Reducing Barriers to Optimal Automated External Defibrillator Use: An Elementary School Intervention Study

Abstract

Background

Timely use of an automated external defibrillator (AED) improves outcomes in sudden cardiopulmonary arrest (SCA). Our project aims were to: 1) identify the barriers to optimal AED use in the Québec City area elementary schools; 2) create targeted educational material regarding AEDs; and 3) measure the impact of the teaching module.

Methods

Using a quality improvement in health-care framework, a survey exploring the barriers to AED use was sent to 139 elementary schools. We then developed a video teaching module on using AEDs to address these barriers. A convenience sample of 92 elementary school professionals participated in a mock scenario. Metrics related to AED use were assessed at baseline and after completing the post-teaching module. The primary outcome was the time to first shock and secondary outcomes consisted of evaluating the completion of each step required for safe and effective AED use.

Results

The barrier analysis survey received a response rate of 52.5%. Most schools reported having an AED (95%), but 48.6% indicated that no formal training was offered. After the teaching module, the appropriate use of the AED in an SCA simulation improved from 53% to 92% (P < 0.001). The average time elapsed before first shock was 66 (95% confidence interval [CI], 63-70) seconds at baseline compared with 47 (95% CI, 45-49) seconds post-teaching module (P < 0.001).

Conclusions

Lack of training, the main barrier to optimal use of AEDs in elementary schools, can be addressed through a brief video teaching module, thus improving the ability to deliver timely and effective defibrillation.

Nontraumatic sudden cardiac arrest (SCA) in children is rare, with an incidence of fewer than 2.1 per 100,000 person-years.1, 2, 3, 4 However, the outcome is often poor and the consequences are devastating for both the family and the community.^4,5 Sudden cardiac death is responsible for approximately 5%-10% of all deaths in children 5-19 of age.⁶ During a pediatric SCA, rapid access to an automated external defibrillator (AED) is critical,⁷ because the survival rate of SCA in educational institutions without an action plan is as low as 10%.⁸ In contrast, survival can reach 64% in schools with a predetermined action plan.^3,9 A recent survey of schools from New York State linked AED deployment to long-term survival without disabilities of 68% post-SCA in adults and students.¹⁰ In children, timely AED use is also associated with a higher survival rate.⁷ In SCA victims under 20 years of age, ventricular fibrillation is the initial rhythm in 19% of out-of-hospital resuscitations.¹¹

With the intent of improving SCA outcomes, many countries have adopted regulations and legislation regarding cardiopulmonary resuscitation (CPR) training and AEDs.^12,13 In the province of Québec (Canada), only high school students have had mandatory CPR training embedded in their academic curriculum (since 2017),¹⁴ with uncertain uptake. Only childcare workers are required to complete a general first aid course in Québec and such training is voluntary for school personnel and support staff. In 2019, the Advanced Coronary Treatment Foundation completed a fundraising campaign to ensure there is an AED for all public high schools in the Province of Québec. Nevertheless, many barriers impeding AED use in school settings have been reported³---chief among these elementary schools not being required to have an AED on site. Insufficient training and difficulties accessing the AED have been reported as significant barriers that negatively impact the willingness to use an AED on school premises.³

In Québec, the potential barriers to AED use by school faculty members and possible mitigation strategies and interventions to improve AED utilisation have never been studied. Therefore, using a quality improvement in health-care framework,¹⁵ we sought to improve knowledge and availability of defibrillation devices for SCA in elementary schools. Specifically, we aimed to: 1) survey and identify common barriers to AED use during pediatric SCA in elementary schools in the Québec City area; 2) create educational content for AED use explicitly designed for elementary school teachers and addressing these barriers; and 3) assess the impact of this educational material on the delay to first shock and appropriateness of AED use during a simulated pediatric SCA.

