Importance and Relevance of CPR

Every year over 320,000 individuals have a cardiac arrest outside of a hospital (Go,

Mozaffarian, et al., 2013). These individuals have lost function of their heart, perhaps due to

heart disease, and die if they do not receive any medical care. Without any medical care being

provided prior to reaching the hospital, only 10.6% of individuals survive to be discharged from

the hospital. This extremely low number demonstrates how important it is to perform life-saving

procedures immediately after an individual has a cardiac arrest.

The most effective life-saving intervention for these individuals is cardiopulmonary

resuscitation, or CPR. This technique is very simple and easy to learn because the sequence only

involves four steps. Traditional forms of CPR include providing rescue breaths, to restore

oxygen to the individual’s lungs, and compressing the chest, to keep the heart beating. In

addition, the use of automated external defibrillators, AEDs, is important because they shock the

heart to restore its normal beating rhythm. Simplified versions of CPR are just as effective for

adults whose cardiac arrest was witnessed. Hands-Only CPR is one example of a simple version

in which only chest compressions are provided because they are more useful for adult patients.

Providing effective bystander CPR and AED shock to a cardiac arrest victim can make her

chance of survival jump from 8% to more than 24%, which is a significant increase in chances of

survival (AHA, 2016).

Problem Statement

With such a clear benefit of providing CPR to patients, it seems obvious that all

individuals should be trained to provide this life-saving intervention. However, the state of

Massachusetts and 18 other states currently do not require students to be trained in Hands-Only

CPR and AED use for various reasons, leading to entire generations of individuals not knowing

the importance of these techniques or how to perform them. The current Massachusetts

legislation on CPR education in schools is limited to the following:

Bill S.282: An Act relative to CPR and AED certification for athletic coaches

SECTION 1. Section 47A of Chapter 71 of the General Laws, as appearing in the

2010 Official Edition is hereby amended by adding the following sentences:- All coaches

shall be required to have a current certification in cardiopulmonary resuscitation and

the use of automatic external defibrillators from the American Red Cross, American

Heart Association or other agency approved by the department of public health. Such

requirement shall not apply to coaches who have a physical disability.(Welch, 2013)

This bill, which was enacted in May 1, 2013, requires only athletic coaches to be certified

in CPR and the use of AEDs. While this is a step in the right direction, this bill only protects

student athletes who may have sudden cardiac arrest during sports practices or games. It does not

provide the students with any knowledge on how to perform CPR if their family, friends, or even

some strangers were to have a cardiac arrest. Since more than 80% of out of hospital cardiac

arrests (OHCA) happen at home, the most likely member of the family to witness such an event

is a child (AHA, 2016). In addition, as the average age of the population increases every year,

there is a larger population of individuals at high-risk for cardiac arrest (Figure 1). All of these

factors indicate that the younger generation must be trained to some degree in CPR, and the best

method of disseminating this knowledge seems to be through school curricula.

CPR Education Policy Across the US

Every state has differences in education policy, and these variances extend to CPR and

AED education. Although Massachusetts has inadequate CPR education legislation, 29 other

states do require high school students to be trained in CPR prior to graduation (AHA, 2015). The

21 states that do not require CPR education in high schools are: Alaska, Arizona, California,

Colorado, Florida, Hawaii, Kansas, Maine, Massachusetts, Michigan, Missouri, Montana,

Nebraska, Nevada, New Hampshire, Ohio, Pennsylvania, South Carolina, South Dakota,

Wisconsin, Wyoming. Recently there has been an increasing push for the implementation of

CPR education in secondary schools throughout the US, and many states have recently proposed

policies that would require students to be trained. Twenty-two of the twenty-nine states

implemented such a policy in the past two years, indicating there is a national desire for policy

change (Figure 2). Figure 3 illustrates the status of CPR education laws in all fifty states.

