ORIGINAL CONTRIBUTION
Disseminating Cardiopulmonary Resuscitation Training by Distributing 9,200 Personal Manikins Edison Ferreira de Paiva, MD, PhD, Roberto de Queiroz Padilha, MD, PhD, Jenny Karol Gomes Sato Sgobero, RN, Fernando Ganem, MD, PhD, and Luiz Francisco Cardoso, MD, PhD
Abstract Objectives: Community members should be trained so that witnesses of cardiac arrests are able to trigger the emergency system and perform adequate resuscitation. In this study, the authors evaluated the results of cardiopulmonary resuscitation (CPR) training of communities in four Brazilian cities, using personal resuscitation manikins. m, Maringá, and Sa ~ o Carlos, Methods: In total, 9,200 manikins were distributed in Apucarana, Itanhae which are cities where the populations range from 80,000 to 325,000 inhabitants. Elementary and secondary school teachers were trained on how to identify a cardiac arrest, trigger the emergency system, and perform chest compressions. The teachers were to transfer the training to their students, who would then train their families and friends. Results: In total, 49,131 individuals were trained (6.7% of the population), but the original strategy of using teachers and students as multipliers was responsible for only 27.9% of the training. A total of 508 teachers were trained, and only 88 (17.3%) transferred the training to the students. Furthermore, the ~o Carlos, the strategy was students have trained only 45 individuals of the population. In Maringá and Sa changed and professionals in the primary health care system were prepared and used as multipliers. This strategy proved extremely effective, especially in Maringá, where 39,041 individuals were trained (79.5% of the total number of trainings). Community health care providers were more effective in passing the training to students than the teachers (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). Conclusions: Instruction of CPR using personal manikins by professionals in the primary health care system seems to be a more efficient strategy for training the community than creating a training network in the schools. ACADEMIC EMERGENCY MEDICINE 2014;21:886–891 © 2014 by the Society for Academic Emergency Medicine
D
espite many technological developments and the emergence of new therapeutic strategies, early and good-quality cardiopulmonary resuscitation (CPR) is still the single measure with the greatest impact on the survival of victims of sudden cardiac arrest (SCA).1–3 Defibrillators are another impact measure, provided that they are used within the first minutes of SCA.2,4 However, without training, a witness to a SCA is unable to trigger the emergency system as quickly and effectively as is needed or to
adequately perform CPR procedures. Thus, it is essential that the community be trained in basic procedures that should be performed in the case of SCA.5,6 There is evidence that the use of personal manikins for CPR training is a good alternative to traditional courses, allowing the training of a large number of people in a short amount of time.7–12 This study aimed to evaluate the results of the use of 9,200 personal manikins in CPR training for the communities in four Brazilian cities.
~ o Paulo; the Municipal Health Department of From the Syrian-Lebanese Teaching and Research Institute (EFdP, RdQP), Sa ~o Paulo, Brazil. Maringá (JKGSS), Paraná; and the Syrian-Lebanese Hospital (FG, LFC), Sa Received November 26, 2013; revisions received January 18, March 18, and March 27, 2014; accepted April 18, 2014. This study was a project organized jointly with the Brazilian Ministry of Health, and all of the expenses were paid by the SyrianLebanese Teaching and Research Institute. The authors have no potential conflicts of interest to disclose. Supervising Editor: Brian O’Neil, MD. Address for correspondence and reprints: Edison Ferreira de Paiva, MD, PhD; e-mail: [email protected].
886 886
ISSN 1069-6563 886 PII ISSN 1069-6563583
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12423
887
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
METHODS Study Design This was a prospective observational study, designed to evaluate the dissemination of CPR training by distributing 9,200 personal manikins. The study was coordinated ~o Paulo in partby the Syrian-Lebanese Hospital in Sa nership with the Ministry of Health of Brazil, and it was approved by the research ethics committee of the Syrian-Lebanese Hospital. Study Setting and Population The study was conducted in four Brazilian cities, two in the state of Paraná (Apucarana and Maringá) and two ~o Paulo (Itanhae m and Sa ~o Carlos). in the state of Sa These are all medium-sized cities, and their populations range from 80,000 to 325,000 inhabitants, totaling 735,025 inhabitants. Study Protocol The town councils of the four cities received 9,200 CPR training kits and were responsible for distributing them to public and private elementary and secondary schools. The kits consisted of a folder with standardized information on SCA, an inflatable manikin that allowed mouth-to-mouth resuscitation and chest compressions, and a video that guided the practical training (Family & Friends CPR Anytime, American Heart Association– AHA & Laerdal Corporation). All the material was translated into Portuguese. The teachers from the four participating cities were invited to attend trainings on the initial measures in the care of SCA in adults, which were conducted by instructors certified to teach basic life support courses. Using the video and the inflatable manikin, the training included the identification of SCA and activation of the emergency medical system and the chance to practice chest compressions using a strategy known as “hands-only CPR.” Once trained, the teachers were instructed and encouraged to disseminate the training to their students using the same kits. The trained students were then instructed and encouraged to use the kit to disseminate the CPR skills among their family and friends. Upon completion of these steps, the population of the city was invited through different media resources to participate in a 1-day event called “Life Marathon” (“Maratona da Vida”). Trained teachers and students participated as facilitators in this mass hands-only CPR training guided by video. At the end of all of the training sessions, it was expected that 25% of the population of the four cities would have been trained.