Methods

Study protocol and ethics approval

Our study protocol was developed using a quality improvement in health-care framework, as described elsewhere.¹⁵

Survey development and administration

We developed a survey to identify the perceived barriers to optimal AED use by elementary school professionals in our region. First, to assess barriers to AED use, we used a validated survey that has already been implemented in the USA and translated it from English.³ Second, the translated survey was pilot tested with 5 teachers to assess comprehension and fidelity of the questions. The final survey included 21 items, of which 8 were relevant as potential barriers. The survey consisted multiple-choice questions. Questions allowed respondents to choose "Other" and specify their narrative text answers. This served as a source for new ideas and discussion among the research team and allowed us to capture a full range of possible responses.¹⁶ The survey aimed to identify perceived barriers to AED use in schools reporting the presence of at least 1 device, but it also identified factors limiting AED acquisition. Third, an electronic version of the survey was sent to all 139 elementary schools in the Québec City area and its outskirts in December 2018. All school staff were eligible to complete the survey. One reminder was sent out approximately 1 month after the initial survey was sent. The responses were collected and collated by 4 emergency medicine residents (P.G.B., F.P., V.G., M.P.L.) who, through thematic analysis, identified the primary barriers that would serve as substrate for the educational content.

Creation of the education material

Based on the survey findings, and with the help of experts with educational expertise, a 4-minute video teaching module was created (in French; see Supplementary Appendix S1). The video described a step-by-step approach to achieving proper and timely AED use after SCA. However, the video did not illustrate all CPR manoeuvres to not distract from the main objective of the module, which was to teach the proper AED use and mitigate the barriers to use of AEDs documented in the survey.

Assessment of the intervention

Three of the responding schools were selected to deliver the intervention and undergo evaluation. Choices were based on the availability of their employees and their perceived training deficit reported at the time of the survey. A convenience sample of 92 school professionals, primarily teachers and evenly distributed among the 3 participating schools, was recruited. Participation was voluntary and consent to participate was obtained from each. Involvement consisted of the simulation exercise before and after viewing the video teaching module. Sequentially, during May 2018, volunteers underwent the first simulation of a child in SCA. Immediately after this mock scenario, the 4-minute teaching video was presented to the participants in groups of 4. No other reference material or training was provided to participants. Finally, participants underwent another SCA simulation immediately after the video teaching module (intervention phase). Due to resource constraints, the before and after data were obtained on the same day and no long-term assessments were performed.

In the pre-phase scenario, each participant was presented with an automatic AED kept in its usual standby mode in its case. A mannequin covered with a shirt was positioned supine on a table with the following text: "This child was found unconscious, not breathing and with no signs of circulation. A colleague asks you to use this AED." Four senior emergency medicine residents, skilled in providing advanced life support, recorded the completion of crucial steps and time to first shock while each volunteer individually operated the AED with no input from the evaluators. The scenario ended when the first shock was delivered or if 2 minutes had elapsed and no shock could be given. AED use was considered safe if the volunteer remained clear of the simulated patient during shock delivery. Participants were then led to another area in the simulation room and viewed the 4-minute video teaching module. Next, they underwent the same mock SCA scenario under the supervision of another emergency medicine resident.

Outcomes

The study’s primary outcome was the delay before delivering the first shock. Emergency medicine residents used a stopwatch to measure the time from the moment each participant completed reading the clinical scenario to delivery of the first shock. We also evaluated the performance of the first responders in the mock scenario using a checklist derived from the validated AED assessment tool described in the Basic Life Support Instructor Manual of the Heart and Stroke Foundation.

Statistical analysis

Survey response rate and answers are expressed as total number of respondents and percent. Findings relative to the time to first shock are presented as point estimates and 95% confidence intervals (CIs). Differences in AED performance were reported using a paired t test (time to first shock) and the McNemar test for paired data (success of the procedure). P ≤ 0.05 was considered statistically significant. Statistical analyses were conducted using SPSS version 19 for Windows (IBM Corp, Armonk, NY).