Among the 29 states there are many commonalities in the CPR education policy. These

similarities arise because most of the states implementing these policies now are taking the

requirements directly from other state legislation. For example, most states are requiring high

school students to be trained in CPR and AED use and are not providing funding to schools to

implement such programs. Some states even specify the means through which this CPR

education will be provided, by stating how many hours must be taught, the level of assessments,

and the course curricula through which it will be taught. Excerpts from the more unique and

detailed policies are listed below by the state in which they are enacted followed by a description

of the different portion of the specific policy:

Delaware Policy:

In addition, no less than two (2) hours of this 1/2 credit course shall cover

include a cardiopulmonary resuscitation (CPR) awareness based on instructional

program which uses the most current evidence-based emergency cardiovascular care

guidelines, and incorporates psychomotor skills learning into the instruction, use of an

Automated External Defibrillator (AED) as well as a component on the life saving and

life enhancing effects of organ and tissue donation.

Delaware specifies the time and class through which CPR and AED use will be taught

(Secretary, 2014).

Iowa Policy:

Every student by the end of grade twelve shall complete a certification course for

cardiopulmonary resuscitation.

Iowa requires students to be certified in CPR, which takes three hours per student and has

monetary costs associated with the certification process (Lalbers, 2009).

Oklahoma Policy:

Each public school district board of education shall ensure that a minimum of

one certified teacher and one noncertified staff member at each school site receives

training in cardiopulmonary resuscitation and the Heimlich maneuver each year.

Oklahoma requires schools to employ teachers trained in these life-saving skills (Roberts, 2014).

Utah Policy:

Each high school that has received funds for the use of CPR and AED Instruction

for Students must have an identified faculty member or district representative responsible

for tracking these performance measures.

Utah State provides the funding needed to train students in CPR and AED use, whereas most

other states expect school districts to bear the cost (Menlove, 2015).

These examples of state legislation regarding CPR education demonstrate that there is

great variance in the type of policy a state can implement. There are positives and negatives to

each part of a policy, however, through an effective cost-benefit analysis, the most productive

and effective policy can be determined and implemented. A big reason states do not enact such

critical policies is that there is a lack of money, and school budgets are being cut. In addition, if

teachers are required to be certified in CPR and AED use, then there general salaries may also

increase as per teacher union rules. Thus, it is important to keep all of these factors, and more, in

mind when deciding the best policy for a state.

Proposed Policy:

Massachusetts is home to 80 hospitals, and even more out-patient medical facilities

(AHD, 2015). Since there is such easy access to medical institutions, extending a person’s time

before there is permanent heart or brain damage by performing CPR can be really helpful. Based

off of many determinants, such as cost of the program, funding sources, time of training, age of

training, method of education delivery, and others, the best policy for Massachusetts is the

following:

Beginning with the 2017-2018 school year, training on how to properly

administer cardiopulmonary resuscitation (which training must be in accordance with

standards of the American Red Cross, the American Heart Association, or another

nationally recognized certifying organization) and how to use an automated external

defibrillator shall be included as a basis for curricula in all secondary schools in this

State. This training shall be provided during the course of one or more classes in the

Health curricula of schools. Students with physical disabilities may be excused from this

training at the discretion of the school board. Excused students will be trained through

visual observation of the techniques being taught.

Each school board is encouraged to have in its employ, or on its volunteer staff,

at least one person who is certified, by the American Red Cross or by another qualified

certifying agency, as qualified to administer first aid and cardiopulmonary resuscitation.

In addition, all athletic coaches employed by a school must be certified in CPR and AED

use by the American Red Cross, the American Heart Association, or another nationally

recognized certifying organization.

Each school board is authorized to allocate appropriate portions of its institute

or in-service days to conduct training programs for teachers and other school personnel

who have expressed an interest in becoming qualified to administer emergency first aid

or cardiopulmonary resuscitation.

This policy addresses many issues relating to CPR education and is a mixture of many

effective policies in other states. With this enacted, all students in secondary schools, from

grades 9-12, will be required to be trained in CPR and AED use based off of the standards of an

accredited CPR training organization. There is a clause to allow students with physical

disabilities to be exempt from the physical training portion In addition, by stating that this

training be provided over the course of at least one health class, there is no ambiguity about the

time in which the training will be conducted. The second portion of this policy addresses the

training of teachers, staff and athletic coaches. Schools are encouraged to employ CPR certified

individuals and are required to employ certified athletic coaches. Finally, the last segment of this

policy allows schools boards to take in-service days in order to train teachers and other school

personnel in basic life support skills.

