase, leading to an increase in the overall rate of lay resuscitation. By teaching school
      children, CPR training can reach all groups of society including those in lower social
      groups. To achieve a statistically significant increase in the resuscitation results, it has
      been estimated that at least 15% of a population need to be trained and such numbers cannot
      be achieved by offering voluntary courses.

      In their systematic review Plant and Taylor found that training school children in CPR from
      the age of 10 years old is effective. Young children can learn about certain elements of
      first aid such as the recovery position and making a 999 call which they are able to retain.
      It has also been shown that early training helps reduces anxieties about making mistakes in
      an emergency situation and also markedly increases participants willingness to help.
      Individuals who have received CPR training are more likely to perform bystander CPR than
      people without training.

      In March 2013, the Department of Health published a Cardiovascular Disease Outcomes Strategy.
      One of their targeted outcomes is "to consider ways of increasing the numbers trained in CPR
      and using automated external defibrillators (AED)". Delivering BLS training to every school
      child would achieve this outcome. Using secondary schools to teach first aid would capture a
      large proportion of the population as it is compulsory to attend secondary education up until
      16 years of age. There is a growing level of support for this approach from Health Care
      Professionals such as Cardiologists. A joint statement was released by the European Patient
      Safety Foundation (EuPSF), the European Resuscitation Council (ERC), the International
      Liaison Committee on Resuscitation (ILCOR) and the World Federation of Societies of
      Anesthesiologists (WFSA) to call for all children across the world to be trained in the
      performance of CPR. This initiative supports the training of children at the age of 12 for 2
      hours per year in emergency life support and has received strong backing from the World
      Health Organisation.

      The investigators literature review revealed learning technology such as computer or
      multi-media based resuscitation training programs has been previously evaluated. Studies have
      found that computer- based simulation provided a learning environment with realistic
      scenarios when compared to traditional classroom-based teaching. Students who participated in
      computer or multi-media CPR training had equivalent or superior knowledge and skill
      acquisition when compared with traditional training. Studies that examined the use of new
      learning technology merely as a vehicle of delivering the same learning content have failed
      to improve learning. The systematic review by Plant and Taylor concluded that CPR training in
      school children could be successful using a variety of approaches. In order to engage and
      capture the attention the current generation of school children, innovative interactive games
      could be used in CPR training. To date there has been no studies that investigated the use of
      immersive interactive scenario training as a standalone education tool or in combination with
      face-to-face instructor-led training.

      The investigators believe that Lifesaver Programme can provide age-appropriate training to
      schoolchildren. The novel 'game-in-film' format of Lifesaver is an immersive interactive
      website or application which provides an engaging learning experience and real life scenarios
      whereby the user helps a victim of cardiac arrest of choking. It is free to use and has
      currently been downloaded over 46,800 times and the website has been visited over 423,000
      times. There is already anecdotal evidence of two lives saved as a result. Furthermore,
      Lifesaver has won a Webby award, five e-Learning Age awards, and was shortlisted for a
      British Academy of Film and Television Arts (BAFTA) award.

      This study aims to assess the effectiveness of Lifesaver on CPR attitudes, knowledge, skills
      acquisition and retention in school children. Additionally, it aims to examine whether
      Lifesaver provides additional benefits in terms of CPR attitudes, knowledge, skills
      acquisitions and retention in school children when combined with face-to-face BLS training.

      Three secondary schools in the West Midlands will participate. Parents of the participating
      school pupils will be provided with detailed and sufficient information to allow them to
      consent on behalf of their child for participation in the study. After the initial
      intervention, 2 and 4 month follow up visits will be conducted to assess the retention of the
      pupils CPR knowledge, skills and attitudes.
    

Intervention name(s): Face-to-face BLS training; Lifesaver training; Lifesaver and Face-to-Face BLS training
Intervention type(s): Other; Other; Other
Intervention description(s): Pupils will receive CPR training by standardised face-to-face BLS training only; Pupils will receive CPR training by Lifesaver programme only; Pupils will receive CPR training by Lifesaver and standardised face-to-face BLS training
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: CPR; Schools; Education; Lifesaver