Results

Survey results

The survey was sent to 139 elementary schools and completed by 73 respondents, including 1 partially completed survey (response rate 52.5%; Table 1). Most schools were public (n = 61, 83.6%) and considered to be in middle (n = 30, 41.1%) or high (n = 29, 39.7%) socioeconomic locations. Almost all schools (n = 70, 95.9%) had an AED on site. Only 4 respondents (5.7%) were aware of an SCA episode that had happened on their campus. Among these, the AED was used only once (1.4%). Most respondents (n = 55, 79.7%) believed that AED training by well-established organisations (eg, Red Cross or Heart and Stroke Foundation) was effective in general and that the location of the AEDs was known by staff members (n = 63, 90.0%). The most commonly identified perceived barriers to effective AED use were insufficient training (54.2%) and the reluctance of staff members to deliver a shock (37.1%; Table 2). In addition, 34 (48.6%) participants expressed that no training was offered after AED acquisition. Fourteen (20.0%) participants stated that they did not perceive any barrier to AED use during an SCA event. For the 3 schools without an AED, 2 reported financial resources as the main barrier to acquiring a device.

Table 1.

Survey results

Variable	n of N	Percent∗
1. What job title describes your position?
Principal	38 of 73	53.4%
Teacher	5 of 73	8.2%
Member of the administration	30 of 73	38.4%
2. Your school is:
Private	12 of 73	16.4%
Public	61 of 73	83.6%
3. Your school is:
Suburban	30 of 73	41.1%
Rural	5 of 73	6.8%
Urban	38 of 73	52.1%
4. What is the socioeconomic status of the students in your school?
Low socioeconomic status	14 of 73	19.2%
Middle socioeconomic status	30 of 73	41.1%
High socioeconomic status	29 of 73	39.7%
5. How many students does your school have?
251-500	16 of 73	50.7%
501-750	37 of 73	21.9%
< 250	16 of 73	21.9%
> 751	4 of 73	5.5%
6. How many personnel members does your school have?
11-25	8 of 73	11.0%
26-50	27 of 73	37.0%
51-75	25 of 73	34.2%
> 75	13 of 73	17.8%
7. Does your school possess an AED?
No	3 of 73	4.1%
Yes	70 of 73	95.9%
8. Where is (are) the AED(s) located?
Other	5 of 70	7.1%
Hallway	32 of 70	45.7%
Gymnasium	32 of 70	45.7%
School nurse’s office	1 of 70	1.4%
9. Is the location(s) of the AED(s) known by the direct respondent staff
No	7 of 70	10.0%
Yes	63 of 70	90.0%
10. Did your faculty receive training regarding the use of an AED?
No	34 of 70	48.6%
Yes---Videos	10 of 70	14.3%
Yes---Lectures	14 of 70	20.0%
Yes---Web/computer	1 of 70	1.4%
Yes---Written manuals	0 of 70	0%
Yes---Red Cross training	14 of 70	20.0%
11. Do you personally believe that the AED training is efficient and sufficient?
No	14 of 69	20.3%
Yes	55 of 69	79.7%
12. Is the functional status of the AED(s) checked frequently?
No	30 of 69	43.5%
Yes	39 of 69	56.5%
13. Has there ever been a cardiac arrest in your establishment?
No	66 of 70	94.3%
Yes---With use of the school’s AED	1 of 70	1.4%
Yes---Without the use of the school’s AED	3 of 70	4.3%

AED, automated external defibrillator.

^∗Percentage after excluding missing values.

Table 2.

Identified barriers to AED use

Barrier to AED use	n of N	Establishments with an AED
Staff members are not properly trained	38 of 70	54.2%
Staff members are hesitant to deliver AED shock	26 of 70	37.1%
Staff members do not know where the AED is located	4 of 70	5.7%
If cardiac arrest in the evening, staff members do not know where the AED is located	3 of 70	4.3%
If cardiac arrest in the evening, AED is located in a locked area and access is limited	1 of 70	1.4%
Others	0 of 70	0.0%
None	14 of 70	20.0%

AED, automated external defibrillator.

Impact of the educational session

A total of 92 participants agreed to participate in the pediatric SCA simulation and viewed the video. The teaching module was developed to address the barriers identified by the survey, such as the availability of on-site training and the safety of AEDs. Before viewing the video module, the average delay before administration of the first shock was 66 (95% CI, 63-70) seconds compared with 47 (95% CI, 45-49) seconds after the teaching session (P < 0.001; Fig. 1). Thus, there was a mean improvement of 19 seconds (P < 0.0001) after the educational session (an absolute reduction of 29%). Other AED-related variables included in the Heart and Stroke Foundation assessment tool also showed improvement. The proportion of participants who operated the AED properly improved from 53.3% to 92.5% (P < 0.001; Table 3). Fifty-six percent of participants reported undergoing previous training in AED use. Previous training was found to be a strong predictor of sequence success before the video teaching module (odds ratio = 3.15; 95% CI, 1.33-7.42; P = 0.009; Table 4).