Measurements A secure website was created to record the data on the internet (http://defesadavida.hsl.org.br). The following fields were registered: city, school, name, sex, age, and area of expertise of the teacher; name, sex, age, and grade of the student; and name, sex, and age of general population individual. Teachers received a user name and password and were responsible for entering the information into the system, including the number of trainings passed on by the students to the population. Only the coordinators of the Syrian-Lebanese Hospital had access to complete data. Data Analysis All data were processed through Excel worksheets (MS Office 2010). We evaluated the total number of individuals trained, divided by city, while maintaining the relationship of the teacher with his or her student and of the student with the individual from the general population. To verify differences in the implementation of training, the chi-square test and odds ratios (ORs) with 95% confidence intervals (CIs) were used. Tests were considered significant if p < 0.05 (two-tailed). RESULTS The training began with the first training session of the teachers on May 8, 2010, and lasted until the last Life Marathon on October 9, 2011 (17 months). The initial strategy consisted of teachers acting as the first wave of trainers and students acting as the second wave, but this strategy was only followed in the city of Apucarana. Due to the difficulties in getting teachers to train their students, and in response to pressures from coordina~o Cartion, the local coordinators from Maringá and Sa los, in agreement with the central coordination, decided to use professionals in the primary health care system as multipliers of the training. Physicians, nurses, and nursing technicians from various health units were trained, and they assumed the role of teachers and replicated the training for their colleagues in their unit. The latter, in turn, accepted the role as trainers in the second wave and transferred the training they had received to the general population. Table 1 summarizes the total number of people trained and the number of kits distributed per city. In total, 49,131 individuals were trained, which corresponded to 6.7% of the population of the four cities. Maringá was the city with the highest percentage of the population trained (12.0%), followed ~o Carlos (1.5%), and Itanhae m by Apucarana (5.5%), Sa (0.7%). In the city of Maringá, 39,041 individuals were
Table 1 Total Population, Trained Population, and Number of Kits Distributed per City City Apucarana m Itanhae Maringa ~o Carlos Sa Total
Inhabitants, N 115,323 80,778 325,968 212,956 735,025
Trained Population, n (%) 6,391 577 39,041 3,122 49,131
(5.5) (0.7) (12.0) (1.5) (6.7)
Kits Distributed, n 1,150 1,150 4,150 2,750 9,200
Data are reported as n, unless otherwise noted. *The data refer to active teachers and students, i.e., the ones who performed at least one training.
Maximum
7 – – – 7 1 – – – 1
Minimum Mean
2.5 – – – 2.5 45 0 0 0 45 (0.4) (0.0) (0.0) (0.0) (0.2) 18 0 0 0 18 755 87 335 288 755
Maximum Minimum
4 1 1 3 1 176.4 31.6 60.6 65.4 96.3 5,116 316 2,122 916 8,470 (22.8) (9.3) (33.7) (8.3) (17.3) 29 10 35 14 88 127 108 104 169 508
Mean City
Apucarana m Itanhae Maringa ~ o Carlos Sa Total
Trainings per Student*
Population Trained by Students Active Students* n (%) Trainings per Teacher*
Trained Students Active Teachers, n (%) Trained Teachers
trained, which represented 79.5% of the total number of trainings conducted. The training data regarding the initial strategy using the schools are shown in Table 2. Of the 508 trained teachers, 420 (82.7%) did not transfer the training to any students, while the remaining 88 (17.3%) trained 8,470 students, for an average of 96.3 students per teacher. Among the 88 active teachers, 22 (4.3% of the 508 teachers) trained 100 or more students and together accounted for 65.3% of these trainings. The maximum number of students trained by a single teacher was 755. Most of the students (80.2%) were between 10 and 16 years of age, 51.3% were female, and 73.9% were between the fourth and ninth grades of elementary school. Apucarana was the only city in which students conducted some trainings, although only 45 friends and family members were trained by 18 students (an average of 2.5 people trained per student, with a minimum of 1 and a maximum of 7; Table 2). Table 3 shows all of the training data, including for the schools, the health units, and the trainings conducted during selected marathons. The original strategy of using teachers and students as multipliers was responsible for the training of 13,727 individuals, which represents only 27.9% of 49,141 people trained. The new strategy, using health care professionals, allowed the training of the remaining 72.1% (34,404 people). In Maringá alone, 33,832 individuals were trained through the health units, including teachers, students, and community members, representing 68.9% of all the people trained in the four cities. The chances of passing the training to students were higher when the teacher was a health care professional than when he or she was from the area of education (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). In the city of Maringá, 127 professionals in the first wave trained 725 colleagues (an average of 5.7 colleagues per professional). In addition to the colleagues, these professionals directly trained the population, and each one trained an average of 159.6 individuals. The second wave of health professionals was also active, and each one trained an average of 17.5 people from the community. After the first and second waves of health professionals from the city of Maringá were trained, which occurred in July and August 2011, different strategies were employed to disseminate the training. Initially, all of the professionals in the health department were trained, including the community health workers and administrative staff. These trainings were conducted in a gymnasium in shifts that lasted approximately 30 minutes and were supervised by nurses. The community itself was separately trained by the health units in September and October 2011. The trainings were held in community halls on specific dates, with the participation of users who spontaneously sought the health units, family members contacted during home visiting, people invited by the local health councils, and even students and teachers from nearby schools. The trainings were prescheduled and repeated several times a day. m abandoned the project early, did The city of Itanhae not hold the Life Marathon, and trained only 577 people. During the marathons held in the three remaining