One of the biggest reasons for such a policy not being implemented in Massachusetts

schools already was a lack of funding. The Massachusetts Department of Education did not want

to bear the burden of this policy and training all students on themselves since there have been

nation-wide budget cuts for school programs including art, music, and sports. Even as of March

2016, there are looming threats of budget cuts causing financial deficits in the school systems.

Boston Public School students staged a walkout over budget cuts that were proposed that would

cause a $50 million budget shortfall (Balonon-Rosen, 2016). Thus, it was seemingly unnecessary

to spend money on a non-essential training program. In fact, in 2009 there was a bill proposed

that would require students to be trained in CPR prior to graduation from high school:

Bill H.410: An Act requiring instruction in cardiopulmonary resuscitation and

the use of automatic external defibrillators for high school graduation.

The first paragraph of section 1 of Chapter 71 of the General Laws, as appearing

in the 2002 Official Edition, is hereby am ended by striking out the sixth sentence and

inserting in place thereof the following 2 sentences:-

All public high school students shall be required to study and to demonstrate a

general knowledge of cardiopulmonary resuscitation and the use of automatic external

defibrillators as a prerequisite for graduation. The department of education shall pay the

cost of such instruction, which may be taught by anyone who is certified in

cardiopulmonary resuscitation. (Haddad, 2009)

However, this bill was never passed because it seemed too costly to impose this

requirement across schools in Massachusetts. Allyson P. from the Massachusetts American

Heart Association is the main individual working on having improved CPR education legislation

passed in Massachusetts and spoke about Bill H.410 (Interview of MA AHA Representative,

2016). She stated that a proper cost-benefit analysis was never done when this bill was proposed,

and it was just assumed that the costs outweighed the benefits. Cameron S. from the Office of

State Senator James Welch also confirmed that Bill S.282 was passed, but a cost analysis

between training coaches and all faculty members/students of a school was not done (Interview

of Cameron S., 2016.). With this information in mind, it is clear that it was always assumed that

training all students in high school would be too expensive and not worth the cost, even though

there was no data supporting this assumption.

Cost-Benefit Analysis:

With the proposed policy, the State Department of Education is not responsible for

funding the CPR training program for students or the certification for athletic coaches. Athletic

coaches must pay for their own certification to be eligible for employment by Massachusetts

secondary schools. In addition, each school district would need to pay the cost for their own

schools’ CPR training program for students. While it may seem like this is a very large cost for

school districts to bear, the following cost-benefit analysis will demonstrate that the costs of this

program are manageable in Massachusetts.

For CPR and AED use to be taught in secondary school Health classes, there are capital

and operational expenses that should be determined. Capital expenses (CAPEX) are funds that an

organization uses to buy services or physical goods that are needed to generate positive outcomes

(Maverick, 2015). The capital expenses for this program include the CPR training equipment,

certification for the health teacher, and documentation tools. Operational expenses (OPEX) are

expenditures that an organization incurs to participate in any activities not directly associated

with the production of the positive outcome (Maverick, 2015). In this type of training program,

there do not seem to be any operational expenses that are a direct result of CPR training. The

model of training that will be most effective in secondary schools is a ratio of approximately 20

students to one teacher who knows CPR. At least one health class for students in grade 12 will be

dedicated to teaching CPR and AED use. One class session typically ranger from 40-55 minutes,

so this gives students enough time to learn Hands-Only CPR. There must be adequate

documentation of the students who have been trained so that schools are accountable and can be

checked for their compliance to the legislation. The costs of such a program have been described

below:

Description of Items Cost of Item

CPR in Schools Training Kit1 $625

Trained AED2 $90

Health Teacher CPR Certification3 $50

Documentation Tool4 $961 The CPR in Schools Training Kit includes 10 Mini Anne® Plus inflatable manikins, 10 kneel

mats with carry bags, 10 practice-while-watching training DVDs, a Hand pump for manikin

inflation, 2 mesh collection and storage bags, a Classroom carry bag, 50 replacement airways, 50

manikin wipes, 10 replacement face masks, and a Facilitator Guide. This kit contains many

different items useful during training, however, since schools only need to teach Hands-Only

CPR, they will not have use for the replacement airways. With two students per manikin, 20

students can be trained at one time. In addition, this kit is the first to have both light and dark-

skinned manikins (Figure 4).