Figure 1.

Time to first shock (in seconds) at baseline (white bar) and after teaching module (black bar), with 95% confidence interval. ∗P < 0.001 vs control.

Table 3.

Evaluation of the impact of video teaching module

Variable	Pre/yes, n of N (%)	Post/yes, n of N (%)	Difference	P value
Turning on AED	92 of 92 (100%)	92 of 92 (100%)	+0%	---
Stripping of thorax	65 of 92 (70.7%)	92 of 92 (100%)	+29.3%	<0.0001
Plug the electrodes	92 of 92 (100%)	91 of 92 (98.9%)	−1.1%	1.0000
Apply the electrodes properly	62 of 92 (67.4%)	88 of 92 (95.7%)	+28.3%	<0.0001
Assuring that no one is touching the patient during analysis	86 of 92 (93.5%)	92 of 92 (100%)	+6.5%	0.0313
Shock delivery when suggested	89 of 92 (96.7%)	92 of 92 (100%)	+3.3%	0.2500
Assuring to not touch the patient during shock delivery	86 of 92 (93.5%)	90 of 92 (97.8%)	+4.3%	0.2891
Sequence success?	49 of 92 (53.3%)	85 of 92 (92.4%)	+39.1%	<0.0001

AED, automated external defibrillator.

Table 4.

Previous training and sequence success prior to video teaching module

Variable	Level	Pre/sequence success?				Odds ratio (95% CI)	AUC	P value∗
		No		Yes
		n of N	Percent	n of N	Percent
Previous training	No	25 of 40	62.5%	15 of 40	37.5%		0.64	0.0088
	Yes	18 of 52	34.6%	34 of 52	65.4%	3.15 (1.33-7.42)

AUC, area under the curve; CI, confidence interval.

^∗Based on bivariate logistic regression with Wald confidence interval, and Firth correction for bias when appropriate.

Discussion

The results of this study emphasise there are significant barriers to AED use by elementary school staff members. However, we have shown that a tailored brief video educational session can significantly reduce the delay before the first shock in a simulated pediatric SCA setting (29% time decrease) while increasing the percentage of participants who successfully complete the entire defibrillation sequence.

In the Québec City area, almost all elementary schools were found to have an AED on premisis. Therefore, acquiring an AED did not appear to be a significant barrier, at least in the jurisdiction in which this study was conducted. In contrast, insufficient training and fear of using the AED remained as the main perceived obstacles to AED use by elementary school staff. These findings have been replicated in studies from the USA.^3,17 For the minority of institutions reporting no AED on school premises, 2 barriers to AED acquisition were identified: 1) lack of financial resources and 2) not entertaining its purchase. Both barriers are modifiable factors with simple actions, such as raising awareness and financial support. Notably, data from the Resuscitation Outcomes Consortium Epistry database show that schools represent 72.5% of registered AED-covered cardiac arrest locations.¹⁸

Initially, most survey respondents in our study reported that AED training was effective (n = 55, 79.7%). Nevertheless, the most frequently reported barrier identified was insufficient training. It is important to consider that question 11 inquired about participants' perception of AED training as offered by the Red Cross or other well-established first-aid teaching programs. The participants believed that, although the available AED training was appropriate at their institution, the staff and direct respondents remained undertrained. Accordingly, nearly half of the respondents (48.6%) answered that no training was offered since the school acquired the AED. This result is similar that from the survey conducted in Toronto by Hart et al., who found that only 47% of schools provided AED training to staff.¹⁹ Previous studies on AED use in various school settings have also highlighted insufficient training.^3,19,20 Recently, Allan et al. surveyed all publicly funded schools in Ontario and found that only 60% provided staff with CPR training.²¹ Our data combined with findings by Hart et al.¹⁹ illustrate that the training offered to school staff is likely insufficient, suggesting that clearer recommendations are needed. In Québec, the Commission des normes, de l'équité, de la santé et de la sécurité du travail administers the First Aid in the Workplace Program. Under this program, the Commission regulates the training and dictates the employer's obligations concerning first aid. Depending on the workplace and the number of workers, the number of first responders required varies. Only 2 first responders are mandated for schools with fewer than 150 workers. These meagre legal minimum requirements may explain why school directions do not provide staff with more training.