de Paiva et al. • DISSEMINATING CPR TRAINING
Table 2 Data From the Training of Teachers, Students, and the General Population Trained by the Students in Each City
888
889
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
Table 3 Results From All of the Trainings Conducted in the Schools, by Health Units, and During Marathons in the Four Cities
City
Teachers
Apucarana (schools) Subtotal 127 m (schools) Itanhae Subtotal 108 Maringa Schools 104 Health units* 127 Subtotal 231 ~o Carlos Sa Schools 169 Health units* 15 Subtotal 184 Total 650
Students
Population Trained by Students
Population Trained by Teachers
Total Population
Marathon
Total
(19.5)
5,116 (55.6)
45 (0.4)
436 (1.7)
481 (1.3)
667 (40.6)
6,391 (13.0)
(16.7)
316 (3.4)
0 (0.0)
153 (0.6)
153 (0.4)
0 (0.0)
577 (1.2)
(16.0) (19.5) (35.5)
2,122 (23.1) 725 (7.9) 2,847 (31.0)
0 (0.0) 12,716 (99.6) 12,716 (99.6)
2,359 (9.5) 20,264 (81.4) 22,623 (90.9)
2,359 (6.3) 32,980 (87.6) 35,339 (93.9)
(26.0) (2.3) (28.3) (100.0)
916 0 916 9,195
0 0 0 12,761
114 1,557 1,671 24,883
114 1,557 1,671 37,644
(10.0) (0.0) (10.0) (100.0)
(0.0) (0.0) (0.0) (100.0)
(0.5) (6.3) (6.8) (100.0)
(0.3) (4.1) (4.4) (100.0)
– – 624 (38.0) – – 351 (21.4) 1,642 (100.0)
4,585 (9.3) 33,832 (68.9) 39,041 (79.5) 1,199 1,572 3,122 49,131
(2.4) (3.2) (6.3) (100.0)
All data are n (%); — = not applicable *Health professionals who received the first training are identified as teachers, and the colleagues trained by them are identified as students.
cities, 1,642 individuals were trained, for an average of 547.3 individuals per marathon (Table 3). Although the system allowed us to record some of the characteristics of the population trained, such as age, occupation, and relationship with the trainer, less than 5% of the records were completely filled, making it impossible to analyze these data. DISCUSSION In this study, the initial estimate was that each teacher would train 50 students and each student would transfer the training they had received to at least 20 relatives and friends, thus allowing the initial expectation of training 25% of the population to be easily met. However, the vast majority of teachers (82.7%) did not train any students. The delay in the distribution of the kits after the teachers had already been trained is one possible explanation for this fact. When the study was being planned, there were no kits in Portuguese, and the process of translation, production outside of the country, and importation took longer than initially expected. It is possible that over time, the teachers became discouraged and felt unprepared to train the students, despite the material, including the video, being self-explanatory. A questionnaire given to Belgian teachers found that only 31% of them felt able and willing to provide CPR training to their students, even though 59% of them had received prior training. The main reasons given were the perceived lack of knowledge and inability to perform CPR correctly.13 After the study was completed, an e-mail was sent to teachers who had not trained any students, asking them the main reason. We had responses from only 52 of 420 (12.4%) and the main reasons were insecurity (53.8%), transfer of school (21.2%), and never having received the training kits (19.2%). An additional 5.8% said they had trained some students, but had problems accessing the system to record the training.
A small percentage of the teachers in our study showed great motivation, and 22 of them (4.3% of the total) were responsible for training 65.3% of the 8,470 students. It is likely that repeated trainings increased the confidence of these teachers and made it easier for them to disseminate the knowledge to new classes. The distribution of personal manikins to students to disseminate CPR training has been used in other studies, and each student has passed the training on to 1.7 to 2.9 people, which has been considered effective by the authors.10–12 In Apucarana, the only city in which students conducted some training, the average number of trained individuals was similar to these studies (2.5 per student), but very far from the expectation that a student would train 20 family members and friends. Political issues were also a reason why the project did not follow the originally proposed training cascade. The local coordinators were connected to the municipal government, and they had to contact both municipal and state education secretaries, who were often from different political parties and had different interests. Furthermore, the effectiveness of the interventions of the ~o Paulo, central coordination of the project, located in Sa was hampered by the distance between the cities, which reached up to 650 km. Due to the difficulties in developing the project in ~o Carlos and Maringá chose to schools, the cities of Sa use the primary health care network, which proved to be very effective, particularly in the city of Maringá. With this strategy, in only 4 months, Maringá was responsible for 33,832 trainings or 68.9% of the 49,131 trainings conducted in the four cities. The heavy involvement of health professionals, which was a key part in the success of this strategy, most likely occurred because they knew the relevance of the topic and the importance of disseminating information on initial SCA care. Moreover, it was unlikely that the health professionals would not feel capable of teaching basic concepts of resuscitation to the general population. In
890
de Paiva et al. • DISSEMINATING CPR TRAINING
Table 4 Suggestions for Creating a Community CPR Training Program 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Create a public-private partnership that gives financial support to the project. Use the network of the public, primary health care system. Involve health professionals who have direct contact with the population. Develop activities during working hours of professionals. Encourage community participation through campaigns in health facilities and homes. If available, use different media resources to invite the community to participate in the project. Use simple training kits, guided by video, enabling the practice of skills in a standardized manner. Prevent key actions to be attributed to people with conflicts of interest. Train local professionals to act as coordinators, thus allowing the decentralization of control. Maintain constant control over the quality of the information collected.
