Bystander cardiopulmonary resuscitation (CPR) is known to improve survival of cardiac arrest; however, there is a disparate geographic variation in cardiac arrest survival and only a small number of the U.S. population is trained in CPR annually. According to the Institute for Medicine (IOM), high school students may be an excellent target for CPR training. A review published in the Journal of the American College of Cardiology found that over half of U.S. states require some form of CPR training in high school, but there is wide variability in instruction.

Researchers identified 32 states with CPR laws using the American Heart Association’s “CPR in Schools” website in June 2016. Maine was unintentionally omitted due to misidentification on the website. The superintendents in each of these states were sent an email survey containing 12 questions on demographics and the current status of CPR instruction in the school. Follow-up emails were sent at one and three months and researchers also attempted to identify district-level superintendents and individual school principals. In total, 424 of 25,694 eligible high schools in 32 states completed the survey. Of the participating schools, 96 percent were public schools and 3 percent were private schools. All surveyed schools are in states that require CPR training in high school by law; however, only 77 percent of respondents indicated they provide CPR training at their school. Several of the surveyed states had passed laws within the last year and schools in these states commented they are creating programs in response to the new laws.

About 97 percent of responding schools provide CPR training during school hours. CPR training most commonly took place in health class for 9th and 10th grade students. Most schools indicated using a CPR-certified teacher/coach or other CPR-certified instructor; however, 11 percent reported using a non-certified teacher/coach. Ninety-six percent of schools use hands-on CPR practice as part of their training. Automated external defibrillator (AED) training occurs in 63 percent of schools. However, even in states where multiple schools responded, variation occurred in responses.

In September 2017 researchers found an additional seven states had passed CPR legislation since the time of the survey. The respective legislation in all 39 states was categorized on the following:

• Class specified for CPR training
• Instructor certification to teach CPR required
• AED instruction
• CPR training program recommended/required
• Hands-on practice required
• State funding availability

Upon examination of the 39 states with legislation, researchers found the following:

• One does not require hands-on training
• 89 percent require a “nationally recognized” method
• 8 percent do not specify a training method
• One state requires full CPR certification
• 77 percent require AED training
• 8 percent of states require the instructor be certified to teach CPR
• 75 percent specify CPR training take place during a specific class, typically health class

“Prior CPR training is the single most powerful factor contributing to a person performing bystander CPR in an emergency,” said Lorrel E. Brown, MD, FACC, associate director of the Cardiovascular Medicine Fellowship Program at the University of Louisville School of Medicine and lead author. “By requiring high school students to receive training before graduation, we are creating a group of potential lifesavers each year.” 

Brown notes that bystander CPR has increased in Norway, Denmark and Minnesota following the institution of school CPR training. “CPR training is most effective when it is taken as a societal responsibility to the community, rather than only under the purview of medical professionals,” he adds. “Nearly 700,000 high school students live in states without CPR training legislation, representing a missed opportunity to equip our population with this vital skill.”

Valentin Fuster, MD, PhD, MACC, editor-in-chief of the Journal of the American College of Cardiology, agrees. “I believe that implementation of CPR training in U.S. high schools should be strongly considered, and these types of mandates should begin to be instituted by the state government,” Fuster said. “This approach could save thousands of lives.”

“The ACC actively worked with our chapters in all of these states to pass CPR legislation,” said Frank Ryan, ACC’s director of state advocacy. “Passing legislation in the remaining states continues to be a priority for the College, its Chapters and the ACC’s State Advocacy team. From there, our job is to advocate for implementation of these programs.”

Keywords: United States, American Heart Association, Research Personnel, State Government, Minnesota, Maine, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division, Defibrillators, Cardiopulmonary Resuscitation, Schools, Students, Heart Arrest, Certification

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