Reimagining CPR Training to Enable More Real-World Applications

Relatively few people get formal training, while the public generally perceives that only formally trained people can do CPR.

Looked at objectively, the current emphasis on formal CPR training—go to a class, get a card—isn’t succeeding very well according to some key measures. Relatively few people get formal training, while the public generally perceives that only formally trained people can do CPR. As a result, the vast majority of sudden cardiac arrest (SCA) victims don’t get CPR.

This misconception is one reason for the low SCA survival rates in this country. Alternative approaches, however, have the potential to educate massive numbers of people and dramatically in- crease the number of SCA victims who get CPR. That, in turn, could give us the much-needed power to finally improve survival rates.  

Anatomy of Sudden Cardiac Arrest
The sheer magnitude of SCA as a public health threat is easy to describe. Nearly 400,000 people experience SCA outside of hospitals in the United States every year. Approximately 120,000 of these—roughly 30 percent— are stricken in public places outside of the home.

Now, imagine a map of the United States—all 3.8 million square miles—with a dot on every office building and campus, shopping mall, retail store, hotel, manufacturing plant, airport, amusement park, gambling establishment, government building, health club, school, church, sports arena, public park, side- walk, and every other similar workplace and community setting (that’s a lot of dots!). These are the public locations where one of the 120,000 SCA events per year might happen at any given moment. But, of course, it is impossible to predict precisely who, when or where SCA may strike. At any one of these given locations, SCA can only be expected roughly once every 10 to 40 years.

We know that quickly delivering CPR can help keep an SCA victim’s heart “defibrillation-ready” for a time and, along with AED use, can contribute to saving the lives of many more SCA victims. This means there must be someone nearby at the time SCA strikes who is equipped and willing to do CPR. But today, only about six in 100 SCA victims are likely to survive, in part because there are too few volunteer bystanders allowed, willing and able to quickly start CPR (and because of the AED shortage).1

CPR Training, Effectiveness and Success Barriers Today
The dominant training model today harkens back to the 1960s, the dawn of CPR education for the general public. It emphasizes (or requires) formal, in-person, fee-based, instructor-led, card-issuing CPR training and is widely touted as the best way to educate and get volunteer lay-bystanders to do CPR. Is this model working? Arguably not.

Logistically, a very large volunteer “SCA responder squad” is needed to ensure someone is almost always nearby who is willing to help.2 But less than five per- cent of the U.S. public is formally trained in CPR due to time and cost barriers, among other reasons. And only about one-quarter of SCA victims receive bystander CPR in public. There are many reasons for this persistently low CPR rate, but here are some of the biggest barriers:

Widespread public perception that only formally trained people, with a valid course completion card, are permitted to try CPR. This perception is created by AED laws (see below), training organizations, lawsuits, social media, etc., and dramatically reduces the number of people who might otherwise try to help.

Difficulty recognizing SCA. Upwards of 50 percent of trained and untrained bystanders fail to accurately identify SCA and start CPR. This is not surprising since a SCA situation is one they may encounter perhaps once in a lifetime.

Persistent concerns about legal liability. As an expert witness in SCA lawsuits where CPR is not started, I see first-hand how real the liability risk is and why many bystanders remain fearful of helping, a sentiment that is not likely to wane in our highly litigious society.

Another giant barrier is created by AED laws in 30+ states that require formal CPR training for volunteer lay-bystanders in public access AED programs. While these requirements have little impact on AED program preparation or performance, they dramatically increase the cost of having AEDs and contribute to the perception that current training is a precondition to being allowed to perform CPR. This is particularly true when the training requirement is linked to the availability of Good Samaritan legal protections.

Bottom line: The current emphasis on formal, instructor-led, course completion card-based training, coupled with other barriers to success, leaves most SCA victims without a potentially life-saving intervention they desperately need.

Reimagining CPR Training for Meaningful Impact
So, how do we create a large-scale SCA responder squad that gets more people to learn and do CPR?

Let’s break things down into bite-size pieces to help us reimagine new models for success.

Measure the right things. In a reimagined SCA responder model, the most important measures are the number of general public members who learn CPR skills from any source and the number of SCA victims who get early CPR. It is not the number of course completion cards issued.

Clearly define the limited skills expected of the general public for effective hands-only CPR. We want SCA responder squad members to:

  • Know how to recognize SCA
  • Call 9-1-1
  • Quickly volunteer to try and help
  • Put his/her hands in the right place
  • Do two-inch deep chest compressions 100 to 120 times per minute, while allowing the chest to come all the way up each time
  • Not stop until an AED is applied, or professional emergency medical services resources arrive to take over

Expressly allow and encourage lots of different ways to communicate CPR skills. Deem members of the general public as “trained” regardless of where they learn CPR skills. Leverage on- line-only learning platforms, augmented reality (AR) technologies, social media, video platforms, stadium video screens, kiosks, and every other medium that can communicate CPR content. Studies show that good CPR effectiveness can be achieved using online training only—even without skills practice—and ultra-brief videos. These technologies are the only way to scalably “train” large numbers of people. We should not hesitate to put them to good use.

Don’t let perfection be the enemy of the good. Good CPR is hard to do for both volunteer bystanders and professional health- care workers alike. Simply put, CPR is a difficult skill for anyone, at any skill level, to perform well, particularly for people who may first be called upon to perform the task unexpectedly at one highly stressful and emotional point in time. CPR quality under a mass- training model admittedly won’t be perfect, but for the three out of four SCA victims who don’t get CPR now, less-than-perfect CPR is much better than none.

Recognize the limitations of formal training. Formal CPR training does not result in “certification” from any regulatory body. Trainees simply receive a course completion card saying they successfully completed a class as determined by a course instructor. Importantly, such training is not evidence of competence nor a predictor of how lay bystanders will act when faced with an actual emergency. Given these limitations, it is better to scalably train masses of people in lots of different ways than limit the pool of potential rescuers willing to help by requiring formal training.

Change the laws. There is certainly a role for formal CPR training for those types of jobs that should require it, and many organizations will continue to formally train employees even under a reimagined model. For lay-bystanders working in places with AED programs, formal training should not, however, be a legal requirement. AED laws should be changed to reflect this and to encourage everyone to learn CPR skills in whatever way works best for them. Good Samaritan laws should also be strengthened to provide real legal protections for everyone who steps in to try and help SCA victims.
 
Let the market evolve a wide variety of CPR training business models. Fee-based, formal CPR (and AED) training is big business with revenues of about $500 million annually. But, because of time and cost barriers, it necessarily limits the number of people trained and willing to help. If allowed to emerge and thrive, one can imagine a wide range of new business models supporting alternative training methods. Examples might include free, advertising- based, subscription-based, traditional fee-based and many others. The training market will find its own path, orders-of-magnitude more members of the general public will be trained, and more SCA victims will get early CPR. Win-win-win.

Wrapping Things Up
Arming massive numbers of the general public with CPR skills and allowing and encouraging everyone to try CPR when faced with a person believed to be in SCA are critical steps if we truly want to meaningfully increase SCA survival rates. Reimagining and implementing a new CPR training model can realistically help us achieve that goal. We simply can’t ignore that change is needed in order to make it happen. This matters too much. Lives are in the balance, just waiting for us to act.

REFERENCES
1 https://readisys.com/the-aed-shortage/
2 https://readisys.com/squad-goals-moving-the-needle-on-sudden- cardiac-arrest-requires-a-new-model/

This article originally appeared in the January/February 2020 issue of Occupational Health & Safety.

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