addition, health professionals were linked only to the municipal health secretariat, limiting the number of political actors involved. Considering all the investment and dividing it proportionally to the population of each city, it is estimated that every individual trained in the city of Maringá has cost 7.75 dollars. The intention to train at least 25% of the population turned out to be a serious error of estimation, because the political interests involved in programs of this magnitude are very well known and it would not have been difficult to anticipate the problems encountered. We also knew that insecurity of teachers could be a barrier to the spread of the training, but the late delivery of the kits increased the time between training and replication, which certainly contributed to increased insecurity. Typical problems of a country still in development, as the constant change in place of employment and the lack of sensitivity of the administrators, also contributed to most of the teachers never doing any training, because they were not in the same workplace, or because they never received the training kits. Nevertheless, thanks to the involvement and active participation of health professionals, it was possible to train a significant portion of the population in Maringá. In underdeveloped and developing countries, the initiatives for training the community in public health problems are rare, generally isolated, dependent on medical societies, and of limited scope. In this study, there was a partnership between the Ministry of Health and a private nonprofit institution, which allowed disseminating the knowledge of the basic steps of CPR to the community, and we believe that this experience can be replicated successfully in other centers. From the difficulties encountered during the study, we identified 10 points that can contribute to the success of similar projects in the future (Table 4). LIMITATIONS The main limitation of this study was that the strategy that allowed the training of a large number of people in the city of Maringá did not follow the initial plan. Thus, there is no guarantee that the same results would have been obtained if the same strategy had been implemented in the other cities. Another limitation is that no evaluation of the effect of training on survival of adult victims of SCA was performed. Indeed, the initial study design included the comparison of data from prehospital care before and after the training. However, in our
country there is no culture of keeping records of good quality, and although a simple evaluation form was created, it was never used in the pretraining phase, which prevented any possibility of comparison. Despite these limitations, we believe that our results indicate that the involvement of health care professionals in training the general population in basic CPR maneuvers is very effective and should be tested in future studies. CONCLUSIONS The distribution of personal resuscitation manikins is an effective way to train people in cardiopulmonary resuscitation. The involvement of primary health care professionals in the training appears to be a more efficient multiplier strategy than a training network composed of teachers and students. References 1. Eftestøl T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during outof-hospital cardiac arrest. Circulation 2004;110:10–5. 2. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832–47. 3. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO. The location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987;16:787–91. 4. Stokes NA, Scapigliati A, Trammell AR, Parish DC. The effect of the AED and AED programs on survival of individuals, groups and populations. Prehosp Disaster Med 2012;27:419–24. 5. White RD, Bunch TJ, Hankins DG. Evolution of a community-wide early defibrillation program experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 2005;65:279–83. 6. Eckstein M. The Los Angeles public access defibrillator (PAD) program: ten years after. Resuscitation 2012;83:1411–2. 7. Done ML, Parr M. Teaching basic life support skills using self-directed learning, a self-instructional
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
video, access to practice manikins and learning in pairs. Resuscitation 2002;52:287–91. 8. Isbye DL, Rasmussen LS, Lippert FK, Rudolph SF, Ringsted CV. Laypersons may learn basic life support in 24 min using a personal resuscitation manikin. Resuscitation 2006;69:435–42. 9. Lynch B, Einspruch EL, Nichol G, Becker LB, Aufderheide TP, Idris A. Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation 2005;67:31– 43. 10. Corrado G, Rovelli E, Beretta S, Santarone M, Ferrari G. Cardiopulmonary resuscitation training in high-school adolescents by distributing personal
891
manikins. The Como-Cuore experience in the area of Como, Italy. J Cardiovasc Med (Hagerstown) 2011;12:249–54. 11. Isbye DL, Rasmussen LS, Ringsted C, Lippert FK. Disseminating cardiopulmonary resuscitation training by distributing 35,000 personal manikins among school children. Circulation 2007;116:1380–5. 12. Lorem T, Palm A, Wik L. Impact of a self-instruction CPR kit on 7th graders’ and adults’ skills and CPR performance. Resuscitation 2008;79:103–8. 13. Mpotos N, Vekeman E, Monsieurs K, Derese A, Valcke M. Knowledge and willingness to teach cardiopulmonary resuscitation: a survey amongst 4273 teachers. Resuscitation 2013;84:496–500.