The impact of the educational video module can be reflected through the significant reduction in time to first shock and the quality of the defibrillations. Despite reaching statistical significance, one could argue that the reduced time to first shock measured may not be clinically significant. However, according to the 3-phase time-sensitive model of cardiac arrest, the first 4 minutes of out-of-hospital cardiac arrest (OHCA)---the electrical phase---represents a unique window of opportunity. Survival rates are approaching 50% for patients defibrillated during the electrical phase compared with less than 10% for patients with OHCA.²² Previous studies characterized the deleterious effects of time on survival to OHCA, with each passing minute decreasing survival by 7%-10%.²³ Moreover, our data show that the video teaching module not only reduced the time to first shock but also improved the adequate defibrillation sequence by 39%. In this context, an improvement of 20 seconds in the electrical phase of OHCA could be critical.

Interestingly, 56.5% of the participants had received training before the AED evaluation, yet only 65.4% of this group had a successful sequence before the training module. Among the participants who did not receive previous training, sequence success was obtained in only 37.5%. This raises the question of whether previous training is truly sufficient or if repeat training is necessary. A recent systematic review reported that, despite the very low certainty of evidence, spaced learning could improve resuscitation skill performance at 1 year after the course.²⁴ The same review also highlighted the questions as to how much training is needed for proper AED use. In 1999, Grundy et al. showed that the difference in the delay to deliver a shock using an AED was less than 30 seconds between naive sixth-grade school children and emergency medical technicians.²⁵ Minimal training such as the one we provided could therefore be associated with acceptable AED use in the short term, although the long-lasting benefits are unclear. Studies have demonstrated comparable results between simulated SCA and actual event performances²⁶ and favourable actual patient outcomes through simulation training.²⁷ Although small, the reductions in time to defibrillations we have described are likely significant considering the time-sensitive nature of this life-threatening scenario.

Limitations of the study

Our study has some limitations. First, although we obtained an appropriate sample size, the response rate to the initial survey was 53%, indicating that nearly half of the schools we hoped to include did not participate. Although comparable with previous studies,³ this could be a source of bias as the schools that decided to participate may attribute more importance to first aid and AED training. However, our results still reveal perceived barriers to proper use and inadequate performance. Although we did not identify significant differences between schools of different socioeconomic backgrounds regarding proper AED use or perceived barriers, previous research has documented a possible association.³ As such, the present data may be biased considering our smaller sample of lower socioeconomic schools included. Also, survey respondents were primarily school principals or administrative staff, yet most participants in our simulation were teachers. Some subjective measures, such as perceived lack of training, may differ between those groups. Another limitation to our study is that we conducted same-day evaluations of the teaching module. Close repetition of the AED sequence could have improved the first-shock delay by itself. However, we measured the concurrent improvement in compliance with the proper AED sequence. Although our results suggest that previous training is a strong predictor of sequence success in a mock SCA scenario, information on time since last certification was not collected. Thus, further study is warranted to measure skill maintenance over time. Further evaluations of participants, making the teaching module accessible online, and planned prompts to reassess the teaching module are all future possibilities for properly evaluating the impact of the video module on AED use. It might also help improving direct respondents' performance over time, which is considered ideal to be able to draw firm conclusions.²⁸

Conclusions

Almost all surveyed elementary schools in the Québec City area have an AED. However, the lack of AED training remains the primary barrier to its proper use. A brief educational video intervention was associated with a 29% reduction in the delay before the first shock during a pediatric SCA simulation. Further studies are needed to determine the impact of this educational intervention and for defining the optimal approach to continuous training and skill maintenance in use of AEDs.