2 Trainer AEDs are used to demonstrate how an AED works without actually providing any

shocks (Figure 5). One trainer AED can be used for each class of 20 since its use can be taught

through visual demonstrations rather than through physical practice.

3 Health Teachers training students in CPR should be certified. While this would not be a

requirement imposed by the new policy, having a certified individual teaching CPR will provide

students with a better level of education. A CPR certification lasts for 2 years, so to remain up to

date, a health teacher will need to recertify every 2 years.

4 Documentation of the students trained will be very important if the Massachusetts Department

of Education audits a school’s adherence to curriculum. Most documentation tools will already

be in place at schools, however, in case a school needs such a tool, the cost of Excel is $96.

The total cost of this program in one school would be $811 + $50x, with x being the

number of years since the program was started divided by two. For example, if this policy was

implemented in 2016 Fall, then by 2018 Fall the school would have paid $861 and by 2020 Fall

the school would have paid $911 total. In addition, this cost analysis is a bit conservative because

the policy does not require the CPR training instructor to be CPR certified, schools within a

certain distance can share equipment, and most schools already have a license for Excel and

would not need to buy the whole program. If y number of schools were to split the cost of the

CPR training kit and trainer AED, Excel did not need to be purchased, and the Health teachers

were certified just once, the cost equation per school would be $715/y +$50. In this scenario, if

three schools split the cost and the policy was implemented in 2016 Fall, then by 2018 Fall each

school would have paid $288.33, and this cost would not have changed in the years after. If

manikins are damaged, which typically takes 5 years with extensive use, but 10 years with

minimal use, individual replacement manikins can be bought. From this cost analysis it is evident

that each individual school would not need to pay much money to have this program

implemented.

Even though the individual schools would be paying for the CPR training, it would be

helpful to understand the costs imposed on the entire state by this policy. As stated above, the

more accurate cost equation per school is $715/y +$50. In Massachusetts there are 353 high

schools and there are a total of 308,060 high school students. It can be assumed that one-fourth

of the total number of students would approximately be the number of high school seniors, which

is 77,015 individuals. From this it can be approximated that there are 77,015 students per 353

high schools, which is about 218 seniors per school. The average class size in Massachusetts

public high schools is 24.5 students per teacher (NCES, 2012). Although 10 manikins are best

used with 20 students, there could be groups of three, allowing the CPR Training Kits to be used

for whole classes. If three schools were to share the cost of the equipment, then based off of the

equation, a total of $101,782 would be spent by all the high schools in Massachusetts. This cost

is very minimal compared to the benefits of training every student coming out of the school

system in CPR and AED use.

There are many benefits of CPR training being implemented in schools, and some are

obvious while others are not. As mentioned before, without effective bystander CPR being

performed on an OHCA patient prior to arrival at the hospital, only 10.6% of individuals survive.

However, when it is performed, this number of survivors jumps up to 24% of OHCA patients

(Go, Mozaffarian, et al., 2013). There is a clear correlation between the performance of CPR and

survival post-cardiac arrest. A study released in February 2016 showed that patients were more

likely to receive CPR in communities with higher proportions of residents with CPR-

Awareness, CPR-Any-Training, CPR-Recent-Training, CPR-Manikin-Training, and CPR-Self-

Efficacy. Higher CPR capacity at community level was associated with higher

bystander CPR and survival to discharge rates after OHCA (Ro, Shin, et al., 2016). The more

trained a community is, the more likely an OHCA patient in that community is likely to survive.

Having an increased number of survivors affects entire communities, and allows loved ones to be

happier and survivors to continue living, which is not quantifiable.