Disseminating Cardiopulmonary Resuscitation Training by Distributing 9,200 Personal Manikins Edison Ferreira de Paiva, MD, PhD, Roberto de Queiroz Padilha, MD, PhD, Jenny Karol Gomes Sato Sgobero, RN, Fernando Ganem, MD, PhD, and Luiz Francisco Cardoso, MD, PhD
Abstract Objectives: Community members should be trained so that witnesses of cardiac arrests are able to trigger the emergency system and perform adequate resuscitation. In this study, the authors evaluated the results of cardiopulmonary resuscitation (CPR) training of communities in four Brazilian cities, using personal resuscitation manikins. m, Maringá, and Sa ~ o Carlos, Methods: In total, 9,200 manikins were distributed in Apucarana, Itanhae which are cities where the populations range from 80,000 to 325,000 inhabitants. Elementary and secondary school teachers were trained on how to identify a cardiac arrest, trigger the emergency system, and perform chest compressions. The teachers were to transfer the training to their students, who would then train their families and friends. Results: In total, 49,131 individuals were trained (6.7% of the population), but the original strategy of using teachers and students as multipliers was responsible for only 27.9% of the training. A total of 508 teachers were trained, and only 88 (17.3%) transferred the training to the students. Furthermore, the ~o Carlos, the strategy was students have trained only 45 individuals of the population. In Maringá and Sa changed and professionals in the primary health care system were prepared and used as multipliers. This strategy proved extremely effective, especially in Maringá, where 39,041 individuals were trained (79.5% of the total number of trainings). Community health care providers were more effective in passing the training to students than the teachers (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). Conclusions: Instruction of CPR using personal manikins by professionals in the primary health care system seems to be a more efficient strategy for training the community than creating a training network in the schools. ACADEMIC EMERGENCY MEDICINE 2014;21:886–891 © 2014 by the Society for Academic Emergency Medicine
D
espite many technological developments and the emergence of new therapeutic strategies, early and good-quality cardiopulmonary resuscitation (CPR) is still the single measure with the greatest impact on the survival of victims of sudden cardiac arrest (SCA).1–3 Defibrillators are another impact measure, provided that they are used within the first minutes of SCA.2,4 However, without training, a witness to a SCA is unable to trigger the emergency system as quickly and effectively as is needed or to
adequately perform CPR procedures. Thus, it is essential that the community be trained in basic procedures that should be performed in the case of SCA.5,6 There is evidence that the use of personal manikins for CPR training is a good alternative to traditional courses, allowing the training of a large number of people in a short amount of time.7–12 This study aimed to evaluate the results of the use of 9,200 personal manikins in CPR training for the communities in four Brazilian cities.
~ o Paulo; the Municipal Health Department of From the Syrian-Lebanese Teaching and Research Institute (EFdP, RdQP), Sa ~o Paulo, Brazil. Maringá (JKGSS), Paraná; and the Syrian-Lebanese Hospital (FG, LFC), Sa Received November 26, 2013; revisions received January 18, March 18, and March 27, 2014; accepted April 18, 2014. This study was a project organized jointly with the Brazilian Ministry of Health, and all of the expenses were paid by the SyrianLebanese Teaching and Research Institute. The authors have no potential conflicts of interest to disclose. Supervising Editor: Brian O’Neil, MD. Address for correspondence and reprints: Edison Ferreira de Paiva, MD, PhD; e-mail: [email protected].
886 886
ISSN 1069-6563 886 PII ISSN 1069-6563583
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12423
887
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
METHODS Study Design This was a prospective observational study, designed to evaluate the dissemination of CPR training by distributing 9,200 personal manikins. The study was coordinated ~o Paulo in partby the Syrian-Lebanese Hospital in Sa nership with the Ministry of Health of Brazil, and it was approved by the research ethics committee of the Syrian-Lebanese Hospital. Study Setting and Population The study was conducted in four Brazilian cities, two in the state of Paraná (Apucarana and Maringá) and two ~o Paulo (Itanhae m and Sa ~o Carlos). in the state of Sa These are all medium-sized cities, and their populations range from 80,000 to 325,000 inhabitants, totaling 735,025 inhabitants. Study Protocol The town councils of the four cities received 9,200 CPR training kits and were responsible for distributing them to public and private elementary and secondary schools. The kits consisted of a folder with standardized information on SCA, an inflatable manikin that allowed mouth-to-mouth resuscitation and chest compressions, and a video that guided the practical training (Family & Friends CPR Anytime, American Heart Association– AHA & Laerdal Corporation). All the material was translated into Portuguese. The teachers from the four participating cities were invited to attend trainings on the initial measures in the care of SCA in adults, which were conducted by instructors certified to teach basic life support courses. Using the video and the inflatable manikin, the training included the identification of SCA and activation of the emergency medical system and the chance to practice chest compressions using a strategy known as “hands-only CPR.” Once trained, the teachers were instructed and encouraged to disseminate the training to their students using the same kits. The trained students were then instructed and encouraged to use the kit to disseminate the CPR skills among their family and friends. Upon completion of these steps, the population of the city was invited through different media resources to participate in a 1-day event called “Life Marathon” (“Maratona da Vida”). Trained teachers and students participated as facilitators in this mass hands-only CPR training guided by video. At the end of all of the training sessions, it was expected that 25% of the population of the four cities would have been trained.
Measurements A secure website was created to record the data on the internet (http://defesadavida.hsl.org.br). The following fields were registered: city, school, name, sex, age, and area of expertise of the teacher; name, sex, age, and grade of the student; and name, sex, and age of general population individual. Teachers received a user name and password and were responsible for entering the information into the system, including the number of trainings passed on by the students to the population. Only the coordinators of the Syrian-Lebanese Hospital had access to complete data. Data Analysis All data were processed through Excel worksheets (MS Office 2010). We evaluated the total number of individuals trained, divided by city, while maintaining the relationship of the teacher with his or her student and of the student with the individual from the general population. To verify differences in the implementation of training, the chi-square test and odds ratios (ORs) with 95% confidence intervals (CIs) were used. Tests were considered significant if p < 0.05 (two-tailed). RESULTS The training began with the first training session of the teachers on May 8, 2010, and lasted until the last Life Marathon on October 9, 2011 (17 months). The initial strategy consisted of teachers acting as the first wave of trainers and students acting as the second wave, but this strategy was only followed in the city of Apucarana. Due to the difficulties in getting teachers to train their students, and in response to pressures from coordina~o Cartion, the local coordinators from Maringá and Sa los, in agreement with the central coordination, decided to use professionals in the primary health care system as multipliers of the training. Physicians, nurses, and nursing technicians from various health units were trained, and they assumed the role of teachers and replicated the training for their colleagues in their unit. The latter, in turn, accepted the role as trainers in the second wave and transferred the training they had received to the general population. Table 1 summarizes the total number of people trained and the number of kits distributed per city. In total, 49,131 individuals were trained, which corresponded to 6.7% of the population of the four cities. Maringá was the city with the highest percentage of the population trained (12.0%), followed ~o Carlos (1.5%), and Itanhae m by Apucarana (5.5%), Sa (0.7%). In the city of Maringá, 39,041 individuals were
Table 1 Total Population, Trained Population, and Number of Kits Distributed per City City Apucarana m Itanhae Maringa ~o Carlos Sa Total
Inhabitants, N 115,323 80,778 325,968 212,956 735,025
Trained Population, n (%) 6,391 577 39,041 3,122 49,131
(5.5) (0.7) (12.0) (1.5) (6.7)
Kits Distributed, n 1,150 1,150 4,150 2,750 9,200
Data are reported as n, unless otherwise noted. *The data refer to active teachers and students, i.e., the ones who performed at least one training.
Maximum
7 – – – 7 1 – – – 1
Minimum Mean
2.5 – – – 2.5 45 0 0 0 45 (0.4) (0.0) (0.0) (0.0) (0.2) 18 0 0 0 18 755 87 335 288 755
Maximum Minimum
4 1 1 3 1 176.4 31.6 60.6 65.4 96.3 5,116 316 2,122 916 8,470 (22.8) (9.3) (33.7) (8.3) (17.3) 29 10 35 14 88 127 108 104 169 508
Mean City
Apucarana m Itanhae Maringa ~ o Carlos Sa Total
Trainings per Student*
Population Trained by Students Active Students* n (%) Trainings per Teacher*
Trained Students Active Teachers, n (%) Trained Teachers
trained, which represented 79.5% of the total number of trainings conducted. The training data regarding the initial strategy using the schools are shown in Table 2. Of the 508 trained teachers, 420 (82.7%) did not transfer the training to any students, while the remaining 88 (17.3%) trained 8,470 students, for an average of 96.3 students per teacher. Among the 88 active teachers, 22 (4.3% of the 508 teachers) trained 100 or more students and together accounted for 65.3% of these trainings. The maximum number of students trained by a single teacher was 755. Most of the students (80.2%) were between 10 and 16 years of age, 51.3% were female, and 73.9% were between the fourth and ninth grades of elementary school. Apucarana was the only city in which students conducted some trainings, although only 45 friends and family members were trained by 18 students (an average of 2.5 people trained per student, with a minimum of 1 and a maximum of 7; Table 2). Table 3 shows all of the training data, including for the schools, the health units, and the trainings conducted during selected marathons. The original strategy of using teachers and students as multipliers was responsible for the training of 13,727 individuals, which represents only 27.9% of 49,141 people trained. The new strategy, using health care professionals, allowed the training of the remaining 72.1% (34,404 people). In Maringá alone, 33,832 individuals were trained through the health units, including teachers, students, and community members, representing 68.9% of all the people trained in the four cities. The chances of passing the training to students were higher when the teacher was a health care professional than when he or she was from the area of education (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). In the city of Maringá, 127 professionals in the first wave trained 725 colleagues (an average of 5.7 colleagues per professional). In addition to the colleagues, these professionals directly trained the population, and each one trained an average of 159.6 individuals. The second wave of health professionals was also active, and each one trained an average of 17.5 people from the community. After the first and second waves of health professionals from the city of Maringá were trained, which occurred in July and August 2011, different strategies were employed to disseminate the training. Initially, all of the professionals in the health department were trained, including the community health workers and administrative staff. These trainings were conducted in a gymnasium in shifts that lasted approximately 30 minutes and were supervised by nurses. The community itself was separately trained by the health units in September and October 2011. The trainings were held in community halls on specific dates, with the participation of users who spontaneously sought the health units, family members contacted during home visiting, people invited by the local health councils, and even students and teachers from nearby schools. The trainings were prescheduled and repeated several times a day. m abandoned the project early, did The city of Itanhae not hold the Life Marathon, and trained only 577 people. During the marathons held in the three remaining