There are many monetary benefits to providing an OHCA patient with CPR. For

example, post-resuscitative costs are lowered since there was better care provided prior to arrival

at the hospital and the cumulative value of lives saved increases. The most significant monetary

benefit that can be derived from spreading CPR education across the state is based on the value

of life. Many entities quantify the value of life differently. The Environmental Protection Agency

considers the value of a human life to be $9.1 million. The Transportation Department values a

human value at $9.4 million and the Food and Drug Administration values it at $7.9 million.

Even if this benefit analysis is done conservatively, and the value of life is considered to be the

smallest of these values at $7.9 million, this is still significant (Partnoy, 2012). Current

information states that 326,200 individuals have an OHCA every year in the US. Without CPR,

only 10.6% of these individuals survive, however, a study in Seattle showed that 30% of these

individuals would survive if CPR training was widespread (Wagner, 2010). Below, the

mathematical analysis of the benefits of a CPR training program being instituted throughout the

US is shown.

Without National CPR program:

326,000 individuals have an OHCA every year, with only 10.6% surviving

326,200 individuals *0.106 = 34,577 individuals surviving OHCA

With National CPR Program:

326,000 individuals have an OHCA every year, with 30% surviving

326,200 individuals *0.3 = 97,860 individuals surviving OHCA

The difference between the number individuals surviving where CPR is widespread and

where it is not is 97860-34577 = 63,283

$7.9 million/individual* 63,283 individuals ≈ $499,357,000,000

Based exclusively on the value of life consideration, every year US residents would save

$500 billion cumulatively. There are some limitations to this analysis since this policy would

only apply to Massachusetts and not the entire US, and so this value saved is not referring just to

a change in MA legislation. In addition, the 30% survival rate achieved in Seattle was also

dependent on accessibility to medical facilities, which is not prevalent in many more rural

locations in the US. Despite these considerations, it is obvious that providing CPR education in

schools has the potential to save additional tens of thousands of individuals every year, which is

valuable monetarily and emotionally.

Stakeholder Analysis:

There are very few individuals who believe that CPR should not be taught in schools,

however, there are many who believe it is not worth the funding this program would require. The

stakeholders listed below would be affected by this policy issue:

Stakeholders for CPR Education in Schools:

Massachusetts American Heart Association: This group has been the biggest lobbying

organization for CPR to be taught in schools. They pushed for the passage of H.410.

Their main goal’s as an organization is to improve health of Americans, especially by

teaching CPR. However, they would also gain monetarily if the proposed policy were

passed since they sell the CPR Training Kits. With 353 high schools in MA, if three

schools split the cost of the CPR Training Kit, the AHA would be paid $73,541 for one

set of Training Kits. In addition, any additional materials a school purchases or any

teachers who get certified would most likely go through the AHA or American Red Cross.

American Red Cross: They heavily support CPR education in high schools for similar

reasons as the MA AHA, however, there monetary benefits are not as high as those of the

AHA.

Massachusetts Department of Public Health: It is in their best interest to promote public

health education initiatives since MA is currently behind most states in CPR education.

In addition, such a program would improve statewide health outcomes.

Massachusetts Hospital System: Health care being provided prior to arrival at the

hospital has favorable outcomes for the patients and improves the hospitals’ survival

rates.

Massachusetts Emergency Medical Services System: Health care being provided prior to

EMS arrival has favorable outcomes for the patients and improves the EMS OHCA

survival rates.

Stakeholders against CPR Education in Schools:

Massachusetts Department of Education: They are worried about the financial burden

this program would be on the state education system as well as on individual schools. In

addition, they want to ensure the integrity of the school curricula by not adding

unnecessary material to it. In addition, they will have to monitor schools to ensure they

are complying with the new policy.

High Schools: They do not want to bear the financial cost of implementing this program

for their students.

Tax Payers: Without understanding the actual costs of this program, some tax payers

may be concerned that their money is going towards unnecessary education.

Analysis of Results:

Based off of the analysis of the importance of CPR, the policies in other states, the costs

and benefits of the proposed policy, and the stakeholders’ motivations, it is very clear that a

change needs to be made in CPR education policy. The policy proposed earlier would address

many of the current issues and takes an intermediate stance in the wide variance of CPR policies

in other states. Thus, it is a happy medium since it does not require students to be certified, yet

requires them to be trained in class. In addition, the financial burden on the state will not be

much since each individual school pays a few hundred dollar to implement this training program.