de Paiva et al. • DISSEMINATING CPR TRAINING
Table 2 Data From the Training of Teachers, Students, and the General Population Trained by the Students in Each City
888
889
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
Table 3 Results From All of the Trainings Conducted in the Schools, by Health Units, and During Marathons in the Four Cities
City
Teachers
Apucarana (schools) Subtotal 127 m (schools) Itanhae Subtotal 108 Maringa Schools 104 Health units* 127 Subtotal 231 ~o Carlos Sa Schools 169 Health units* 15 Subtotal 184 Total 650
Students
Population Trained by Students
Population Trained by Teachers
Total Population
Marathon
Total
(19.5)
5,116 (55.6)
45 (0.4)
436 (1.7)
481 (1.3)
667 (40.6)
6,391 (13.0)
(16.7)
316 (3.4)
0 (0.0)
153 (0.6)
153 (0.4)
0 (0.0)
577 (1.2)
(16.0) (19.5) (35.5)
2,122 (23.1) 725 (7.9) 2,847 (31.0)
0 (0.0) 12,716 (99.6) 12,716 (99.6)
2,359 (9.5) 20,264 (81.4) 22,623 (90.9)
2,359 (6.3) 32,980 (87.6) 35,339 (93.9)
(26.0) (2.3) (28.3) (100.0)
916 0 916 9,195
0 0 0 12,761
114 1,557 1,671 24,883
114 1,557 1,671 37,644
(10.0) (0.0) (10.0) (100.0)
(0.0) (0.0) (0.0) (100.0)
(0.5) (6.3) (6.8) (100.0)
(0.3) (4.1) (4.4) (100.0)
– – 624 (38.0) – – 351 (21.4) 1,642 (100.0)
4,585 (9.3) 33,832 (68.9) 39,041 (79.5) 1,199 1,572 3,122 49,131
(2.4) (3.2) (6.3) (100.0)
All data are n (%); — = not applicable *Health professionals who received the first training are identified as teachers, and the colleagues trained by them are identified as students.
cities, 1,642 individuals were trained, for an average of 547.3 individuals per marathon (Table 3). Although the system allowed us to record some of the characteristics of the population trained, such as age, occupation, and relationship with the trainer, less than 5% of the records were completely filled, making it impossible to analyze these data. DISCUSSION In this study, the initial estimate was that each teacher would train 50 students and each student would transfer the training they had received to at least 20 relatives and friends, thus allowing the initial expectation of training 25% of the population to be easily met. However, the vast majority of teachers (82.7%) did not train any students. The delay in the distribution of the kits after the teachers had already been trained is one possible explanation for this fact. When the study was being planned, there were no kits in Portuguese, and the process of translation, production outside of the country, and importation took longer than initially expected. It is possible that over time, the teachers became discouraged and felt unprepared to train the students, despite the material, including the video, being self-explanatory. A questionnaire given to Belgian teachers found that only 31% of them felt able and willing to provide CPR training to their students, even though 59% of them had received prior training. The main reasons given were the perceived lack of knowledge and inability to perform CPR correctly.13 After the study was completed, an e-mail was sent to teachers who had not trained any students, asking them the main reason. We had responses from only 52 of 420 (12.4%) and the main reasons were insecurity (53.8%), transfer of school (21.2%), and never having received the training kits (19.2%). An additional 5.8% said they had trained some students, but had problems accessing the system to record the training.
A small percentage of the teachers in our study showed great motivation, and 22 of them (4.3% of the total) were responsible for training 65.3% of the 8,470 students. It is likely that repeated trainings increased the confidence of these teachers and made it easier for them to disseminate the knowledge to new classes. The distribution of personal manikins to students to disseminate CPR training has been used in other studies, and each student has passed the training on to 1.7 to 2.9 people, which has been considered effective by the authors.10–12 In Apucarana, the only city in which students conducted some training, the average number of trained individuals was similar to these studies (2.5 per student), but very far from the expectation that a student would train 20 family members and friends. Political issues were also a reason why the project did not follow the originally proposed training cascade. The local coordinators were connected to the municipal government, and they had to contact both municipal and state education secretaries, who were often from different political parties and had different interests. Furthermore, the effectiveness of the interventions of the ~o Paulo, central coordination of the project, located in Sa was hampered by the distance between the cities, which reached up to 650 km. Due to the difficulties in developing the project in ~o Carlos and Maringá chose to schools, the cities of Sa use the primary health care network, which proved to be very effective, particularly in the city of Maringá. With this strategy, in only 4 months, Maringá was responsible for 33,832 trainings or 68.9% of the 49,131 trainings conducted in the four cities. The heavy involvement of health professionals, which was a key part in the success of this strategy, most likely occurred because they knew the relevance of the topic and the importance of disseminating information on initial SCA care. Moreover, it was unlikely that the health professionals would not feel capable of teaching basic concepts of resuscitation to the general population. In
890
de Paiva et al. • DISSEMINATING CPR TRAINING
Table 4 Suggestions for Creating a Community CPR Training Program 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Create a public-private partnership that gives financial support to the project. Use the network of the public, primary health care system. Involve health professionals who have direct contact with the population. Develop activities during working hours of professionals. Encourage community participation through campaigns in health facilities and homes. If available, use different media resources to invite the community to participate in the project. Use simple training kits, guided by video, enabling the practice of skills in a standardized manner. Prevent key actions to be attributed to people with conflicts of interest. Train local professionals to act as coordinators, thus allowing the decentralization of control. Maintain constant control over the quality of the information collected.
addition, health professionals were linked only to the municipal health secretariat, limiting the number of political actors involved. Considering all the investment and dividing it proportionally to the population of each city, it is estimated that every individual trained in the city of Maringá has cost 7.75 dollars. The intention to train at least 25% of the population turned out to be a serious error of estimation, because the political interests involved in programs of this magnitude are very well known and it would not have been difficult to anticipate the problems encountered. We also knew that insecurity of teachers could be a barrier to the spread of the training, but the late delivery of the kits increased the time between training and replication, which certainly contributed to increased insecurity. Typical problems of a country still in development, as the constant change in place of employment and the lack of sensitivity of the administrators, also contributed to most of the teachers never doing any training, because they were not in the same workplace, or because they never received the training kits. Nevertheless, thanks to the involvement and active participation of health professionals, it was possible to train a significant portion of the population in Maringá. In underdeveloped and developing countries, the initiatives for training the community in public health problems are rare, generally isolated, dependent on medical societies, and of limited scope. In this study, there was a partnership between the Ministry of Health and a private nonprofit institution, which allowed disseminating the knowledge of the basic steps of CPR to the community, and we believe that this experience can be replicated successfully in other centers. From the difficulties encountered during the study, we identified 10 points that can contribute to the success of similar projects in the future (Table 4). LIMITATIONS The main limitation of this study was that the strategy that allowed the training of a large number of people in the city of Maringá did not follow the initial plan. Thus, there is no guarantee that the same results would have been obtained if the same strategy had been implemented in the other cities. Another limitation is that no evaluation of the effect of training on survival of adult victims of SCA was performed. Indeed, the initial study design included the comparison of data from prehospital care before and after the training. However, in our
country there is no culture of keeping records of good quality, and although a simple evaluation form was created, it was never used in the pretraining phase, which prevented any possibility of comparison. Despite these limitations, we believe that our results indicate that the involvement of health care professionals in training the general population in basic CPR maneuvers is very effective and should be tested in future studies. CONCLUSIONS The distribution of personal resuscitation manikins is an effective way to train people in cardiopulmonary resuscitation. The involvement of primary health care professionals in the training appears to be a more efficient multiplier strategy than a training network composed of teachers and students. References 1. Eftestøl T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during outof-hospital cardiac arrest. Circulation 2004;110:10–5. 2. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832–47. 3. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO. The location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987;16:787–91. 4. Stokes NA, Scapigliati A, Trammell AR, Parish DC. The effect of the AED and AED programs on survival of individuals, groups and populations. Prehosp Disaster Med 2012;27:419–24. 5. White RD, Bunch TJ, Hankins DG. Evolution of a community-wide early defibrillation program experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 2005;65:279–83. 6. Eckstein M. The Los Angeles public access defibrillator (PAD) program: ten years after. Resuscitation 2012;83:1411–2. 7. Done ML, Parr M. Teaching basic life support skills using self-directed learning, a self-instructional
ACADEMIC EMERGENCY MEDICINE • August 2014, Vol. 21, No. 8 • www.aemj.org
video, access to practice manikins and learning in pairs. Resuscitation 2002;52:287–91. 8. Isbye DL, Rasmussen LS, Lippert FK, Rudolph SF, Ringsted CV. Laypersons may learn basic life support in 24 min using a personal resuscitation manikin. Resuscitation 2006;69:435–42. 9. Lynch B, Einspruch EL, Nichol G, Becker LB, Aufderheide TP, Idris A. Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation 2005;67:31– 43. 10. Corrado G, Rovelli E, Beretta S, Santarone M, Ferrari G. Cardiopulmonary resuscitation training in high-school adolescents by distributing personal
891
manikins. The Como-Cuore experience in the area of Como, Italy. J Cardiovasc Med (Hagerstown) 2011;12:249–54. 11. Isbye DL, Rasmussen LS, Ringsted C, Lippert FK. Disseminating cardiopulmonary resuscitation training by distributing 35,000 personal manikins among school children. Circulation 2007;116:1380–5. 12. Lorem T, Palm A, Wik L. Impact of a self-instruction CPR kit on 7th graders’ and adults’ skills and CPR performance. Resuscitation 2008;79:103–8. 13. Mpotos N, Vekeman E, Monsieurs K, Derese A, Valcke M. Knowledge and willingness to teach cardiopulmonary resuscitation: a survey amongst 4273 teachers. Resuscitation 2013;84:496–500.