The most important factors to consider after determining this policy to be the most effective for

Massachusetts are about implementation, monitoring, and evaluating the outcomes of the policy.

Implementation of Proposed Policy:

For this policy to be implemented in all Massachusetts secondary schools, teachers must

be trained or certified in CPR and students must be trained in Hands-Only CPR (Figure 6).

Knowledge of this policy must be disseminated to each school, which is most easily done by

communicating with the Superintendent of a district of public schools. In addition, the

headmaster of private schools will also need to be informed. These administrators will require

health teachers in each of their schools to become trained in CPR through informal programs or

certified by the AHA, American Red Cross, or other nationally accredited certifying

organizations. These courses can be found by visiting the websites of the certifying organizations

and are provided with relative frequency. This allows teachers to become trained or certified

without too much hassle or difficulty.

Through this policy schools have some flexibility in how they would like to teach CPR to

their students. Since class times typically range from 40-55 minutes, health teachers must be able

to fit the CPR and AED Use material into this short time if they would like to finish during one

class period. Below is an example of the structure of the CPR lesson plan:

Introduction and Importance of CPR: 3 minutes

Video on Hands-Only CPR: 2 minutes

Demonstration of CPR: 2 minutes

Practice CPR with Partner: 10 minutes

Demonstration of AED Use: 3 minutes

Practice CPR and AED Use with Partner: 10 minutes

Question & Answers Period: 5 minutes

Choking Management: 5 minutes

This lesson plan demonstrates that entire classes can be taught CPR, AED Use, and even

Choking Management within 40 minutes effectively. This curriculum was created with the

mentorship of Paramedic Mark F, who has been a CPR Instructor for over 25 years (Interview

with Mark F., 2016). He believes that this type of lesson plan would be sufficient to make an

individual competent at providing this life-saving care.

Monitoring the Implementation of the Proposed Policy:

Measures would be put in place to ensure that the outcomes of the policy can be

monitored. Schools will send the list of teachers certified or trained who will teach CRP to the

MA Department of Education. In addition, schools will be required to document each student

who was trained in a form that identifies the student without ambiguity and the school he is from.

This information will also be sent to the MA Department of Education at the end of each school

year. The MA Department of Education will do a random audit on some schools to check that all

seniors are being trained in CPR prior to graduation. Although the hope is that every school will

properly implement the new training program, not every school will be audited because this

would put a heavy burden on the Massachusetts Department of Education. Schools that were

audited and did not properly implement the program will be evaluated for the next three for their

adherence to school and state curricula.

Evaluating the Outcomes of the Proposed Policy:

There is not much data on the number of OHCA and survivors specific to Massachusetts,

making it difficult to assess the outcomes in terms of increase in OHCA survivors. However,

schools can evaluate the efficacy of their CPR training program by administering a small

assessment at the beginning and end of the students’ senior year of high school. This assessment

would indicate the level of competency each student has in the skills being taught, and would

also indicate a flaw in the training program if there was a consistent mistake being made by

students after they were taught CPR. Since there are many factors affecting the number of

OHCA, including the increasing median age of the population, it would require extensive

mathematical research after 10 years to see if this training improved outcomes for these patients.

Such programs in other cities in states have shown that the average survival rate increases after

implementation, which suggests that Massachusetts will see a similar trend.

Summary:

CPR is an extremely critical, life-saving intervention that can improve a person’s chance

of survival after OHCA significantly. Currently, Massachusetts legislation on CPR training in

high schools is inadequate, so the policies must be changed. High school students should be

required to be trained in CPR prior to graduation, and individual schools will fund this program

and implement it in one or more Health class sessions. The benefits of implementing this

program outweigh the costs, so this policy should be implemented as soon as possible.

Figure 1:

(Pew Research Center, 2012)

Figure 2:

Figure 3:

*There are some inaccuracies due to recent changes in policy.

(Pro Training, 2015)

Figure 4:

(CPR in Schools)

Figure 5:

(AED Trainers)

Figure 6:

Certify Teachers in

CPR

Train Students in

Hands-Only CPR

Document Training

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